Jorge Kavakama

Centrilobular Fibrosis: An Underrecognized Pattern in Systemic Sclerosis

Background: The impressive association of lung involvement and gastroesophageal reflux in scleroderma raises the possibility of a cause-effect relationship. Objectives: To determine clinical, radiological and histopathological features of systemic sclerosis (SSc) patients according the presence or absence of centrilobular fibrosis (CLF). Methods: Twenty-eight SSc patients with lung involvement were submitted to open lung biopsy and the specimens classified for the presence of CLF (bronchocentric distribution of the lesions and intraluminal matter according to the classification of idiopathic interstitial pneumonia). HRCT, pulmonary function tests and esophageal analysis were also performed. Subsequently, cyclophosphamide was introduced for the nonspecific interstitial pneumonia subgroup and antireflux treatment was intensified for isolated CLF patients. Results: Isolated CLF was found in 21% of the biopsies and also found associated to nonspecific interstitial pneumonia in 84% of these patients. The other 3 cases had usual interstitial pneumonia, pulmonary hypertension and respiratory bronchiolitis-associated interstitial lung disease. The histopathological analysis revealed that all 6 patients with isolated CLF had the bronchocentric distribution and intraluminal basophilic content, with foreign bodies detected in one third of them. The central distribution of lung involvement on HRCT was found in 67% of these patients with a consistent patchy distribution (100%). Ground glass (67%) and consolidation (33%) were the predominant patterns found. The constant clinical finding in all isolated CLF cases was dyspnea, esophageal abnormalities and a moderate lung impairment (FVC: 63.83 ± 16.31%; DLCO: 61.66 ± 18.84%). Lung function parameters in isolated CLF patients remained stable after 1 year of exclusively intensive antireflux treatment (FVC, p = 0.23; DLCO, p = 0.59). Conclusions: The novel description of CLF pattern in SSc lung disease with peculiar histological, tomographic and clinical features will certainly contribute to a more appropriate therapeutic approach.

High-resolution CT in silicosis: correlation with radiographic findings and functional impairment.

Objective: To assess high-resolution computed tomography (HRCT) findings in silicosis and to better define the role of HRCT in early detection of parenchymal abnormalities in silica-exposed workers. Methods: Forty-one stone carvers were evaluated with chest radiographs (CR), HRCT, and pulmonary function tests (PFT). Inter-reader agreement was calculated using the kappa statistic (k). Correlation between radiographic and HRCT profusion scores and PFT was assessed using the Spearman correlation coefficient. Results: The most common HRCT findings were branching centrilobular structures, seen in 28/41 workers (68.3%). Nodules consistent with silicosis were detected in 53.7% workers on CR and in 56.1% workers on HRCT. Inter-reader agreement for diagnosis of silicosis was better on HRCT (k = 0.84) than on CR (k = 0.54). Small opacity profusion on HRCT correlated inversely with total lung capacity and FVC%. Conclusion: Profusion of opacities on HRCT correlates with functional impairment. The presence of branching centrilobular structures may be helpful in early recognition of silicosis.

Randomized trial comparing pulmonary alterations after conventional with venovenous bypass versus piggyback liver transplantation

During the anhepatic phase of conventional liver transplantation (LT), the inferior vena cava (IVC) is cross‐clamped and venovenous bypass (VVB) is usually indicated for diversion of IVC and portal blood flow. VVB can theoretically lead to pulmonary complications due to the contact of the blood with the surfaces of the circuit. In the piggyback method, preservation of the IVC avoids VVB. The aim of this study is to compare pulmonary alterations after conventional with VVB versus piggyback LT. Sixty‐seven patients were randomized for conventional VVB (n = 34) or piggyback (n = 33) LT. Pulmonary static compliance (Cst) and PaO2/FIO2 ratio were measured pre‐ and post‐LT. Chest X‐rays were obtained daily from the 1st to the 5th postoperative day. Pre‐ and post‐LT Cst were 73.4 ± 36.0 mL/cm H2O and 59.7 ± 22.0 mL/cm H2O in the conventional group and 69.1 ± 20.0 mL/cm H2O and 58.7 ± 27.1 mL/cmH2O in the piggyback group. The difference between the two groups was not significant (P = .702). Cst significantly decreased after LT (P = .008). The pre‐ and post‐LT PaO2/FIO2 were 455.6 ± 126.6 mm Hg and 463.1 ± 105.9 mm Hg in the conventional group and 468.9 ± 114.1 mm Hg and 483.3 ± 119.8 mm Hg in the piggyback group. The difference among the two groups was not significant (P = 0.331). There was no significant difference after LT (P = .382). Upon the radiological evaluation, piggyback group presented a higher frequency of pulmonary infiltrates (80.6% vs. 50.0%; P = .025). In conclusion, piggyback LT recipients have a higher rate of pulmonary infiltrates when compared to those operated upon using the conventional VVB method. (Liver Transpl 2004;10:425–433.)

Consenso Brasileiro sobre a Terminologia dos Descritores de Tomografia Computadorizada do Tórax

JORGE L PEREIRA-SILVA PRESIDENTE Faculdade de Medicina da Universidade Federal da Bahia. JORGE KAVAKAMA VICE-PRESIDENTE Faculdade de Medicina da Universidade de São Paulo. MÁRIO TERRA FILHO SECRETÁRIO Faculdade de Medicina da Universidade de São Paulo. NELSON DA S. PORTO PRESIDENTE DE HONRA Universidade Federal do Rio Grande do Sul. ARTHUR SOARES SOUZA JÚNIOR Faculdade de Medicina de São José do Rio Preto. EDSON MARCHIORI Universidade Federal Fluminense. CÉSAR DE ARAÚJO NETO Faculdade de Medicina da Universidade Federal da Bahia. MARCELO CHAVES Faculdade de Medicina da Universidade de São Paulo. KLAUS L. IRION Universidade Federal do Rio Grande do Sul. DANY JASINOVODOLINSK Universidade Federal de São Paulo. PEDRO DALTRO Clínica de Diagnóstico por Imagem do Centro Médico Barrashopping. LUIZ FELIPE NOBRE Faculdade de Medicina de Santa Catarina. MARCELO FUNARI Faculdade de Medicina da Universidade de São Paulo. DANTE L. ESCUISSATO Universidade Federal do Paraná.

