The Role of CT Perfusion in Differentiating Benign Versus Malignant Focal Pulmonary Lesions.

BACKGROUND: Contrast-enhanced CT scan is the standard imaging for the characterization and evaluation of focal parenchymal lung lesions. It relies on morphology and enhancement patterns for the characterization of lung lesions. However, there is significant overlap among imaging features of various malignant and benign lesions. Hence, it is often necessary to obtain tissue diagnosis with invasive percutaneous or endoscopic-guided tissue sampling. It is often desirable to have non-invasive techniques that can differentiate malignant and benign lung lesions. CT perfusion is an emerging CT technology that allows functional assessment of tissue vascularity through various parameters and can help in differentiating benign and malignant focal lung lesions. OBJECTIVE: The purpose of this study was to assess the role of the CT perfusion technique in differentiating malignant and benign focal parenchymal lung lesions. MATERIALS AND METHODS: In this prospective observational study, CT perfusion was performed on 41 patients with focal parenchymal lung lesions from December 2020 to June 2022. The four-dimensional range was planned to cover the entire craniocaudal extent of the lesion, followed by a volume perfusion CT (VPCT) of the lesion. A total of 27 dynamic datasets were acquired with a scan interval of 1.5 seconds and a total scan time of 42 seconds. CT perfusion parameters of blood flow (BF), blood volume (BV), and k-trans of the lesion were measured with mathematical algorithms available in the Syngo.via CT perfusion software (Siemens Healthcare, Erlangen, Germany). RESULTS: The median BV in benign lesions was found to be 5.5 mL/100 g, with an interquartile range of 3.3-6.9 and a p-value < 0.001. The median BV in malignant lesions was found to be 11.35 mL/100 g, with an interquartile range of 9.57-13.21 and a p-value ≤ 0.001. The median BF for benign lesions was 45.5 mL/100 g/min, with an interquartile range of 33.8-48.5 and a p-value ≤ 0.001. The median BF for malignant lesion was 61.77 mL/100 g/min, with an interquartile range of 33.8-48.5 and a p-value ≤ 0.001. The median k-trans in the case of benign lesions was found to be 4.2 mL/100 g/min, with an interquartile range of 3.13-6.8 and a p-value ≤ 0.001. The median k-trans in the case of the malignant lesion was found to be 12.05 mL/100g/min, with an interquartile range of 7.20-33.42 and a p-value < 0.001. Our study has also shown BV to have an accuracy of 92.68%, sensitivity of 93.3%, and specificity of 90.01%. CONCLUSION: Our study has shown that CT perfusion values of BV, BF, and k-trans can be used to differentiate between benign and malignant focal lung parenchymal lesions. K-trans is the most sensitive parameter while BV and BF have greater accuracy and specificity.

Evaluating the efficacy of percutaneous puncture biopsy guided by contrast-enhanced ultrasound for peripheral pulmonary lesions.

BACKGROUND: The incidence and mortality of lung cancer have increased annually. Accurate diagnosis can help improve therapeutic efficacy of interventions and prognosis. Percutaneous lung biopsy is a reliable method for the clinical diagnosis of lung cancer. Ultrasound-guided percutaneous lung biopsy technology has been widely promoted and applied in recent years. AIM: To investigate the diagnostic value of contrast-enhanced ultrasound (CEUS)-guided percutaneous biopsy in peripheral pulmonary lesions. METHODS: We retrospectively collected data on 237 patients with peripheral thoracic focal lesions who underwent puncture biopsy at Wuxi People's Hospital. The patients were randomly divided into two groups: The CEUS-guided before lesion puncture group (contrast group) and conventional ultrasound-guided group (control group). Analyze the diagnostic efficacy of the puncture biopsy, impact of tumor size, and number of puncture needles and complications were analyzed and compared between the two groups. RESULTS: Accurate pathological results were obtained for 92.83% (220/237) of peripheral lung lesions during the first biopsy, with an accuracy rate of 95.8% (113/118) in the contrast group and 89.9% (107/119) in the control group. The difference in the area under the curve (AUC) between the contrast and the control groups was not statistically significant (0.952 vs 0.902, respectively; P > 0.05). However, when the lesion diameter ≥ 5 cm, the diagnostic AUC of the contrast group was higher than that of the control group (0.952 vs 0.902, respectively; P < 0.05). In addition, the average number of puncture needles in the contrast group was lower than that in the control group (2.58 ± 0.53 vs 2.90 ± 0.56, respectively; P < 0.05). CONCLUSION: CEUS guidance can enhance the efficiency of puncture biopsy of peripheral pulmonary lesions, especially for lesions with a diameter ≥ 5 cm. Therefore, CEUS guidance has high clinical diagnostic value in puncture biopsy of peripheral focal lung lesions.

