Accuracy of Ultralow-Dose Photon-counting CT in the Detection of Lung Changes after Lung Transplant.

Background Data on the diagnostic accuracy of ultralow-dose (ULD) CT protocols for periodic surveillance in recipients of lung transplant are lacking. Purpose To assess the potential for radiation dose reduction using ULD photon-counting CT (PCT) to detect lung abnormalities in recipients of lung transplant during repeat CT follow-up. Materials and Methods Consecutive adult recipients of lung transplant undergoing same-day standard-of-care low-dose (LD) and ULD PCT from March 2023 to May 2023 were prospectively included. The ULD protocols were performed with two target effective doses comprising 20% (hereafter, ULD1) and 10% (hereafter, ULD2) of the standard LD protocol. The 1-mm reconstructions were reviewed by three readers. Subjective image quality, the visibility of certain anatomic structures (using a five-point Likert scale), and the presence of lung abnormalities were independently assessed. The χ2 or t tests were used to evaluate differences between the ULD1 and ULD2 protocols. Results A total of 82 participants (median age, 64 years [IQR, 54-69 years]; 47 male) were included (41 participants for each ULD protocol). The mean effective doses per protocol were 1.41 mSv ± 0.44 (SD) for LD, 0.26 mSv ± 0.08 for ULD1, and 0.17 mSv ± 0.04 for ULD2. According to three readers, the subjective image quality of the ULD images was deemed diagnostic (Likert score ≥3) in 39-40 (ULD1) and 40-41 (ULD2) participants, and anatomic structures could be adequately visualized (Likert score ≥3) in 33-41 (ULD1) and 34-41 (ULD2) participants. The detection accuracy for individual lung anomalies exceeded 70% for both ULD protocols, except for readers 1 and 3 detecting proximal bronchiectasis and reader 3 detecting bronchial wall thickening and air trapping. No evidence of a statistically significant difference in noise (P = .96), signal-to-noise ratio (P = .77), or reader accuracy (all P ≥ .05) was noted between the ULD protocols. Conclusion ULD PCT was feasible for detecting lung abnormalities following lung transplant, with a tenfold radiation dose reduction. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Ciet in this issue.

Right lung hypoplasia associated with polysplenia: A case report and literature review.

Pulmonary agenesis is a very rare congenital abnormality that can be missed in a routine radiographic examination, which delays diagnosis until adulthood. It can be associated with other congenital malformations, such as valvular heart disease and gastrointestinal organ abnormalities. Computed tomography (CT) is a useful modality for its better delineation of pulmonary and vascular structures. The reported case here is for an adult male who presented with dextroposition of the heart and was found to have a unilobed right lung associated with polysplenia. This has not been previously reported in the literature.

Longitudinal registration of thoracic CT images with radiation-induced lung diseases: A divide-and-conquer approach based on component structure wise registration using coherent point drift.

BACKGROUND AND OBJECTIVE: Registration of pulmonary computed tomography (CT) images with radiation-induced lung diseases (RILD) was essential to investigate the voxel-wise relationship between the formation of RILD and the radiation dose received by different tissues. Although various approaches had been developed for the registration of lung CTs, their performances remained clinically unsatisfactory for registration of lung CT images with RILD. The main difficulties arose from the longitudinal change in lung parenchyma, including RILD and volumetric change of lung cancers, after radiation therapy, leading to inaccurate registration and artifacts caused by erroneous matching of the RILD tissues. METHODS: To overcome the influence of the parenchymal changes, a divide-and-conquer approach rooted in the coherent point drift (CPD) paradigm was proposed. The proposed method was based on two kernel ideas. One was the idea of component structure wise registration. Specifically, the proposed method relaxed the intrinsic assumption of equal isotropic covariances in CPD by decomposing a lung and its surrounding tissues into component structures and independently registering the component structures pairwise by CPD. The other was the idea of defining a vascular subtree centered at a matched branch point as a component structure. This idea could not only provide a sufficient number of matched feature points within a parenchyma, but avoid being corrupted by the false feature points resided in the RILD tissues due to globally and indiscriminately sampling using mathematical operators. The overall deformation model was built by using the Thin Plate Spline based on all matched points. RESULTS: This study recruited 30 pairs of lung CT images with RILD, 15 of which were used for internal validation (leave-one-out cross-validation) and the other 15 for external validation. The experimental results showed that the proposed algorithm achieved a mean and a mean of maximum 1 % of average surface distances <2 and 8 mm, respectively, and a mean and a maximum target registration error <2 mm and 5 mm on both internal and external validation datasets. The paired two-sample t-tests corroborated that the proposed algorithm outperformed a recent method, the Stavropoulou's method, on the external validation dataset (p < 0.05). CONCLUSIONS: The proposed algorithm effectively reduced the influence of parenchymal changes, resulting in a reasonably accurate and artifact-free registration.

