Ralph Shipley

Value of computed tomography of the lung in the management of primary spontaneous pneumothorax

The treatment of patients with primary spontaneous pneumothorax remains controversial, since recurrence and the ultimate need for thoracotomy [corrected] cannot be predicted. In the current study, computed tomography (CT) of the lung was performed prospectively on 26 consecutive patients with primary spontaneous pneumothorax to determine whether the size and/or the number of apical blebs would correlate with recurrence and/or need for thoracotomy [corrected]. Both the number of blebs and the bleb score (calculated by the number of blebs multiplied by a numeric value assigned a range of bleb sizes) of the affected lung was significantly greater in patients with a history of recurrent pneumothorax and/or ultimate need for thoracotomy [corrected] as treatment. CT of the lung may be useful in predicting the natural history of pneumothorax.

Changes in Chest Roentgenogram of Sarcoidosis Patients During a Clinical Trial of Infliximab Therapy Comparison of Different Methods of Evaluation

BACKGROUND The best method to interpret the chest roentgenogram and its sensitivity to detect effect of treatment for sarcoidosis remains unclear. In a double-blind, randomized trial of infliximab for chronic pulmonary sarcoidosis, changes in serial chest roentgenograms were examined by radiologists, blinded to order or treatment. METHODS Chest roentgenograms were obtained at 0, 6, and 24 weeks of therapy with either placebo, 3 mg/kg infliximab, or 5 mg/kg infliximab. Films were reviewed in random order by two independent radiologists, unaware of treatment. The films were compared using two methods: the prespecified objective assessment, a scoring system previously proposed by Muers; and the post hoc assessment, a 5-point Likert scale global assessment between two films. RESULTS Of 138 patients enrolled in the study, chest roentgenograms for all studies were available on 130 patients. There was only fair agreement between the two radiologists in the original stage of the chest roentgenogram (weighted kappa = 0.43; 95% confidence interval [CI], 0.32 to 0.54). For the Likert scale of global assessment of change, there was good agreement between the two readers (weighted kappa = 0.61; 95% CI, 0.51 to 0.71). There was good correlation between the two readers for the various components of the Muers score, especially the reticulonodular (R) score (R = 0.578; p < 0.05). The initial R score was positively correlated with improvement in FVC with infliximab therapy (R = 0.239; p < 0.05). CONCLUSION Global assessment and the Muers scoring system were associated with good agreement between two expert readers. Improvement in both scores correlated with improvement in FVC. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00073437.

Predictive value of gallium scan, angiotensin-converting enzyme level, and bronchoalveolar lavage in two-year follow-up of pulmonary sarcoidosis

Evaluation of patients with pulmonary sarcoidosis with serum angiotensin-converting enzyme (ACE), gallium scan, and bronchoalveolar lavage (BAL) has proved useful in demonstrating active disease, especially in the lungs. Long-term prognosis based on the results of pretreatment ACE, gallium scan, and BAL has not been previously clarified. We studied 44 patients with initially symptomatic pulmonary sarcoidosis who were begun on steroid therapy after initial evaluation. At 2 years, 21 of 44 (48%) patients still had worsening disease. Of 31 patients who had positive gallium scan pretreatment, 21 (68%) still had worsening disease at 2 years. None of the 13 patients with a negative gallium scan had worsening disease at 2 years (Chi square =14.2,P <0.01). Similar analysis of the pretreatment serum ACE level, percentage of lymphocytes in the BAL fluid, and ratio of T-helper/inducer to T-suppressor/cytotoxic (T4/T8) in the BAL fluid also had some predictive value for worsening disease at 2 years; however, these tests were less sensitive than the gallium scan. In patients with pulmonary sarcoidosis, the finding of a negative gallium scan suggests a small likelihood that disease activity will worsen after 2 years.

HRCT/CT and associated spirometric effects of low Libby amphibole asbestos exposure.

Objective: Evaluate the relationship between cumulative fiber exposure and high-resolution or conventional chest computed tomography (HRCT/CT) changes and spirometry of workers with Libby amphibole asbestos exposure. Methods: Of the original 1980 cohort (n = 513), 431 were living and asked to participate. Images were evaluated for localized pleural thickening (LPT), diffuse pleural thickening (DPT), and parenchymal changes. Results: A total of 306 participants provided either HRCT/CT scans (n = 191) or chest radiographs (n = 115). Of the 191 with HRCT/CT, 52.9% had pleural changes and 13.1% had parenchymal changes. Those with LPT only, LPT and/or DPT, or DPT and/or parenchymal changes had mean 6.1, 8.0, and 18.0 loss in percent predicted forced vital capacity, respectively. Conclusions: Exposure to vermiculite containing amphibole fibers is associated with pleural and parenchymal HRCT/CT changes at low cumulative fiber exposure; these changes are associated with spirometric decrements.

Cardiopulmonary Imaging in Sarcoidosis

Sarcoidosis is a disease with protean clinical manifestations ranging from no symptoms to sudden death. Radiologic tests are often the key to diagnosis. In this article, the authors review current imaging techniques and discuss emerging technologies used in the noninvasive cardiopulmonary evaluation of the patient who has sarcoidosis.

Vitamin D deficiency and reduced lung function in connective tissue-associated interstitial lung diseases.