Identification of rounded atelectasis in workers exposed to asbestos by contrast helical computed tomography

Rounded atelectasis (RA) is a benign and unusual form of subpleural lung collapse that has been described mostly in asbestos-exposed workers. This form of atelectasis manifests as a lung nodule and can be confused with bronchogenic carcinoma upon conventional radiologic examination. The objective of the present study was to evaluate the variation in contrast uptake in computed tomography for the identification of asbestos-related RA in Brazil. Between January 1998 and December 2000, high-resolution computed tomography (HRCT) was performed in 1658 asbestos-exposed workers. The diagnosis was made in nine patients based on a history of prior asbestos exposure, the presence of characteristic (HRCT) findings and lesions unchanged in size over 2 years or more. In three of them the diagnosis was confirmed during surgery. The dynamic contrast enhancement study was modified to evaluate nodules and pulmonary masses. All nine patients with RA received iodide contrast according to weight. The average enhancement after iodide contrast was infused, reported as Hounsfield units (HU), increased from 62.5+/-9.7 to 125.4+/-20.7 (P < 0.05), with a mean enhancement of 62.5+/-19.7 (range 40 to 89) and with a uniform dense opacification. In conclusion, in this study all patients with RA showed contrast enhancement with uniform dense opacification. The main clinical implication of this finding is that this procedure does not permit differentiation between RA and malignant pulmonary neoplasm.

Imagem nas doenças ocupacionais pulmonares

This chapter consists of a review of the literature regarding radiographic and tomographic characteristics of the principal occupational respiratory diseases (silicosis and asbestosis). Special attention is given to the practical relevance of high-resolution computed tomography, which is the most sensitive and specific method of identifying and quantifying the extent of pleural and parenchymal lesions related to such diseases.

Estudo comparativo entre tomografia computadorizada de alta resolução e radiografia de tórax no diagnóstico da silicose em casos incipientes

Introduction: At present, chest radiography (CR) is the main instrument used in the diagnosis of silicosis, following the International Labor Organization (ILO) recommendations. In incipient cases, the interpretation of radiographs is difficult and disagreement may occur, even among experienced readers. Recently, the possibility of evaluating incipient cases by using high resolution computed tomography (HRCT) has been considered. Objective: To compare CR with HRCT results. Patients and methods: An original group of 135 ex-miners were evaluated by CR, according to ILO recommendations, examined by three readers, from November 1997 to December 1999. HRCT was indicated to 68 patients whose median profusion readings was 1/0 or below. HRCT results were examined by two readers and, in cases of disagreement, a third reader was consulted. HRCT results were classified according to micronodule profusion into categories 0 to 3. CR and HRCT results were compared using McNemar test, weighed Kappa coefficient and log-linear models. Results and conclusion: There was good agreement among the methods in category 0, so it was concluded that both methods are similar in excluding the diagnosis of silicosis. However, in category 1 or greater (diagnosis of the disease) a good agreement among the methods was not observed.

Placas pleurais relacionadas com o asbesto: Revisão da literatura

Pleural plaques (PP) are considered to be hallmarks of asbestos exposure. They constitute focal thickenings of the pleura and are commonly seen in patients without lung disease. They can involve parietal, diaphragmatic and mediastinal pleura. Chest x-ray is frequently used for PP diagnosis, but computed tomography, especially when used the high-resolution technique, is the imaging exam with the greatest sensibility and specificity. PP are almost always asymptomatic, but there are some controversial about their relationship with asbestos exposure indexes, pulmonary functional alterations and risk of neoplasias. Rev Port Pneumol 2005; XI (5): 487-497

Sarcoidose pulmonar: achados na tomografia computadorizada de alta resolução

A sarcoidose e uma doenca sistemica de causa indeterminada, caracterizada por granulomas nao-caseosos. Embora possa afetar qualquer orgao, esta doenca tem sua morbi-mortalidade relacionada principalmente ao acometimento pulmonar, presente em 80% a 90% dos pacientes. Este artigo ilustra as principais manifestacoes pulmonares da sarcoidose na tomografia computadorizada de alta resolucao, incluindo as formas tipicas e atipicas.

Alterações pleurais e parenquimatosas relacionadas com a exposição ao asbesto: Ensaio pictórico

Pleural and pulmonary asbestos-related diseases range from benign conditions, like pleural effusion and pleural plaques, to some neoplasias, such as lung cancer and malignant mesothelioma. Pleural effusion is the earliest finding after asbestos exposure, but the imaging findings are not specific. Diffuse pleural thickening involves the visceral pleura and pleural plaques are considered to be hallmarks of exposure. Asbestosis is the pulmonary fibrosis due to asbestos. Rounded atelectasis is a peripheral lung collapse in these individuals, generally related to pleural disease. Some neoplasias, like lung carcinoma and pleural mesothelioma, are more prevalent in asbestos-exposed subjects. The aim of this essay is to illustrate the main imaging findings of asbestos-related diseases. Rev Port Pneumol 2005; XI (5): 477-485