JOURNAL CLUB: Evidence of Interstitial Lung Disease on Low-Dose Chest CT Images: Prevalence, Patterns, and Progression.

OBJECTIVE: The purposes of this study were to determine the prevalence of interstitial lung disease (ILD) in a cohort undergoing low-dose CT screening for lung cancer, to identify the CT patterns of fibrosis, and to determine prognostic factors of disease progression. MATERIALS AND METHODS: The study drew from a database of 951 participants in a lung cancer screening program between 2010 and 2014. Three thoracic radiologists reviewed CT scans to identify the ILD findings, defined as traction bronchiectasis, ground-glass opacities with traction bronchiectasis, reticulations with traction bronchiectasis, and honeycombing. Evidence of ILD was considered present if at least two of three reviewing radiologists agreed. Age, smoking history, and CT evidence of emphysema were also documented. RESULTS: Of the 951 participants, 63 (6.6%) had CT evidence of ILD, and 16 of the 63 (1.7% of the total cohort) had honeycombing. Significant univariate predictors of ILD were male sex (p = 0.003), older age (p < 0.0001), higher number of pack-years of cigarette smoking (p = 0.0003), and greater severity of emphysema (p = 0.004), but only age and male sex remained significant in the multivariate analysis. The most common pattern of ILD was peripheral fibrosis without honeycombing involving multiple lobes. The presence of honeycombing was significantly associated with progression of fibrosis score (p = 0.0001) and extent of fibrosis (p = 0.005). CONCLUSION: A potential added benefit of CT screening is earlier diagnosis of ILD in older smokers, who are at increased risk. Radiologists should recognize the earliest findings of ILD and understand the importance of early recognition.

Pulmonary Embolism at CT Pulmonary Angiography in Patients with COVID-19.

PURPOSE: To evaluate pulmonary embolism (PE) prevalence at CT pulmonary angiography in patients testing positive for coronavirus disease 2019 (COVID-19) and factors associated with PE severity. MATERIALS AND METHODS: A retrospective, single-center study evaluated 62 patients who tested positive for COVID-19 who underwent CT pulmonary angiography between March 13 and April 5, 2020. Another 62-patient cohort who underwent CT pulmonary angiography before the first reported local COVID-19 case was retrospectively selected. The relative rate of CT pulmonary angiography positivity was recorded. For the COVID-19 positive cohort, comorbidities, laboratory values, clinical outcome, and venous thrombosis of the patients were recorded. Two thoracic radiologists assessed embolic severity using the Mastora system and evaluated right heart strain. Factors associated with PE and arterial obstruction severity were evaluated by using statistical analysis. A P value < .05 was considered significant. RESULTS: Of the patients testing positive for COVID-19, 37.1% had PE, higher than 14.5% of pre-COVID-19 patients (P = .007). d-dimer levels closest to CT pulmonary angiography date correlated with the Mastora obstruction score. Receiver operating characteristic analysis identified optimal sensitivity (95%) and specificity (71%) for PE diagnosis at 1394 ng/mL d-dimer units. The mean d-dimer level was 1774 ng/mL and 6432 ng/mL d-dimer units in CT pulmonary angiography-negative and CT pulmonary angiography-positive subgroups, respectively (P < .001). One additional patient with negative results at CT pulmonary angiography had deep venous thrombosis, thus resulting in 38.7% with PE or deep venous thrombosis, despite 40% receiving prophylactic anticoagulation. Other factors did not demonstrate significant PE association. CONCLUSION: A total of 37.1% of COVID-19 patients underwent CT pulmonary angiographic examinations diagnosing PE. PE can be a cause of decompensation in patients testing positive for COVID-19, and d-dimer can be used to stratify patients in terms of PE risk and severity.Supplemental material is available for this article.© RSNA, 2020.

Laparoscopic nephrectomy for a nonfunctioning pelvic kidney in preparation for renal transplantation.

Pelvic kidneys pose a problem for any planned surgical intervention given their anomalous blood supply. Although minimally invasive approaches have been described for the management of benign conditions, only a handful of reports have described the use of laparoscopy for removal of ectopic or fused kidneys. We describe the laparoscopic removal of a symptomatic pelvic kidney in a patient before renal transplantation.

The use of isodose levels to interpret radiation induced lung injury: a quantitative analysis of computed tomography changes.