Computed Tomography (CT)-Guided Needle Biopsy of Lung Lesions: A Single Center Experience.

(1) Objective: Lung cancer is one of the leading causes of cancer death among men and women across the globe. The accurate and timely diagnosis of lung lesions is of paramount importance for prognosis. This single-center study is the first to assess the diagnostic yield and complication rate of a computed tomography (CT)-guided needle biopsy of pulmonary parenchymal and pleural nodules in an academic training center in the United States. (2) Methods: This is a retrospective study approved by IRB. Patients who underwent CT-guided needle biopsy between 2016 and 2020 were reviewed. A CT-guided needle biopsy involving mediastinal lesions was excluded, focusing only on lung parenchymal and pleural lesions. A CT-guided needle biopsy aborted at any point during the procedure was also excluded from this study. (3) Results: 1063 patients were included in this study; 532 were males, and 531 were females. Lesion size ranged from 0.26 cm to 9.2 cm. 1040 patients received diagnoses, among which 772 had a specific diagnosis, and 268 had nonspecific inflammatory or non-malignant diagnoses. Twenty-three cases were non-diagnostic. Among the patients with specific diagnoses, 691 were malignant, 5 were hamartomas, 30 were fungal infections, 6 were acid-fast-positive organisms, and 40 were unspecified atypical cells. Of the patients that had a malignant diagnosis, 317 were adenocarcinoma, 197 were squamous cell carcinoma, 26 were a neuroendocrine tumor, 45 were non-small cell carcinoma (undifferentiated), 17 were small cell carcinoma, and 89 were other metastatic malignancies to the lung. Various common complications, including pneumothorax (337), hemorrhage (128), and hemoptysis (17), were observed, and 42 of the cases required chest tube intervention; others were treated with observation. Other rare complications observed included hemothorax (4) and oxygen desaturation (2), and there was no death in this series. (4) Conclusions: CT-guided needle biopsy is a reliable diagnostic modality for patients with lung parenchymal and pleural nodules, and it can effectively distinguish between benign and cancerous lesions before invasive procedures such as video-assisted thoracoscopy (VATs) or thoracotomy are planned. Our study showed a higher rate of pneumothorax and pulmonary hemorrhage compared to the rates established in guidelines, attributable to the varying experience level in a busy training academic center.

FDG uptake of pulmonary lesions in synchronous primary lung cancers and lung metastases.

Purpose: In lung cancer patients, the distinction between synchronous primary lung cancer and intrapulmonary metastasis can be challenging. The intensity of FDG uptake in pulmonary lesions has been shown to be potentially useful in classifying synchronous lung cancer. The aim of this retrospective study is to investigate the effectiveness of FDG uptake in differentiating metastases from synchronous primary lesions in the setting of lung cancer. Methods: Consecutive patients with primary lung cancer with two or more malignant lung lesions referred for (18F)-FDG PET-CT imaging between 2010 and 2019 were reviewed and classified into synchronous and metastasis groups. Lesional maximum standardized uptake values (SUVmax), relative differences in SUVmax and SUVmax ratios were calculated and compared using receiver operating characteristic (ROC) curve analysis. Intra-group correlation in SUVmax between lesion pairs was examined using Pearson's and Spearman's correlation analysis. Results: 94 patients were included for analysis, divided into synchronous (n = 62; 68 lesion pairs) and metastasis (n = 32; 33 lesion pairs) groups. The correlation of FDG uptake between lesions in the metastasis group was strong (r = 0.81). A significant difference in mean relative difference in SUVmax (synchronous: 0.50±0.23 metastasis: 0.34±0.17, p = 0.001) and mean SUVmax ratio (synchronous: 2.6 ± 1.7 metastasis: 1.7 ± 0.6, p < 0.001) was observed. ROC analysis revealed a fair AUC (0.71-0.72) for these parameters, with an associated sensitivity of 59 % and specificity of 82 % at optimal cut-off values. Conclusion: Differences in FDG uptake intensity among multiple synchronously presenting malignant nodules may be helpful to distinguish second primary lung tumours from metastatic spread.

Tri-Compartmental Restriction Spectrum Imaging Based on 18F-FDG PET/MR for Identification of Primary Benign and Malignant Lung Lesions.

