Pedro Arguis

Large vessel involvement in biopsy-proven giant cell arteritis: prospective study in 40 newly diagnosed patients using CT angiography

Background Necroscopic and surgical studies have suggested that giant cell arteritis (GCA) may target the aorta and its main branches. Imaging techniques are able to detect large vessel vasculitis (LVV) non-invasively in patients, but the prevalence of LVV in GCA has not been clearly established. Objective To assess prospectively the prevalence, characteristics and topography of LVV in patients with newly diagnosed GCA and to determine the associated clinical and laboratory features. Methods CT angiography (CTA) was performed in 40 consecutive patients with newly diagnosed biopsy-proven GCA. Patients were treatment-naïve or had been treated with corticosteroids for <3 days. Vessel wall thickness and vessel diameter (dilation or stenoses) at four aortic segments (ascending aorta, aortic arch, descending thoracic and abdominal aorta) and at the main aortic branches were evaluated. Results LVV was detected in 27 patients (67.5%). The vessels involved were as follows: aorta (26 patients, 65%), brachiocephalic trunk (19 patients, 47.5%), carotid arteries (14 patients, 35%), subclavian arteries (17 patients, 42.5%), axillary arteries (7 patients, 17.5%), splanchnic arteries (9 patients, 22.5%), renal arteries (3 patients, 7.5%), iliac arteries (6 patients, 15%) and femoral arteries (11 patients, 30%). Dilation of the thoracic aorta was already present in 6 patients (15%). Cranial ischaemic events were significantly less frequent in patients with LVV (p=0.029). Treatment-naïve patients had a higher frequency of LVV (77% vs 29%, p=0.005). Conclusions CTA-defined LVV occurs in two-thirds of patients with GCA at the time of diagnosis and aortic dilation is already present in 15%. Previous corticosteroid treatment may decrease CTA-detected LVV.

Pulmonary Sarcoidosis: Typical and Atypical Manifestations at High-Resolution CT with Pathologic Correlation

Sarcoidosis is a multisystem disorder that is characterized by noncaseous epithelioid cell granulomas, which may affect almost any organ. Thoracic involvement is common and accounts for most of the morbidity and mortality associated with the disease. Thoracic radiologic abnormalities are seen at some stage in approximately 90% of patients with sarcoidosis, and an estimated 20% develop chronic lung disease leading to pulmonary fibrosis. Although chest radiography is often the first diagnostic imaging study in patients with pulmonary involvement, computed tomography (CT) is more sensitive for the detection of adenopathy and subtle parenchymal disease. Pulmonary sarcoidosis may manifest with various radiologic patterns: Bilateral hilar lymph node enlargement is the most common finding, followed by interstitial lung disease. At high-resolution CT, the most typical findings of pulmonary involvement are micronodules with a perilymphatic distribution, fibrotic changes, and bilateral perihilar opacities. Atypical manifestations, such as masslike or alveolar opacities, honeycomb-like cysts, miliary opacities, mosaic attenuation, tracheobronchial involvement, and pleural disease, and complications such as aspergillomas, also may be seen. To achieve a timely diagnosis and help reduce associated morbidity and mortality, it is essential to recognize both the typical and the atypical radiologic manifestations of the disease, take note of features that may be suggestive of diseases other than sarcoidosis, and correlate imaging features with pathologic findings to help narrow the differential diagnosis.

Development of aortic aneurysm/dilatation during the followup of patients with giant cell arteritis: A cross‐sectional screening of fifty‐four prospectively followed patients

OBJECTIVE Giant cell arteritis (GCA) may involve the aorta. Retrospective studies have demonstrated a higher prevalence of aortic aneurysm among patients with GCA compared with the general population. We investigated the prevalence of aortic aneurysm in a cohort of patients with biopsy-proven GCA using a defined protocol and assessed whether persisting low-grade disease activity is associated with higher risk of developing aortic aneurysm. METHODS Fifty-four patients with GCA (14 men and 40 women) were cross-sectionally evaluated after a median followup of 5.4 years (range 4.0-10.5 years). The screening protocol included a chest radiograph, abdominal ultrasonography scan, and computed tomography scan when aortic aneurysm was suspected or changes with respect to the baseline chest radiograph were observed. Clinical and laboratory data, corticosteroid requirements, and relapses were prospectively recorded. RESULTS Twelve patients (22.2%) had significant aortic structural damage (aneurysm/dilatation), 5 of them candidates for surgical repair. Aortic aneurysm/dilatation was more frequent among men (50%) than women (12.5%; relative risk 3.5, 95% confidence interval 1.53-8.01, P = 0.007). At the time of screening, patients with aneurysm/dilatation had lower serum acute-phase reactants, lower relapse rate, and needed shorter periods to withdraw prednisone than patients without aortic structural damage. CONCLUSION There is a substantial risk of developing aortic aneurysm/dilatation among patients with GCA. Our data do not support that aneurysm formation mainly results from persistent detectable disease activity. Additional factors including characteristics of the initial injury or the target tissue may also determine susceptibility to aortic aneurysm/dilatation.

