Rodrigo Caruso Chate

Reduction of poor contrast enhancement of the pulmonary artery in computed tomography angiography using an alternative respiratory maneuver.

Purpose: The aim of the study was to compare the effects of different respiratory maneuvers in computed tomography pulmonary angiography for the diagnosis of pulmonary embolism (PE) on the contrast enhancement of pulmonary circulation and on the quality of lung window images. Materials and Methods: A retrospective analysis of 520 examinations, half obtained after deep inspiration followed by breath-holding and half solely during breath-holding. Subjective quality analyses and objective measurements of pulmonary arterial enhancement and lung parenchyma attenuation were performed. Results: Elimination of deep inspiration reduced suboptimal opacification of the pulmonary artery (PA), from 7.3% to 2.7%, with 2.7% of the deep inspiration scans having attenuation values <150 Hounsfield units (HU). The prevalence of PE was similar between the groups (19% vs. 23%, respectively), with excellent interobserver diagnostic agreement (&kgr;=0.89 to 0.91). Lung windows were compromised in 6.9% of the studies with respiratory pause, and these examinations had a higher attenuation of the lung parenchyma (median: −709.8 HU) compared with deep inspiration (−794.8 HU). A positive correlation between attenuation of the PA and the ascending aorta was observed (r=0.40 to 0.56). Conclusions: Eliminating deep inspiration before image acquisition had opposite effects with the same magnitude: it caused a reduction in inadequate PA enhancement at the cost of an increased number of nondiagnostic lung images and did not compromise diagnostic consistency for PE.

Safety and systemic consequences of pleurodesis with three different doses of silver nitrate in patients with malignant pleural effusion.

Background: Silver nitrate (SN) is an alternative to talc pleurodesis in patients with malignant pleural effusion (MPE). Nevertheless, SN complications have not been thoroughly investigated so far. Objective: To evaluate frequent adverse events (AE) of SN treatment at three different doses for pleurodesis in patients with MPE. The secondary objective was to evaluate systemic inflammation, efficacy and quality of life in these patients. Methods: A double-blind, randomized, clinical trial was conducted in patients with recurrent MPE at a tertiary university hospital. The study patients underwent pleural catheter insertion and were randomly assigned to one of the three pleurodesis groups treated with 30 ml 0.3%, 30 ml 0.5% or 60 ml 0.3% SN. Patients were discharged 3 days after the procedure, and returned to follow-up visits on days 10 and 30. During follow-up, AE, inflammatory markers, quality of life and CT scans were systematically assessed and documented. Results: Sixty patients (11 males and 49 females, median age 62.13 years) were included. Overall, 199 AE were observed, including 23 serious AE. Grade 1/2 metabolic AE, such as increases in creatinine and liver enzymes, were the most frequent. Grade 3/4 hypoxia was observed in 13 patients. Four patients died, 3 due to disease progression and in 1 patient death was possibly related to pleurodesis. C-reactive protein levels increased in a dose-dependent manner and peaked 48 h after pleurodesis. No significant difference was observed among groups regarding quality of life or clinical/radiological recurrence. Conclusion: Hypoxia was the most significant AE following SN pleurodesis; mild metabolic events were very common. SN instillation causes substantial dose-dependent systemic inflammatory responses.

Do Current Lung Cancer Screening Guidelines Apply for Populations With High Prevalence of Granulomatous Disease? Results From the First Brazilian Lung Cancer Screening Trial (BRELT1)

BACKGROUND Low-dose computed tomography (LDCT) screening for lung cancer has been demonstrated to be effective in reducing cancer mortality. However, these studies have not been undertaken in countries where the incidence of granulomatous disease is high. The First Brazilian Lung Cancer Screening Trial (BRELT1) has completed initial accrual and is now in the follow-up phase. We present results from the initial prevalence round of screening. METHODS The inclusion criteria were the same as those for the National Lung Cancer Screening Trial (NLST). Pulmonary nodules larger than 4 mm were considered positive and required evaluation by a multidisciplinary team. Indeterminate nodules were evaluated with fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) or biopsy when indicated. Statistical analysis was performed with Fishers exact test to compare our positive findings with those of the NLST. RESULTS From January 2013 to July 2014, 790 participants were enrolled. Positive LDCT scans were reported in 312 (39.4%) participants, with a total of 552 nodules larger than 4 mm. The comparison between positive findings in the NLST (7,191 of 26,722 cases) and those in the BRELT1 (312 of 790 cases) showed a significant difference (p < 0.001). The positive predictive value was lower in BRELT1 than in the NLST (3.2% versus 3.8%, respectively). Follow-up imaging was indicated in 278 of 312 (89.1%) participants; 35 procedures were performed in 25 participants. In 15 cases, benign lesions were diagnosed. Non-small-cell lung cancer (NSCLC) was diagnosed in 10 patients (prevalence of 1.3%). In 8 patients (stage IA/IB disease), treatment was by resection only, in 1 patient neoadjuvant chemotherapy was used (stage IIIA), and in 1 patient advanced disease was diagnosed (stage IV). CONCLUSIONS Using NSLT criteria, a larger number of patients had positive scans (nodules), compared with previous lung cancer screening studies. However, the number of participants requiring surgical biopsy procedures and who were ultimately identified as having cancer was similar to other reports. This supports the role of screening in patient populations with a high incidence of granulomatous inflammation.