BACKGROUND: Restriction spectrum imaging (RSI), as an advanced quantitative diffusion-weighted magnetic resonance imaging technique, has the potential to distinguish primary benign and malignant lung lesions. OBJECTIVE: To explore how well the tri-compartmental RSI performs in distinguishing primary benign from malignant lung lesions compared with diffusion-weighted imaging (DWI), and to further explore whether positron emission tomography/magnetic resonance imaging (PET/MRI) can improve diagnostic efficacy. STUDY TYPE: Prospective. POPULATION: 137 patients, including 108 malignant and 29 benign lesions (85 males, 52 females; average age = 60.0 ± 10.0 years). FIELD STRENGTH/SEQUENCE: T2WI, T1WI, multi-b value DWI, MR-based attenuation correction, and PET imaging on a 3.0 T whole-body PET/MR system. ASSESSMENT: The apparent diffusion coefficient (ADC), RSI-derived parameters (restricted diffusion f 1 $$ {f}_1 $$ , hindered diffusion f 2 $$ {f}_2 $$ , and free diffusion f 3 $$ {f}_3 $$ ) and the maximum standardized uptake value (SUVmax) were calculated and analyzed for diagnostic efficacy individually or in combination. STATISTICAL TESTS: Student's t-test, Mann-Whitney U test, receiver operating characteristic (ROC) curves, Delong test, Spearman's correlation analysis. P < 0.05 was considered statistically significant. RESULTS: The f 1 $$ {f}_1 $$ , SUVmax were significantly higher, and f 3 $$ {f}_3 $$ , ADC were significantly lower in the malignant group [0.717 ± 0.131, 9.125 (5.753, 13.058), 0.194 ± 0.099, 1.240 (0.972, 1.407)] compared to the benign group [0.504 ± 0.236, 3.390 (1.673, 6.030), 0.398 ± 0.195, 1.485 ± 0.382]. The area under the ROC curve (AUC) values ranked from highest to lowest as follows: AUC (SUVmax) > AUC ( f 3 $$ {f}_3 $$ ) > AUC ( f 1 $$ {f}_1 $$ ) > AUC (ADC) > AUC ( f 2 $$ {f}_2 $$ ) (AUC = 0.819, 0.811, 0.770, 0.745, 0549). The AUC (AUC = 0.900) of the combined model of RSI with PET was significantly higher than that of either single-modality imaging. CONCLUSION: RSI-derived parameters ( f 1 $$ {f}_1 $$ , f 3 $$ {f}_3 $$ ) might help to distinguish primary benign and malignant lung lesions and the discriminatory utility of f 2 $$ {f}_2 $$ was not observed. The RSI exhibits comparable or potentially enhanced performance compared with DWI, and the combined RSI and PET model might improve diagnostic efficacy. TECHNICAL EFFICACY: Stage 2.

Seronegative Granulomatosis With Polyangiitis With Isolated Lung Lesions: A Case Report.

Granulomatosis with polyangiitis (GPA), previously referred to as Wegener's granulomatosis, is an uncommon form of necrotizing vasculitis that predominantly targets small and medium-sized blood vessels as a result of granulomatous inflammation. Granulomatosis with polyangiitis is defined by the existence of necrotizing granulomas in the upper respiratory tract, along with renal involvement, which includes necrotizing glomerulonephritis with extra capillary crescents. From a diagnostic perspective, there is a high correlation between GPA and proteinase-3 anti-neutrophil cytoplasmic antibody (PR3-ANCA) because of the release of inflammatory cytokines, reactive oxygen species (ROS), and lytic enzymes. While ANCA-positive serology is commonly used as the diagnostic criteria, we present a seronegative GPA case with isolated lung lesions. A 54-year-old woman was referred for an assessment of hemoptysis and alterations in her chest radiograph. The patient's laboratory results showed a positive QuantiFERON test but negative results for ANCA and antinuclear antibodies (ANA) tests. A chest CT scan showed the presence of several pulmonary nodules in both lungs, with some cavitation. A CT-guided biopsy was conducted on a nodule located in the lower lobe of the right lung. The results showed that the nodule had non-neoplastic chronic inflammation and an area of geographic necrosis. A second robotic-assisted left upper and lower lobe wedge resection was done, which showed white to tan granular lesions with necrotizing granulomatous inflammation and lymph nodes with anthracosis and a lot of histiocytes, which is typical of GPA. The patient received a six-month course of intravenous rituximab treatment.

Human umbilical cord-derived mesenchymal stem cell transplantation improves the long COVID.