Incidence of occult mediastinal node involvement in cN0 non-small-cell lung cancer patients after negative uptake of positron emission tomography/computer tomography scan.

OBJECTIVE This study sought to assess the real incidence of pN2 among patients with non-small-cell lung cancer (NSCLC) (cN0) with negative mediastinal uptake of 2-deoxy-2-(18F)-fluoro-o-glucose (FDG). METHODS During 30 consecutive months (January 2007-May 2009), all patients with NSCLC scheduled for surgery in our unit had a preoperative FDG-positron emission tomography (PET)/computed tomography (CT) in our institution, after a dedicated chest CT (n=259). Only patients with both FDG-PET/CT and negative dedicated chest CT scan (N1 and N2 nodes <1cm) were prospectively included (n=125). Patients with cN1/cN2/cN3 and patients who had undergone preoperative chemo-radiotherapy were excluded. No invasive surgical staging was carried out in this group and curative resection plus systematic mediastinal dissection was performed except in the event of unexpected oncological contraindication. All variables were collected prospectively and, when pathological information was obtained, all the cases were carefully reviewed. RESULTS Mediastinal assessment by FDG-PET/CT, negative predictive value (NPV) was 85.6%, confidence interval (CI): [77-91]; false negatives (FNs) for mediastinal lymph nodes involvement was 14.4% (18 cases). The pN2 stations most frequently involved were: 4R (six cases), seven (six cases) and five (five cases). Multiple-level pN2 occurred in six (4.8%) cases. Occult (pN2) lymph nodes were more frequent in women (p<0.01), adenocarcinoma (p<0.05) and pN1 (p<0.05). Pathological N2 prevalence for pN1 was 34 (27.7%). Considering pathological staging as the gold standard, the agreement was 70% and 47.5% for stage IA and IB (Kappas index: 0.72 and 0.76) and, in all patients, 47% (Kappas index: 0.27). In general, down-staging is more frequent than up-staging. CONCLUSIONS Mediastinal staging of NSCLC by FDG-PET/CT showed a considerable incidence of FNs. NPV is lower than previously reported and the preoperative mediastinal staging by 18FDG-PET/CT may jeopardise the accurate treatment for early stage NSCLC patients.

Early detection of hepatic artery thrombosis after liver transplantation by Doppler ultrasonography: prognostic implications.

We assessed the usefulness of routine Doppler ultrasonography for early detection of hepatic artery thrombosis after orthotopic liver transplantation and repercussions in patient prognosis. Seventeen confirmed cases of early hepatic artery thrombosis initially diagnosed by Doppler ultrasonography (10 of them before clinical indication) were reviewed. All patients underwent Doppler ultrasonographic studies in the first 3 days after orthotopic liver transplantation. Twelve cases of hepatic artery thrombosis (70.6%) were detected by this early Doppler ultrasonography. All 10 unsuspected cases of hepatic artery thrombosis and 5 of the 7 cases diagnosed after clinical indication were treated by revascularization. Grafts were salvaged in 80% of asymptomatic patients and in 42.8% of symptomatic patients. Furthermore, biliary complications were less serious in the first group. In conclusion, Doppler ultrasonography performed routinely in the first 3 days after orthotopic liver transplantation may permit early detection of hepatic artery thrombosis, even before clinical indications. This allows hepatic artery repermeabilization before liver function damage, improving graft rescue and patient prognosis.