Efficacy of Lung Ultrasound vs Chest X-Ray in Detecting Lung Consolidation and Edema in Premature Infants in the NICU.

BACKGROUND The incidence of lung diseases in premature newborns is significantly higher than in full-term newborns due to their underdeveloped lungs. Ultrasound and X-ray are commonly-used bedside examinations in neonatology. This study primarily compares the efficacy of chest X-ray (CXR) and lung ultrasound (LUS) images in evaluating lung consolidation and edema in premature newborns at Neonatal Intensive Care Units (NICU). MATERIAL AND METHODS A retrospective analysis was conducted on LUS and CXR examination results, along with clinical records of premature newborns admitted to our hospital's NICU from November 1, 2019, to December 31, 2021. CXR and LUS scans were performed on the same newborn within a day. We evaluated the consolidations and edema by interpreting the CXR and LUS images, then compared the findings. RESULTS Out of 75 cases, 34 showed lung consolidations on LUS (45%), while only 14 exhibited consolidations on CXR (19%). The detection rate of consolidations by LUS was significantly higher compared to CXR (34/75 vs 14/75, P<0.001). Differences were observed between the 2 bedside examinations in identifying consolidations, with some cases seen only on LUS. CXR struggled to accurately assess the severity of lung edema visible on LUS, showing significant disparity in detecting interstitial edema (53/75 vs 21/75, P<0.001). CONCLUSIONS LUS outperforms chest CXR for bedside assessment of lung consolidation and edema in premature newborns.

Deep-learning model accurately classifies multi-label lung ultrasound findings, enhancing diagnostic accuracy and inter-reader agreement.

Despite the increasing use of lung ultrasound (LUS) in the evaluation of respiratory disease, operators' competence constrains its effectiveness. We developed a deep-learning (DL) model for multi-label classification using LUS and validated its performance and efficacy on inter-reader variability. We retrospectively collected LUS and labeled as normal, B-line, consolidation, and effusion from patients undergoing thoracentesis at a tertiary institution between January 2018 and January 2022. The development and internal testing involved 7580 images from January 2018 and December 2020, and the model's performance was validated on a temporally separated test set (n = 985 images collected after January 2021) and two external test sets (n = 319 and 54 images). Two radiologists interpreted LUS with and without DL assistance and compared diagnostic performance and agreement. The model demonstrated robust performance with AUCs: 0.93 (95% CI 0.92-0.94) for normal, 0.87 (95% CI 0.84-0.89) for B-line, 0.82 (95% CI 0.78-0.86) for consolidation, and 0.94 (95% CI 0.93-0.95) for effusion. The model improved reader accuracy for binary discrimination (normal vs. abnormal; reader 1: 87.5-95.6%, p = 0.004; reader 2: 95.0-97.5%, p = 0.19), and agreement (k = 0.73-0.83, p = 0.01). In conclusion, the DL-based model may assist interpretation, improving accuracy and overcoming operator competence limitations in LUS.

Extremely Rare Coexistence of Peripherally Located Mucous Gland Adenoma and Pulmonary Chondroid Hamartoma.

Pulmonary mucous gland adenomas (MGAs) originating in mucous-secreting cells in the bronchi are extremely rare benign tumours. Pulmonary chondroid hamartomas (PCHs) are the most common benign neoplasms of mesenchymal origin of the lung. This study reports an unusual case where MGA and PCH coexisted in a peripheral intra-parenchymal location. A patient with a 1-cm non-specific nodule in the left lung on a computed tomography scan underwent wedge resection. Microscopically, mesenchymal elements consisting of fat and cartilage tissue were observed. Mucous glands were present around these mesenchymal elements. No cellular atypia or mitosis was observed. This allowed for complete treatment without the need for a segmentectomy.