No effective treatments can ameliorate symptoms of long COVID patients. Our study assessed the safety and efficacy of human umbilical cord-derived mesenchymal stem cells (UC-MSCs) in the treatment of long COVID patients. Ten long COVID patients were enrolled and received intravenous infusions of UC-MSCs on Days 0, 7, and 14. Adverse events and clinical symptoms were recorded, and chest-high-resolution CT (HRCT) images and laboratory parameters were analyzed. During UC-MSCs treatment and follow-up, we did not observe serious adverse events, the symptoms of long COVID patients were significantly relieved in a short time, especially sleep difficulty, depression or anxiety, memory issues, and so forth, and the lung lesions were also repaired. The routine laboratory parameters did not exhibit any significant abnormalities following UC-MSCs transplantation (UMSCT). The proportion of regulatory T cells gradually increased, but it was not statistically significant until 12 months. The proportion of naive B cells was elevated, while memory B cells, class-switched B-cells, and nonswitched B-cells decreased at 1 month after infusion. Additionally, we observed a transient elevation in circulating interleukin (IL)-6 after UMSCT, while tumor necrosis factor (TNF)-α, IL-17A, and IL-10 showed no significant changes. The levels of circulating immunoglobulin (Ig) M increased significantly at month 2, while IgA increased significantly at month 6. Furthermore, the SARS-CoV-2 IgG levels remained consistently high in all patients at Month 6, and there was no significant decrease during the subsequent 12-month follow-up. UMSCT was safe and tolerable in long COVID patients. It showed potential in alleviating long COVID symptoms and improving interstitial lung lesions.

Cavitary Hodgkin Lymphoma of the Lung.

It has been shown that some cases of Hodgkin lymphoma (HL) may present with pulmonary parenchymal involvement usually in the form of multiple irregularly marginated pulmonary nodules. Other radiographic patterns such as consolidation, interstitial infiltrates, and cavitary lesions are less common. We present a case of HL, nodular sclerosis type, with pulmonary involvement presenting as a large cavitary consolidation and axillary and mediastinal lymphadenopathy. Initial diagnostic work-up including sputum culture, bronchoscopy, and a fine needle aspiration of lymph node was not conclusive favoring a reactive process with a presumptive diagnosis of cavitary pneumonia. A follow-up chest imaging revealed worsening right upper lung mass, axillary adenopathy, and new nodular satellite lesions, and a repeat bronchoscopy with multiple biopsies remained non-diagnostic requiring an excisional biopsy of the axillary lymph node confirming HL. Further transthoracic core biopsies of the cavitary lung lesion were consistent with pulmonary lymphoma involvement.

Hypermetabolic Pulmonary and Mediastinal Lesions With Elevated Cancer Antigen (CA) 15-3 and CA 27-29 in a Patient With a History of Ovarian and Breast Cancer.

Breast cancer affects around 13% of women. Breast cancer gene 1 (BRCA1) carriers are prone to lung and lymph node metastasis, while breast cancer gene 2 (BRCA2) carriers tend to have bone metastasis. Findings of pulmonary nodules, mediastinal lymphadenopathy, and elevated markers such as cancer antigen (CA) 15-3 and CA 27-29 suggest metastatic disease. Here, we present the case of a patient with BRCA1-positive breast cancer in remission and a history of ovarian cancer with mediastinal lymphadenopathy and pulmonary nodules, with avid fluorodeoxyglucose uptake on positron emission tomography (PET) scan and elevated CA 15-3 and CA 27-29. A 70-year-old female with a history of bilateral breast and ovarian cancer and a positive BRCA test presented with pulmonary nodules, mediastinal lymphadenopathy, and elevated CA 15-3 and CA 27-29. Imaging showed mediastinal and hilar lymphadenopathy. A PET scan revealed increased metabolic activity in the lymph nodes and pulmonary lesions. Fiberoptic bronchoscopy and endobronchial ultrasound lymph node sampling demonstrated granulomatous inflammation without malignant cells. The patient underwent a therapeutic trial of steroids with clinical improvement of symptoms and decreased hypermetabolic activity in chest lesions, as well as a decrease in tumor markers. The coexistence of sarcoidosis and breast cancer is rare; sarcoidosis can coexist, precede, or appear after breast cancer. In both conditions, tumor markers and PET avidity are seen, which makes diagnosis and management challenging. In case of ambiguity, biopsy is crucial. This case underscores the importance of integrating clinical, pathological, and imaging data to reach an accurate diagnosis and consider a therapeutic trial of steroids. Furthermore, the early PET response to treatment can be pivotal in differentiating between sarcoidosis and malignancy, especially in complex clinical scenarios. Proper differentiation is paramount to avoid therapeutic missteps and ensure appropriate patient management.