Prospective long term follow-up of a cohort of patients with giant cell arteritis screened for aortic structural damage (aneurysm or dilatation)

Background Aortic structural damage (ASD) may complicate the course of patients with giant cell arteritis (GCA). However the frequency and outcome of ASD has not been assessed in long term prospective studies. Methods In a previous screening of 54 biopsy proven GCA patients, significant ASD was detected in 12 (22.2%) after a median follow-up of 5.4 years. These patients were periodically evaluated (every 4 years) over a median of 10.3 years (range 4–16.6 years) in order to investigate the development of new ASD and the outcome of previously detected abnormalities. Results 18 of the 54 patients abandoned the study due to death or other reasons. The remaining 36 patients were subjected to a second screening and 14 to a third screening. 12 (33.3%) of the 36 patients re-screened and 16 (29.6%) of the initial cohort developed ASD, all but one in the thoracic aorta. Aortic diameters at the ascending and descending aorta significantly increased over time. One patient (1.9% of the initial cohort) died from aortic dissection. Surgery was advised in eight (50%) patients with ASD but could only be performed in three patients (37.7%). The development of ASD was not associated with persistence of detectable disease activity. Conclusions The incidence of ASD is maximal within the first 5 years after diagnosis but continues developing over time, affecting up to 33.3% of individuals after long term follow-up. Once ASD occurs, dilatation increases over time, underlining the need for periodic evaluation. Surgical repair is feasible in about one-third of candidates.

Determining the appropriate sleeve lobectomy versus pneumonectomy ratio in central non-small cell lung cancer patients: an audit of an aggressive policy of pneumonectomy avoidance

OBJECTIVE To study the outcomes of broncho ± angioplastic sleeve lobectomy (SL) versus pneumonectomy (PN), and the PN:SL ratio after an aggressive policy of parenchyma-sparing surgery to improve postoperative complications rate and long-term quality of life (QoL). METHODS A prospective study was conducted in 490 patients with non-small cell lung cancer between 2005 and 2009. All patients not suitable for standard lobectomy were scheduled for SL, if possible, or for PN; eight patients with functional impairment were directly scheduled for SL. RESULTS Of 76 procedures, 21 (4%) were PN and 55 (11%) SL (29 bronchoplastic, seven bronchovascular, seven angioplastic; 11 extended to more than one lobe). There were no surgical, oncological or physiological preoperative differences between the groups. The 5-year PN:SL ratio was 1:2.6 (2005: 1:2.1; 2006: 1:2.6; 2007: 1:3.6; 2008: 1:3; 2009: 1:3.5). SL and PN mortality were 2 (3.6%) and 1 (5%), respectively. Postoperative complications occurred in 18 (32%) SL and 7 (33%) PN patients. pN1 (p = 0.04), vascular reconstruction and upper-left SL were risk factors for postoperative complications of SL (p = 0.03) but were not detected as a mortality risk. Overall 5-year survival was 61% for SL and 31% for PN. Survival at 5 years was significantly higher for SL (p = 0.03, Kaplan-Meier). Age <70 years and SL were positive factors for long-term survival. In multivariate modelling, both remained positive factors. Surviving PN patients experienced significantly greater loss of respiratory function and lower QoL than those who avoided this surgery (preoperative score, PN vs SL: 52 vs 51; 3 months, 41 vs 43; and 6 months, 42 vs 51, p = 0.04). The adjuvant treatment complement was higher in SL at 34 (62%) than at PN 10 (47%). The side effects of this treatment were more frequent in patients with more extirpated parenchyma (p = 0.04). CONCLUSIONS Parenchyma-sparing procedures can reduce the PN rate to less than 10%. A PN:SL index lower than 1:1.5 as a quality standard in a specialised thoracic unit should encourage the use of broncho-angioplastic procedures and improve patient outcomes. Long-term survival, QoL, postoperative lung function test and tolerance of adjuvant therapies are significantly better after SL than PN intervention.

The spectrum of vascular involvement in giant‐cell arteritis: clinical consequences of detrimental vascular remodelling at different sites

Although repeatedly reported in the literature, the extracranial involvement by giant‐cell arteritis has been considered anecdotal until recent years. The emergence of new or improved imaging techniques along with a closer follow‐up of these patients and their increase in life expectancy are beginning to underline that the clinical impact of extracranial involvement by GCA may be more relevant than previously thought. This review focuses on the extent of vascular involvement in GCA as reported by pathology and imaging studies as well as the clinical consequences of imperfect vascular remodelling in various vascular territories.

Effect of glucocorticoid treatment on computed tomography angiography detected large-vessel inflammation in giant-cell arteritis. A prospective, longitudinal study.