Diagnostic yield and safety of diagnostic techniques for pulmonary lesions: systematic review, meta-analysis and network meta-analysis.

BACKGROUND: With recent advancements in bronchoscopic procedures, data on the best modality to sample peripheral pulmonary lesions (PPLs) is lacking, especially comparing bronchoscopy with computed tomography-guided transthoracic biopsy or needle aspiration (CT-TBNA). METHODS: We performed a meta-analysis, pairwise meta-analysis and network meta-analysis on studies reporting diagnostic yield and complications with the use of CT-TBNA, radial endobronchial ultrasound (rEBUS), virtual bronchoscopy (VB), electromagnetic navigation (EMN) or robot-assisted bronchoscopy (RAB) to sample PPLs. The primary outcome was diagnostic yield and the secondary outcome was complications. We estimated the relative risk ratios using a random-effects model and used the frequentist approach for the network meta-analysis. We performed extensive analysis to assess the heterogeneity including reporting bias, publication bias, subgroup and meta-regressional analysis. We assessed the quality of the studies using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) and QUADAS-Comparative (QUADAS-C). RESULTS: We included 363 studies. The overall pooled diagnostic yield was 78.1%, the highest with CT-TBNA (88.9%), followed by RAB (84.8%) and the least with rEBUS (72%). In the pairwise meta-analysis, only rEBUS showed inferiority to CT-TBNA. The network meta-analysis ranked CT-TBNA as likely the most effective approach followed by VB, EMN and RAB, while rEBUS was the least effective, with a low-GRADE certainty. CT-TBNA had the highest rate of complications. CONCLUSION: Although CT-TBNA is the most effective approach to sample PPLs, RAB has a comparable diagnostic yield with a lesser complication rate. Further prospective studies are needed comparing CT-TBNA and RAB.

A versatile role for lung ultrasound in systemic autoimmune rheumatic diseases related pulmonary involvement: a narrative review.

Systemic autoimmune rheumatic diseases (SARDs) related pulmonary disease is highly prevalent, with variable clinical presentation and behavior, and thus is associated with poor outcomes and negatively impacts quality of life. Chest high resolution computed tomography (HRCT) is still considered a fundamental imaging tool in the screening, diagnosis, and follow-up of pulmonary disease in patients with SARDs. However, radiation exposure, economic burden, as well as lack of point-of-care CT equipment limits its application in some clinical situation. Ultrasound has found a place in numerous aspects of the rheumatic diseases, including the vasculature, skin, muscle, joints, kidneys and in screening for malignancies. Likewise it has found increasing use in the lungs. In the past two decades, lung ultrasound has started to be used for pulmonary parenchymal diseases such as pneumonia, pulmonary edema, lung fibrosis, pneumothorax, and pleural lesions, although the lung parenchymal was once considered off-limits to ultrasound. Lung ultrasound B-lines and irregularities of the pleural line are now regarded two important sonographic artefacts related to diffuse parenchymal lung disease and they could reflect the lesion extent and severity. However, its role in the management of SARDs related pulmonary involvement has not been fully investigated. This review article will focus on the potential applications of lung ultrasound in different pulmonary scenarios related with SARDs, such as interstitial lung disease, diffuse alveolar hemorrhage, diaphragmatic involvement, and pulmonary infection, in order to explore its value in clinical daily practice.

Congenital Lung Anomalies in Adults.