An unusual case of metastatic trophoblastic neoplasm presenting with diffuse cystic lung disease and pulmonary artery pseudoaneurysms in a teenager.

Diffuse cystic lung diseases (DCLDs) are a diverse group of lung disorders characterized by the presence of multiple air filled cysts within the lung tissue. These cysts are thin walled and surrounded by normal lung tissue. In adults, DCLD can be associated with various conditions such as lymphangioleiomyomatosis (LAM), Langerhans cell histiocytosis, cancers, and more. In children, DCLD is often linked to lung developmental abnormalities, with bronchopulmonary dysplasia being a common cause. Patients with pulmonary cysts are typically asymptomatic, but some may experience mild symptoms or pneumothorax. While DCLD in children is rarely due to malignancy, metastatic lung disease can be a cause. It is important for clinicians to be aware of the possibility of metastatic lung disease when encountering DCLD.

Differentiation of Hamartomas and Malignant Lung Tumors in Single-Phased Dual-Energy Computed Tomography.

This study investigated the efficacy of single-phase dual-energy CT (DECT) in differentiating pulmonary hamartomas from malignant lung lesions using virtual non-contrast (VNC), iodine, and fat quantification. Forty-six patients with 47 pulmonary lesions (mean age: 65.2 ± 12.1 years; hamartomas-to-malignant lesions = 22:25; male: 67%) underwent portal venous DECT using histology, PET-CT and follow-up CTs as a reference. Quantitative parameters such as VNC, fat fraction, iodine density and CT mixed values were statistically analyzed. Significant differences were found in fat fractions (hamartomas: 48.9%; malignancies: 22.9%; p ≤ 0.0001) and VNC HU values (hamartomas: -20.5 HU; malignancies: 17.8 HU; p ≤ 0.0001), with hamartomas having higher fat content and lower VNC HU values than malignancies. CT mixed values also differed significantly (p ≤ 0.0001), but iodine density showed no significant differences. ROC analysis favored the fat fraction (AUC = 96.4%; sensitivity: 100%) over the VNC, CT mixed value and iodine density for differentiation. The study concludes that the DECT-based fat fraction is superior to the single-energy CT in differentiating between incidental pulmonary hamartomas and malignant lesions, while post-contrast iodine density is ineffective for differentiation.

Complications of lymphangioleiomyomatosis in pregnancy: a case report and review of the literature.

Lymphangioleiomyomatosis is a rare cystic lung disease primarily affecting premenopausal females and may be exacerbated by pregnancy. We conducted a literature review of lymphangioleiomyomatosis during pregnancy with a specific focus on related maternal morbidity and obstetrical outcomes. We also report a case of lymphangioleiomyomatosis that presented as an acute spontaneous pneumothorax in the third trimester of pregnancy, followed by significant maternal morbidity. A 37-year-old primigravid woman who presented at 29 weeks 5 days gestation with chest pain was diagnosed with spontaneous pneumothorax. Further imaging demonstrated cystic lung lesions and renal angiomyolipomas. She developed severe abdominal pain concerning for placental abruption that led to an urgent cesarean delivery at 30 weeks 2 days gestation. Her course was complicated by recurrent pneumothorax, superimposed preeclampsia, and significant ileus and bowel dilation complicated by bowel perforation. For patients with a clinical suspicion of lymphangioleiomyomatosis in pregnancy, prompt recognition, diagnosis, and referral to appropriate multidisciplinary subspecialists is critical to mitigate complications and optimize outcomes both during and after pregnancy.

Dosimetry and treatment efficiency of SBRT using TaiChiB radiotherapy system for two-lung lesions with one overlapping organs at risk.