Computed tomography in hypersensitivity pneumonitis: main findings, differential diagnosis and pitfalls

ABSTRACT Introduction: Hypersensitivity pneumonitis (HP) is a disease with variable clinical presentation in which inflammation in the lung parenchyma is caused by the inhalation of specific organic antigens or low molecular weight substances in genetically susceptible individuals. Alterations of the acute, subacute and chronic forms may eventually overlap, and the diagnosis based on temporality and presence of fibrosis (acute/inflammatory HP vs. chronic HP) seems to be more feasible and useful in clinical practice. Differential diagnosis of chronic HP with other interstitial fibrotic diseases is challenging due to the overlap of the clinical history, and the functional and imaging findings of these pathologies in the terminal stages. Areas covered: This article reviews the essential features of HP with emphasis on imaging features. Moreover, the main methodological limitations of high-resolution computed tomography (HRCT) interpretation are discussed, as well as new perspectives with volumetric quantitative CT analysis as a useful tool for retrieving detailed and accurate information from the lung parenchyma. Expert commentary: Mosaic attenuation is a prominent feature of this disease, but air trapping in chronic HP seems overestimated. Quantitative analysis has the potential to estimate the involvement of the pulmonary parenchyma more accurately and could correlate better with pulmonary function results.

Middle lobe pulmonary torsion after recurrent pleural effusions in a cirrhotic patient

A 57-year-old man was admitted with acute chest pain and shortness of breath. He had cirrhosis secondary to hepatitis C infection and had undergone multiple thoracocentesis in the last months for recurrent pleural effusions. Chest X-ray showed increased density in the right lung base and chest CT showed a right pleural effusion, partial atelectasis of the right lower lobe, middle lobe bronchovascular structures twisted on themselves with a swirling appearance, obliteration of the proximal middle lobe artery, narrowing of the accompanying bronchus and ground-glass opacities in this same lobe (figure 1). Symptoms persisted over the next week and …

Angiotomografia computadorizada de coronárias com tomógrafo com 320 fileiras de detectores e utilizando o AIDR-3D: experiência inicial

ABSTRACT Coronary computed tomography angiography (coronary CTA) is a powerful non-invasive imaging method to evaluate coronary artery disease. Nowadays, coronary CTA estimated effective radiation dose can be dramatically reduced using state-of-the-art scanners, such as 320-row detector CT (320-CT), without changing coronary CTA diagnostic accuracy. To optimize and further reduce the radiation dose, new iterative reconstruction algorithms were released recently by several CT manufacturers, and now they are used routinely in coronary CTA. This paper presents our first experience using coronary CTA with 320-CT and the Adaptive Iterative Dose Reduction 3D (AIDR-3D). In addition, we describe the current indications for coronary CTA in our practice as well as the acquisition standard protocols and protocols related to CT application for radiation dose reduction. In conclusion, coronary CTA radiation dose can be dramatically reduced following the “as low as reasonable achievable” principle by combination of exam indication and well-documented technics for radiation dose reduction, such as beta blockers, low-kV, and also the newest iterative dose reduction software as AIDR-3D.

Idiopathic interstitial pneumonias: review of the latest American Thoracic Society/European Respiratory Society classification

The diagnosis of idiopathic interstitial pneumonias (IIPs) involves a multidisciplinary scenario in which the radiologist assumes a key role. The latest (2013) update of the IIP classification by the American Thoracic Society/European Respiratory Society proposed some important changes to the original classification of 2002. The novelties include the addition of a new disease (idiopathic pleuroparenchymal fibroelastosis) and the subdivision of the IIPs into four main groups: chronic fibrosing IIPs (idiopathic pulmonary fibrosis and nonspecific interstitial pneumonia); smoking-related IIPs (desquamative interstitial pneumonia and respiratory bronchiolitis-associated interstitial lung disease); acute or subacute IIPs (cryptogenic organizing pneumonia and acute interstitial pneumonia); rare IIPs (lymphoid interstitial pneumonia and idiopathic pleuroparenchymal fibroelastosis); and the so-called “unclassifiable” IIPs. In this study, we review the main clinical, tomographic, and pathological characteristics of each IIP.

Understanding Lung-RADS 1.0: A Case-Based Review

Lung cancer is the leading cause of cancer death in both men and women in the United States. The National Lung Screening Trial (NLST) demonstrated that low-dose computed tomography (CT) screening reduces lung cancer mortality by 20% compared to screening with chest radiography. Currently, many institutions in the US are implementing lung cancer screening programs. The use of lung-RADS as a quality assurance tool allows standardization of lung cancer screening CT lexicon, reporting and management recommendations, and reduces confusion in lung cancer screening CT interpretations. Lung-RADS will also facilitate outcome monitoring and future auditing of lung cancer screening programs, assist research, and consequently refine and improve lung cancer screening practices. Familiarity with lung-RADS version 1.0 is essential not only for radiologists interpreting low-dose computed tomography screening studies, but all medical personnel involved in multidisciplinary lung cancer screening programs. This article reviews the Lung-RADS categories and management recommendations using a case-based approach.

What happens to the pleural space affected by malignant effusion after bedside pleurodesis

Evaluate radiological characteristics of postpleurodesis pleural space of patients with recurrent malignant pleural effusion(RMPE).

Pulmonary vasculitis: Diagnosis and endovascular therapy

Pulmonary vasculitides are caused by a heterogeneous group of diseases with different clinical features and etiologies. Radiologic manifestations depend on the predominant type of vessel involved, which are grouped into large, medium, or small-sized vessels. Diagnosing pulmonary vasculitides is a challenging task, and radiologists play an important role in their management by providing supportive evidence for diagnosis and opportunities for minimally invasive therapy. This paper aims to present a practical approach for understanding the vasculitides that can affect the pulmonary vessels and lungs. We will describe and illustrate the main radiologic findings, discussing opportunities for minimally invasive treatment.