BACKGROUND Vitamin D is a steroid hormone with pleiotropic effects including immune system modulation, lung tissue remodeling, and bone health. Vitamin D deficiency has been implicated in the development of autoimmune diseases. We sought to evaluate the prevalence of vitamin D deficiency in a cohort of patients with interstitial lung disease (ILD) and hypothesized that vitamin D deficiency would be associated with an underlying connective tissue disease (CTD) and reduced lung function. METHODS Patients in the University of Cincinnati ILD Center database were evaluated for serum 25-hydroxyvitamin D levels as part of a standardized protocol. Regression analysis evaluated associations between 25-hydroxyvitamin D levels and other variables. RESULTS One hundred eighteen subjects were included (67 with CTD-ILD, 51 with other forms of ILD). The overall prevalence of vitamin D deficiency and insufficiency in the study population was 38% and 59%, respectively. Those with CTD-ILD were more likely to have vitamin D deficiency (52% vs 20%, P < .0001) and insufficiency (79% vs 31%, P < .0001) than other forms of ILD. Diminished FVC was associated with lower 25-hydroxyvitamin D(3) levels (P = .01). The association between vitamin D insufficiency and CTD-ILD persisted (OR, 11.8; P < .0001) after adjustment for potential confounders. Among subjects with CTD-ILD, reduced 25-hydroxyvitamin D(3) levels were strongly associated with reduced lung function (FVC, P = .015; diffusing capacity for carbon monoxide, P = .004). CONCLUSIONS There is a high prevalence of vitamin D deficiency in patients with ILD, particularly those with CTD-ILD, and it is associated with reduced lung function. Vitamin D may have a role in the pathogenesis of CTD-ILD.

Can lung cancer screening by computed tomography be effective in areas with endemic histoplasmosis

OBJECTIVE Low-dose chest computed tomography (CT) is being evaluated in several national trials as a screening modality for the early detection of lung cancer. The goal of the present study was to determine whether lung cancer screening could be done while minimizing the number of benign biopsy specimens taken in an area endemic for histoplasmosis. METHODS The subjects were recruited by letters mailed to area physicians and local advertisement. The inclusion criteria were age older than 50 years and at least a 20 pack-year smoking history. The exclusion criteria were symptoms suggestive of lung cancer or a history of malignancy in the previous 5 years. The participants completed a questionnaire and underwent a chest CT scan at baseline and annually for 5 years. The management of positive screening results was determined using a defined algorithm: annual follow-up CT scan for nodules less than 5 mm; 6-month follow-up CT scan for nodules 5 to 7 mm; review by our multidisciplinary tumor board for nodules 8 to 12 mm; and biopsy for nodules greater than 12 mm. RESULTS A total of 132 patients were recruited. Of the 132 patients, 61% had positive baseline CT findings and 22% had positive findings on the annual CT scans. Six cancers were detected. Of these 6 patients, 5 had stage I disease and underwent lobectomy, and 1 had stage IIIA disease and underwent induction chemotherapy and radiotherapy followed by lobectomy. All patients were alive and disease free at a mean follow-up of 41.7 ± 18.6 months. No biopsies were performed for benign lesions. Also, no cancers were missed when the protocol was followed. CONCLUSIONS Screening with CT can be done effectively in an area endemic for histoplasmosis while minimizing benign biopsies.

Fibrosing mediastinitis causing nonvisualization of one lung on pulmonary scintigraphy

An interesting case of fibrosing mediastinitis, which is a rare cause of total nonvisualization of one lung on pulmonary scintigraphy, is presented. Scintigraphy with Tc-99m MAA showed a severe deficit of perfusion in the right lung, with normal perfusion of the left lung. Ventilation images were normal. CT and MRI each demonstrated the mediastinal nodal enlargement and MRI demonstrated the “flow void” signal phenomenon in the right pulmonary artery indicating its patency. Confirmation of actual patency without pulmonary artery emboli and with poor venous opacfication was documented with angiography. Multiple complementary imaging modalities were helpful in correctly diagnosing fibrosing mediastinitis from an extensive list of differential possibilities for unilateral non-visualization of the lung on perfusion scanning.

Computed tomography of the tracheal bronchus.

Surgicalracheal bronchus is an uncommon anomaly in which an ectopic bronchus arises from the trachea above the carina. It occurs on the right side and two types are described: “supernumerary,” which is associated with a normal trifurcating right upper lobe bronchus, and “displaced,” in which instance the ectopic bronchus supplies the apical segment of the upper lobe. The CT appearance of this anomaly is described in two cases. Findings include identification of a bronchus arising from the trachea in a section more cephalad than the carina and the presence of only two segmental bronchi arising from the anatomic right upper lobe bronchus when the anomaly is of the “displaced” type. Thin axial sections and coronal imaging display the tracheal broanchus to best advantage.

Benign Metastasizing Leiomyoma: A Rare Type of Lung Metastases—Two Case Reports and Review of the Literature

Benign metastasizing leiomyoma (BML) is a rare disease that usually occurs in women of reproductive age. They typically have history of uterine leiomyoma treated with hysterectomy. BML can metastasize to distant organs, with the lung being the most common organ. We report two patients who presented with benign metastasizing leiomyoma to the lung. Our first case was a fifty-two-year-old female who presented with multiple lung masses, with a past medical history of uterine leiomyoma who underwent hysterectomy 17 years ago. A CT-guided biopsy showed benign appearing spindle cells and pathology confirmed her diagnosis with additional positive estrogen/progesterone receptor stains. Our second case was a fifty-six-year-old female who presented with multiple cavitary pulmonary nodules. She subsequently underwent a video-assisted thoracoscopic surgery (VATS) with wedge resection of one of the nodules. Pathology confirmed the diagnosis based on morphology and immunohistochemical staining strongly positive for estrogen/progesterone receptors. Benign metastasizing leiomyoma is a rare condition which may affect women of reproductive age. This should be considered in the differential in patients who present with multiple pulmonary nodules, especially with a history of uterine leiomyoma. Additional stains, such as estrogen/progesterone receptors, may need to be done to confirm the diagnosis.