Purpose: This study aims to assess the dosimetry and treatment efficiency of TaiChiB-based Stereotactic Body Radiotherapy (SBRT) plans applying to treat two-lung lesions with one overlapping organs at risk. Methods: For four retrospective patients diagnosed with two-lung lesions each patient, four treatment plans were designed including Plan Edge, TaiChiB linac-based, RGS-based, and a linac-RGS hybrid (Plan TCLinac, Plan TCRGS, and Plan TCHybrid). Dosimetric metrics and beam-on time were employed to evaluate and compare the TaiChiB-based plans against Plan Edge. Results: For Conformity Index (CI), Plan TCRGS outperformed all other plans with an average CI of 1.06, as opposed to Plan Edge's 1.33. Similarly, for R50 %, Plan TCRGS was superior with an average R50 % of 3.79, better than Plan Edge's 4.28. In terms of D2 cm, Plan TCRGS also led with an average of 48.48%, compared to Plan Edge's 56.25%. For organ at risk (OAR) sparing, Plan TCRGS often displayed the lowest dosimetric values, notably for the spinal cord (Dmax 5.92 Gy) and lungs (D1500cc 1.00 Gy, D1000cc 2.61 Gy, V10 Gy 15.14%). However, its high Dmax values for the heart and great vessels sometimes exceeded safety thresholds. Plan TCHybrid presented a balanced approach, showing doses comparable to or better than Plan Edge without crossing safety limits. In terms of beam-on time, Plan TCLinac emerged as the most efficient treatment option in three out of four cases, followed closely by Plan Edge in one case. Plan TCRGS, despite its dosimetric advantages, was the least efficient, recording notably longer beam-on times, with a peak at 33.28 minutes in Case 2. Conclusion: For patients with two-lung lesions treated by SBRT whose one lesion overlaps with OARs, the Plan TCHybrid delivered by TaiChiB digital radiotherapy system can be recommended as a clinical option.

Application of rapid on-site evaluation combined with flexible bronchoscopy in the diagnosis of lung lesions.

BACKGROUND: Pathology is considered the gold standard for the diagnosis of lung lesions, but the pathological result is relatively lagging and cannot provide real-time guidance for the biopsy procedure. OBJECTIVE: To investigate the potential application of rapid on-site evaluation (ROSE) during flexible bronchoscopy (FB) in the evaluation and diagnosis of lung lesions. PATIENTS AND METHODS: Consecutive patients who underwent FB for the diagnosis of lung lesions between August 2022 and February 2023 were included in this retrospective study. 294 patients underwent FB with ROSE, while 304 patients underwent FB without ROSE. The final pathological results and the number of patients undergoing repeat biopsies were recorded in both groups. Specifically, we conducted separate statistical analysis for patients undergoing different biopsy methods, including the endobronchial biopsy (EBB), radial probe endobronchial ultrasound transbronchial lung biopsy with guide sheath (r-EBUS-GS-TBLB), and the endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) to study the detailed roles that ROSE plays under different biopsy methods. RESULTS: The adequacy rate of biopsy specimens from the non-ROSE group was significantly lower than that of the ROSE group (259/281 = 92.17 % vs. 263/268 = 98.13 %, p = 0.001). Meanwhile, fewer patients underwent repeat biopsies in the ROSE group compared to the non-ROSE group (2/294 = 0.68 % vs. 10/304 = 3.29 %, p = 0.023). For the ROSE group, the consistency between ROSE diagnoses and final pathological diagnoses was 94.40 % (κ = 0.886), with 95.58 % for benign diseases and 93.55 % for malignant diseases. CONCLUSION: The utility of ROSE during FB increases the adequacy rate of biopsy specimens and thus decreases the need for repeat biopsies in patients with lung lesions to get a definite diagnosis. Moreover, the high consistency between ROSE diagnoses and final pathological diagnoses suggests that ROSE is a reliable tool for optimizing the diagnosis of lung lesions.

Transbronchial cryobiopsy for small peripheral pulmonary lesions using endobronchial ultrasonography and an ultrathin bronchoscope.

BACKGROUND: Transbronchial biopsy using an ultrathin bronchoscope (UTB) has a high diagnostic yield for peripheral pulmonary lesions (PPLs). When combined with peripheral transbronchial needle aspiration (pTBNA), it improves the diagnostic yield of "adjacent to" radial endobronchial ultrasonography (rEBUS) findings. However, pTBNA is a complicated technique, and the specimen volume is often inadequate for diagnostic and multiplex analyses. Recently, transbronchial cryobiopsy (TBCB) using a 1.1-mm cryoprobe that could be inserted into an UTB has been available. We investigated whether TBCB combined with forceps biopsy using a 1.1-mm cryoprobe with an UTB improved the diagnostic yield of "adjacent to" lesions. METHODS: The data of 66 consecutive patients who underwent TBCB and forceps biopsy using UTB (hemostasis using two-scope method) under rEBUS for small PPLs (≤30 mm) were retrospectively analyzed. The histological diagnosis rate using TBCB and forceps biopsy, TBCB alone, or forceps biopsy alone was compared between cases where the rEBUS probe was "within" and "adjacent to" lesions. RESULTS: The diagnosis rate using TBCB and forceps biopsy was 81.8 % for all lesions ("within" vs. "adjacent to" cases: 88.4 % vs. 69.6 %; p = 0.093). The corresponding rate using TBCB alone was 80.3 % (86.0 % vs. 69.6 %; p = 0.19), and that using forceps biopsy alone was 62.1 % (74.4 % vs. 39.1 %; p = 0.008). Bleeding leading to discontinuation of the examination occurred in four (6.1 %) patients; however, in all cases, bleeding could be controlled endoscopically. CONCLUSION: Forceps biopsy with TBCB during ultrathin bronchoscopy for small PPLs improved the diagnostic yield when the lesions were adjacent to the rEBUS probe.