AbstractComputed tomography angiography (CTA) detects signs of large-vessel vasculitis (LVV) in about 67.5% of patients with giant-cell arteritis (GCA) at the time of diagnosis and early aortic dilatation in 15%. The outcome of CTA-findings of LVV upon glucocorticoid treatment has not been prospectively evaluated.The aim of our study was to prospectively assess glucocorticoid-induced changes in CTA findings of LVV in patients with GCA.Forty biopsy-proven GCA patients evaluated by CTA at diagnosis were prospectively followed and scheduled a new CTA approximately after 1 year of treatment. Vessel wall thickening, diameter, and contrast enhancement of the aorta and its tributaries were evaluated. Results were compared to those obtained at the time of diagnosis.CTA was repeated to 35 patients after a median follow-up of 13.5 months (IQ25–75% 12.4–15.8). Arterial wall thickening was still present in 17 patients (68% of the patients who initially had LVV). The number of affected segments and wall thickness at various aortic segments significantly decreased and no patients developed new lesions, new aortic dilation or increase in previous dilation. Contrast enhancement disappeared in 15 (93.75%) of 16 patients in whom this finding could be assessed.Signs of LVV improve with treatment. While contrast enhancement resolves in the majority of patients, vessel wall thickening persists in two thirds. However, the number of affected aortic segments as well as aortic wall thickness significantly decreases. Longer follow-up is necessary to determine the clinical significance of persisting wall thickening and its relationship with relapses or subsequent development of aortic dilatation or large-vessel stenoses.

False-negative rate after positron emission tomography/computer tomography scan for mediastinal staging in cI stage non-small-cell lung cancer

OBJECTIVES To assess the false-negative (FN) rate of positron emission tomography (PET)-chest computed tomography (CT) scan in clinical non-central cIA and cIB non-small-cell lung cancer (NSCLC) for mediastinal staging. METHODS Between January 2007 and December 2010, 402 patients with potentially operable NSCLC were assessed by thoracic CT scan and 18-fluoro-2-deoxy-d-glucose PET-CT for mediastinal staging and to detect extrathoracic metastases, of which 153 surgically treated patients (79 cIA and 74 cIB cases) were prospectively included in the study. Central tumours were excluded on the basis of CT scan criteria, defined as contact with the intrapulmonary main bronchi, pulmonary artery, pulmonary veins or the origin of the first segmental branches. CT scan was considered negative if lymph nodes were <1 cm at the smaller diameter. 18FDG PET-CT was considered negative when the high maximum standard uptake value (SUVmax) was <2.5. Non-invasive surgical staging was carried out in this group, and curative resection plus systematic mediastinal dissection was performed except in the event of unexpected oncological contraindication. RESULTS Composite non-invasive staging (CT scan, PET-CT) showed a negative predictive value (NPV) of 92% (CI 83.6-96.8) in the cIA group and 85% (CI 74-92) in the cIB group. There were 6 of 79 (7.6%) false-negatives (FNs) in cIA and 11 of 74 (14.8%) in cIB. Multilevel pN2 were detected in four cases, all of them in the cIB group. The most frequently involved N2 was subcarinal (two cases) in cIA and right lower paratracheal (R4) and seven (five cases) in cIB. Occult (pN2) lymph nodes were more frequent in tumour sizes≥5 cm (pT2b, nine cases, four FNs, P=0.03), pN1, adenocarcinoma [excluding minimally invasive adenocarcinoma (MIA) and lepidic predominant growth (LPA)] (P=0.029) and female patients, but no other risk factors for mediastinal metastases were identified (age, clinical stage, tumour location, central or peripheral, P>0.05). Multilevel pN2 was significantly more frequent in the cIB group (P<0.03). In pT≤1 cm (T1a), NPV was significantly better (NPV=100%, P<0.05) than the other subgroups studied (IA>1 cm and IB). CONCLUSIONS Composite results for non-invasive mediastinal staging (CT scan, PET-CT) showed 11% of FNs in cI stage (7.6% in non-central cIA and 14.8% in cIB). In tumours≤1 cm, NPV makes surgical staging unnecessary. In women with adenocarcinoma and non-central cIB, however, the high FN rate makes invasive staging necessary, particularly in pT2b to decrease the incidence of unexpected pN2 in thoracotomy.