Congenital lung anomaly (CLA) refers to a rare group of malformations that are typically identified prenatally or in early childhood. However, a significant proportion of cases evade detection until adulthood and either are incidentally discovered or manifest with symptoms of recurrent respiratory infection or pulmonary hemorrhage. While most CLAs have characteristic imaging findings at CT and MRI, they remain a diagnostic challenge due to the infrequency with which they are encountered in adults. Radiologists frequently play a pivotal role in suggesting the diagnosis and guiding appropriate management strategies, and recognition of characteristic imaging patterns is crucial for accurate diagnosis. The authors examine the imaging appearances and clinical manifestations in adult patients with CLA, with a focus on patients who have bronchopulmonary involvement and those with combined bronchopulmonary and vascular anomalies. Entities discussed include bronchogenic cyst, bronchial atresia, congenital lobar overinflation, congenital pulmonary airway malformation, proximal interruption of the pulmonary artery, bronchopulmonary sequestration, hypogenetic lung syndrome, placental transmogrification of the lung, and hybrid lesions. Common complications that may arise in these patients are discussed and illustrated. ©RSNA, 2024 Supplemental material is available for this article.

Ultrasound evaluation in the postoperative period for surgical treatment of thoracic infectious and inflammatory diseases.

OBJECTIVE: This study aims to evaluate the role of TUSG in the postoperative period and the detection of early complications after surgical treatment, pulmonary resection, or decortication for infectious and inflammatory thoracic diseases, comparing with the standard method (Chest Radiography ‒ CXR). METHODS: Prospective non-randomized self-controlled study. Twenty-one patients over 16 years of age have undergone surgical treatment of inflammatory and infectious lung diseases. These patients were followed up with CXR and TUSG (performed on the 1st and 3rd postoperative days and/or after the chest tube removal). RESULTS: Both exams demonstrated similar results regarding their ability to safely predict the adequate moment for chest drain removal. TUSG allowed chest drain removal in 30% of cases and CXR in 34%. Statistical analysis demonstrates that both exams have similar capabilities in detecting postoperative changes in the pleural space. However, the authors report that TUSG is statistically more accurate in detecting subcutaneous emphysema than CXR (p = 0.037, Kappa [κ = 0.3068]). The analysis of other parameters showed no statistical difference. CONCLUSION: The authors conclude that TUSG in trained hands is equivalent to CXR in searching for postoperative complications regarding the surgical treatment of infectious and inflammatory thoracic diseases and can be used as a complement, and not a substitute, to CXR, when CCT is not feasible, or a more urgent diagnosis is needed.

Improving diagnostic strategies in bronchoscopy for peripheral pulmonary lesions.

INTRODUCTION: In the past two decades, bronchoscopy of peripheral pulmonary lesions (PPLs) has improved its diagnostic yield due to the combination of various instruments and devices. Meanwhile, the application is complex and intertwined. AREAS COVERED: This review article outlines strategies in diagnostic bronchoscopy for PPLs. We summarize the utility and evidence of key instruments and devices based on the results of clinical trials. Future perspectives of bronchoscopy for PPLs are also discussed. EXPERT OPINION: The accuracy of reaching PPLs by bronchoscopy has improved significantly with the introduction of combined instruments such as navigation, radial endobronchial ultrasound, digital tomosynthesis, and cone-beam computed tomography. It has been accelerated with the advent of approach tools such as newer ultrathin bronchoscopes and robotic-assisted bronchoscopy. In addition, needle aspiration and cryobiopsy provide further diagnostic opportunities beyond forceps biopsy. Rapid on-site evaluation may also play an important role in decision making during the procedures. As a result, the diagnostic yield of bronchoscopy for PPLs has improved to a level comparable to that of transthoracic needle biopsy. The techniques and technologies developed in the diagnosis will be carried over to the next step in the transbronchial treatment of PPLs in the future.

Thoracic ultrasound in guiding management of respiratory disease.

INTRODUCTION: The use of ultrasound in respiratory disease has evolved substantially over the past two decades. From a test done to confirm the safe site of pleural fluid drainage, thoracic ultrasound has become a point-of-care test that guides the management of patients on respiratory wards, in clinics and endoscopy. AREAS COVERED: This review overviews the process of ultrasound examination in the chest. It then delves into specific disease areas (pleural disease, lung disease, diaphragm disease, and invasive procedures) to highlight how thoracic ultrasound is being used to refine management. The review concludes with discussion on the training curricula and assessment tools for competency in thoracic ultrasound. Being a scoping review, literature searches were conducted on PubMed using relevant search terms. EXPERT OPINION: In addition to its current uses, there are many avenues where thoracic ultrasound will soon be beneficial. Recent studies show promising roles in areas such as patient-tailored guidance of pleurodesis and non-invasively predicting lung re-expansion after pleural fluid drainage. In addition, auxiliary tools such as contrast-enhanced ultrasound and elastography are proving useful in identifying the etiology and directing the successful sampling of pleural and lung lesions. Studies are also exploring the utility of sonographic biomarkers such as echogenicity and septations to predict outcomes in pleural disease.