DNA image cytometry of bronchial washing as a diagnostic adjunct to radial endobronchial ultrasound-guided sampling of peripheral lung lesions: A single center prospective study.

OBJECTIVE: The objective of this study is to study the adjunct role of combining DNA aneuploidy analysis with radial endobronchial ultrasound (R-EBUS)-guided sampling for diagnosis of peripheral lung lesions (PPLs). METHOD: A single-center prospective study was conducted in patients undergoing R-EBUS-guided sampling for PPLs. DNA image cytometry (DNA-ICM) was used to analyze DNA aneuploidy in bronchial washing from the bronchial segment of the PPL. Clinical information, R-EBUS data, pathology, DNA-ICM results, and follow-up data were analyzed. Sensitivity, specificity, and predictive values for R-EBUS-guided sampling, DNA-ICM, and the two methods combined were measured. Binary logistic regression was performed to determine influencing factors on diagnostic positivity rate. Receiver operating characteristic (ROC) curve analysis was used to determine the optimal cutoff point for DNA-ICM. RESULTS: A total of 101 patients were enrolled. Sixty-four (63.4%) patients had confirmed malignant tumor, of whom 33 were confirmed by R-EBUS-guided sampling (biopsy and/or bronchial brush and wash cytology), and 31 by surgery or percutaneous lung biopsy. Thirty-seven patients were finally considered to have benign lesions, based on clinical information and 1-year follow-up. The sensitivity for malignant disease was 51.6% by R-EBUS, and specificity was 100%. DNA-ICM had a sensitivity of 67.2% and a specificity of 86.5%. When combining the two methods, sensitivity increased to 78.1% and specificity was 86.5%. Lesion size and whether the R-EBUS probe was located in the lesion were significantly associated with positivity rate of the combined methods. The optimal cutoff point for DNA-ICM was 5c for max DNA content, and 1 for aneuploid cell count (sensitivity 67.2%, specificity 86.5%, accuracy 63.4%). CONCLUSION: In malignant PPLs, DNA-ICM combined with R-EBUS-guided sampling can improve diagnostic positivity compared with either method alone.

Meta-Analysis and Systematic Literature Review of the Genus Pneumocystis in Pet, Farm, Zoo, and Wild Mammal Species.

A systematic literature search on Pneumocystis in 276 pet, farm, zoo, and wild mammal species resulted in 124 publications originating from 38 countries that were analyzed descriptively and statistically, for which inclusion and exclusion criteria were exactly defined. The range of recorded Pneumocystis prevalence was broad, yet in half of the citations a prevalence of ≤25% was documented. Prevalence was significantly dependent on the method used for Pneumocystis detection, with PCR revealing the highest percentages. Pet animals showed the lowest median Pneumocystis prevalence, followed by farm, wild, and zoo animals. In contrast, pet and farm animals showed higher proportions of high-grade infection levels compared to zoo and wild mammals. Only in individual cases, all of them associated with severe Pneumocystis pneumonia, was an underlying immunosuppression confirmed. Acquired immunosuppression caused by other diseases was frequently discussed, but its significance, especially in highly immunosuppressive cases, needs to be clarified. This meta-analysis supported a potential influence of the social and environmental factors of the host on Pneumocystis transmission in wildlife, which must be further elucidated, as well as the genetic diversity of the fungus.

The effect of combining different sampling tools on the performance of electromagnetic navigational bronchoscopy for the evaluation of peripheral lung lesions and factors associated with its diagnostic yield.