Exploring pulmonary involvement in newly diagnosed rheumatoid arthritis, and psoriatic arthritis: a single center study.

OBJECTIVES: This cross-sectional study aimed to determine the prevalence, manifestation, and risk factors of pulmonary involvement in newly diagnosed, untreated rheumatoid arthritis (RA) and psoriatic arthritis (PsA) patients, and to evaluate the efficacy of various diagnostic tools in screening for pulmonary involvement. METHODS: Untreated, newly diagnosed patients with RA and PsA underwent an extensive multimodal diagnostic approach including clinical and laboratory assessment, pulmonary function tests, and chest radiography. RESULTS: We recruited 50 arthritis patients (26 RA, 24 PsA) and 26 control subjects. Respiratory symptoms were found in 36.0 % of arthritis patients and 11.5 % of controls (p = 0.031). Pathologically reduced breathing width (< 3.0 cm) was significantly more common in arthritis patients (64.0 %) than in controls (23.1 %) (p < 0.001). Pulmonary function test results did not differ significantly between groups. Chest radiography revealed pulmonary involvement in 37.0 % of arthritis patients, higher in RA (50.0 %) than in PsA (22.7 %). Notably, only 35.3 % of arthritis patients with radiographic pulmonary involvement were symptomatic, with 64.7 % being asymptomatic. Radiographic pulmonary involvement was associated with advanced age (p = 0.002) and increased rheumatoid factor levels (p = 0.024). CONCLUSION: Our research underscores the significant prevalence of largely asymptomatic pulmonary involvement in newly diagnosed RA and PsA patients. These findings highlight the importance of an early, multidisciplinary screening approach, particularly for high-risk individuals. Further large-scale studies are needed to develop comprehensive screening protocols to improve early detection and treatment of pulmonary involvement in arthritis.

Retrospective cohort study identifying pulmonary complications in a cohort of patients with systemic lupus erythematosus.

BACKGROUND: Systemic lupus erythematosus (SLE) is a systemic autoimmune disease with multi organ involvement. One of the most common manifestations is pulmonary disease with a reported prevalence between 5%-90%. PURPOSE: Given this wide range of prevalence, there is a need to more closely define types of pulmonary disease in SLE and associated risk factors. RESEARCH DESIGN: We sought to characterize the presentation of pulmonary manifestations in an established SLE cohort using electronic health record data. STUDY SAMPLE: All patients were >18 years of age and had confirmed SLE by a rheumatologist using SLICC or 2019 ACR/EULAR classification criteria. 220 patients with imaging were included in this study; average age was 42.5 years, 86.7% identified as female, 60.5% identified as white, 37.3% as Black, and 1.82% as Asian. ANALYSIS: Generalized estimating equations were utilized to analyze the data, accounting for its repeated measured nature. RESULTS: We found an association between smoking (present/prior smoker) and radiologist reported disease on computerized tomography (CT) scan, as well as an association between smoking (present/prior smoker), older age, and male sex with having pulmonary disease identified on chest X-ray. The most common findings on CT and X-ray were increased lung density (24%, 12%) and atelectasis (18%, 10%). The most common disease found on CT was pleural effusion (24%) and mediastinal/axillary lymphadenopathy (16%). CONCLUSION: While our study is limited by the retrospective nature, our results show that certain factors, namely smoking, older age, or male sex should prompt clinicians to have a higher suspicion for lung disease in SLE patients.

A pilot study of optical coherence tomography-guided transbronchial biopsy in peripheral pulmonary lesions.

BACKGROUND: The diagnosis of peripheral pulmonary lesions (PPLs) remains challenging. Despite advancements in guided transbronchial biopsy (TBB) techniques, diagnostic yields haven't reached ideal levels. Optical coherence tomography (OCT) has been developed for application in pulmonary diseases, yet no data existed evaluating effectiveness in diagnosing PPLs. RESEARCH DESIGN AND METHODS: This study included patients who underwent OCT and radial endobronchial ultrasound (R-EBUS)-guided TBB. OCT and R-EBUS imaging features were analyzed to differentiate between benign and malignant PPLs and subtypes of lung cancer. RESULTS: A total of 89 patients were included in this study. The diagnostic yield of OCT-guided TBB stood at 56.18%, R-EBUS-guided TBB was 83.15% (P<0.01). The accuracy of OCT to judge the nature of lesions was 92.59%, while R-EBUS was 77.92%. The accuracy of OCT in predicting squamous carcinoma (SCC) and adenocarcinoma were both 91.30%. CONCLUSIONS: Although the diagnostic yield of OCT-guided TBB fell short of that achieved by R-EBUS, OCT possessed the capability to judge the nature of lesions and guide the pathological classification of malignant lesions. Further extensive prospective studies are necessary to thoroughly assess the characteristics of this procedure. CLINICAL TRIAL REGISTRATION: https://register.clinicaltrials.gov/ identifier is NCT06419114.

Fuzzy lattices assisted EJAYA Q-learning for automated pulmonary diseases classification.

This work proposes a novel technique called Enhanced JAYA (EJAYA) assisted Q-Learning for the classification of pulmonary diseases, such as pneumonia and tuberculosis (TB) sub-classes using chest x-ray images. The work introduces Fuzzy lattices formation to handle real time (non-linear and non-stationary) data based feature extraction using Schrödinger equation. Features based adaptive classification is made possible through the Q-learning algorithm wherein optimal Q-values selection is done via EJAYA optimization algorithm. Fuzzy lattice is formed using x-ray image pixels and lattice Kinetic Energy (K.E.) is calculated using the Schrödinger equation. Feature vector lattices having highest K.E. have been used as an input features for the classifier. The classifier has been employed for pneumonia classification (normal, mild and severe) and Tuberculosis detection (presence or absence). A total of 3000 images have been used for pneumonia classification yielding an accuracy, sensitivity, specificity, precision and F-scores of 97.90%, 98.43%, 97.25%, 97.78% and 98.10%, respectively. For Tuberculosis 600 samples have been used. The achived accuracy, sensitivity, specificity, precision and F-score are 95.50%, 96.39%, 94.40% 95.52% and 95.95%, respectively. Computational time are 40.96 and 39.98 s for pneumonia and TB classification. Classifier learning rate (training accuracy) for pneumonia classes (normal, mild and severe) are 97.907%, 95.375% and 96.391%, respectively and for tuberculosis (present and absent) are 96.928% and 95.905%, respectively. The results have been compared with contemporary classification techniques which shows superiority of the proposed approach in terms of accuracy and speed of classification. The technique could serve as a fast and accurate tool for automated pneumonia and tuberculosis classification.

Cardiovascular and pulmonary complications of recreational drugs: A pictorial review.

Recreational drug abuse constitutes a serious health problem worldwide. Consumption of cocaine, amphetamine-type stimulants, opioids and cannabis can lead to multiple acute and chronic cardiopulmonary complications, resulting in high morbidity and mortality. These complications may be first detected at imaging, since clinical presentation is usually non-specific. Cardiovascular complications include myocardial infarction, endocarditis, aortic dissection, infectious pseudoaneurysm, retained needle fragments, cardiomyopathy and pulmonary arterial hypertension. Pulmonary complications encompass pulmonary oedema, crack lung, pneumonia, septic emboli, barotrauma, airway disease, emphysema and excipient lung disease. Knowledge of the cardiopulmonary imaging manifestations of illicit drug use in conjunction with clinical history and a high grade of suspicion enable an accurate diagnosis and appropriate management plan. In this article we aim to provide a pictorial review of the most frequent cardiopulmonary manifestations of recreational drugs, emphasizing the underlying pathophysiologic mechanisms and the various imaging appearances.