BACKGROUND: We assessed the performance of Electromagnetic navigational bronchoscopy (ENB) as a standalone diagnostic technique and the performance of different sampling tools used during the procedure. METHODS: We recruited 160 consecutive patients who underwent ENB for peripheral lung lesions (PLL) at a tertiary care centre. The diagnostic performance of ENB and sampling tools was assessed using a logistic regression model and a ROC-curve in which the dependent variable was diagnostic success. A multivariate model was built to predict diagnostic success before performing ENB to select the best candidates for the procedure. RESULTS: Most patients with PLLs in the study were male (65%), with a mean age of 67.9 years. The yield was 66% when the most common techniques were used together as suction catheter + transbronchial biopsy forceps (TBBx) + bronchoalveolar lavage + bronchial washing (p < 0.001) and increased to 69% when transbronchial needle aspiration (TBNA) and cytology brush were added (p < 0.001). Adding diagnostic techniques such as TBBx and TBNA resulted in an increase in diagnostic performance, with a statistically significant trend (p = 0.002). The logistic model area-under the ROC-curve for diagnostic success during ENB was 0.83 (95% CI:0.75-0.90; p < 0.001), and a logit value ≥ 0.12 was associated with ≥ 50% probability of diagnostic success. CONCLUSIONS: ENB, as a stand-alone diagnostic tool for the evaluation of PLLs when performed by experienced operators using a multi-modality technique, has a good diagnostic yield. The probability of having a diagnostic ENB could be assessed using the proposed model.

Pediatric pulmonary multisystem langerhans cell histiocytosis: does lung lesion severity affect the outcome?

BACKGROUND: The pediatric pulmonary multisystem Langerhans cell histiocytosis (PPM LCH) is associated with either low risk or high risk organ(s). The nodulo-cystic lung lesions although pathognomonic, yet are very variable in severity and remain a source of controversy in certifying pulmonary LCH diagnosis. The study aimed to examine the prognostic value of clinical respiratory manifestations and radiological lung lesions severity. This is through associating a CT chest triad of bilateral, extensive and diffuse lesions. It is a retrospective study of 350 LCH patients who received systemic treatment at Children's Cancer Hospital Egypt during the period from 2007 to 2020. RESULTS: Sixty-seven patients (67/350-19.1%) had PPM LCH at presentation. Severe lung lesions were present in 24 of them. The median follow-up period was 61 months (IQR: 3.4-8.3). The 5-year overall survival (OS) and event free survival (EFS) was 89% and 56.6% respectively. The EFS, for severe radiological lesions triad was 38% ± 20.7 versus 66% ± 16.2 for non-severe lesions triad p 0.002, while for presence of chest X-ray changes 27% ± 22.344 versus absence of chest X ray changes 66% ± 14.7 p 0.001, for clinical respiratory manifestations 13% ± 13.9 versus none 62% ± 22.9 p < 0.001, for RO- with severe lung lesions 47% ± 30.4 versus RO- without severe lung lesions 69% ± 5.9 p 0.04. There was a tendency for the independent prognostic impact of severe lung involvement; aHR = 1.7 (95% CI 0.92-3.13, p = 0.09). CONCLUSION: Although the lung is a low -risk organ per se in LCH, our study demonstrates a non negligeable prognostic impact of severe lung involvement in the risk stratification of pediatric LCH. This warrants further study and external validation.

Unexpected diffuse lung lesions in a patient with pulmonary alveolar proteinosis: A case report.

BACKGROUND: Pulmonary alveolar proteinosis (PAP) often presents nonspecifically and can be easily confused with: (1) Idiopathic interstitial lung fibrosis; (2) alveolar carcinoma; (3) pulmonary tuberculosis; and (4) other lung diseases such as viral pneumonia, mycoplasma pneumonia, and chlamydial pneumonia. CASE SUMMARY: Diagnosis: In this case, a patient was diagnosed with PAP through transbronchial cryobiopsy (TBCB) and quantitative metagenomic next-generation sequencing, which confirmed the impairment of surfactant turnover as the underlying cause of PAP. Interventions: High-volume total lung lavage was performed for this patient. Outcomes: The patient's clinical condition had improved significantly by the 6-month follow-up, with a 92% finger oxygen saturation. A repeat chest computed tomography scan revealed scattered patchy ground-glass shadows in both lungs, which was consistent with alveolar protein deposition but with a lower density than in the radiograph from October 23, 2022. CONCLUSION: TBCB has unique advantages in diagnosing atypical alveolar protein deposition, particularly for enabling the early detection of PAP. This information can help patients take preventive measures to prevent or halt PAP development by avoiding dusty environments and seeking treatment with total lung lavage and inhaled granulocyte macrophage colony-stimulating factor.