BACKGROUND: Patients treated with stereotactic body radiation therapy (SBRT) for lung cancer are often found to have radiation-induced lung injury (RILI) surrounding the treated tumor. We investigated whether treatment isodose levels could predict RILI. METHODS: Thirty-seven lung lesions in 32 patients were treated with SBRT and received post-treatment follow up (FU) computed tomography (CT). Each CT was fused with the original simulation CT and treatment isodose levels were overlaid. The RILI surrounding the treated lesion was contoured. The RILI extension index [fibrosis extension index (FEI)] was defined as the volume of RILI extending outside a given isodose level relative to the total volume of RILI and was expressed as a percentage. RESULTS: Univariate analysis revealed that the planning target volume (PTV) was positively correlated with RILI volume at FU: correlation coefficient (CC) =0.628 and P<0.0001 at 1(st) FU; CE =0.401 and P=0.021 at 2(nd) FU; CE =0.265 and P=0.306 at 3(rd) FU. FEI -40 Gy at 1(st) FU was significantly positively correlated with FEI -40 Gy at subsequent FU's (CC =0.689 and P=6.5×10(-5) comparing 1(st) and 2(nd) FU; 0.901 and P=0.020 comparing 2(nd) and 3(rd) FU. Ninety-six percent of the RILI was found within the 20 Gy isodose line. Sixty-five percent of patients were found to have a decrease in RILI on the second 2(nd) CT. CONCLUSIONS: We have shown that RILI evolves over time and 1(st) CT correlates well with subsequent CTs. Ninety-six percent of the RILI can be found to occur within the 20 Gy isodose lines, which may prove beneficial to radiologists attempting to distinguish recurrence vs. RILI.

Simultaneous extraperitoneal laparoscopic radical prostatectomy and intraperitoneal inguinal hernia repair with mesh.

OBJECTIVE: This report depicts the feasibility of the concomitant repair of a large direct inguinal hernia with mesh by using the intraperitoneal onlay approach after extraperitoneal laparoscopic radical prostatectomy. METHODS: A 66-year-old man with localized adenocarcinoma of the prostate was referred for laparoscopic radical prostatectomy. The patient also had a 4-cm right, direct inguinal hernia, found on physical examination. To minimize the risk of infection of the mesh, an extraperitoneal laparoscopic prostatectomy was performed in the standard fashion after which transperitoneal access was obtained for the hernia repair. The hernia repair was completed by reduction of the hernia sac, followed by prosthetic mesh onlay. In this fashion, the peritoneum separated the prostatectomy space from the mesh. A single preoperative and postoperative dose of cefazolin was administered. RESULTS: The procedure was completed with no difficulty. Total operative time was 4.5 hours with an estimated blood loss of 450 mL. The final pathology revealed pT2cN0M0 prostate cancer with negative margins. No infectious or bowel complications occurred. At 10-month follow-up, no evidence existed of recurrence of prostate cancer or the hernia. CONCLUSION: Concomitant intraperitoneal laparoscopic mesh hernia repair and extraperitoneal laparoscopic prostatectomy are feasible. This can decrease the risk of potential infectious complications by separating the mesh from the space of Retzius where the prostatectomy is performed and the lower urinary tract is opened.

Imaging characteristics of androgen insensitivity syndrome.

Androgen insensitivity syndrome (AIS), also known as testicular feminization, is a genetic disorder which leads to lack of response to androgens caused by a defect in the androgen receptor. It is relatively uncommon and is usually diagnosed through clinical symptoms, laboratory findings, physical exam, radiological imaging, and genetic analysis. Our case is a middle-aged woman with complete AIS and demonstrates the importance of the various imaging modalities that are implemented in initially diagnosing and assisting in surgical management.

Using gene chips to identify organ-specific, smooth muscle responses to experimental diabetes: potential applications to urological diseases.

OBJECTIVE: To identify early diabetes-related alterations in gene expression in bladder and erectile tissue that would provide novel diagnostic and therapeutic treatment targets to prevent, delay or ameliorate the ensuing bladder and erectile dysfunction. MATERIALS AND METHODS: The RG-U34A rat GeneChip (Affymetrix Inc., Sunnyvale, CA, USA) oligonucleotide microarray (containing approximately 8799 genes) was used to evaluate gene expression in corporal and male bladder tissue excised from rats 1 week after confirmation of a diabetic state, but before demonstrable changes in organ function in vivo. A conservative analytical approach was used to detect alterations in gene expression, and gene ontology (GO) classifications were used to identify biological themes/pathways involved in the aetiology of the organ dysfunction. RESULTS: In all, 320 and 313 genes were differentially expressed in bladder and corporal tissue, respectively. GO analysis in bladder tissue showed prominent increases in biological pathways involved in cell proliferation, metabolism, actin cytoskeleton and myosin, as well as decreases in cell motility, and regulation of muscle contraction. GO analysis in corpora showed increases in pathways related to ion channel transport and ion channel activity, while there were decreases in collagen I and actin genes. CONCLUSIONS: The changes in gene expression in these initial experiments are consistent with the pathophysiological characteristics of the bladder and erectile dysfunction seen later in the diabetic disease process. Thus, the observed changes in gene expression might be harbingers or biomarkers of impending organ dysfunction, and could provide useful diagnostic and therapeutic targets for a variety of progressive urological diseases/conditions (i.e. lower urinary tract symptoms related to benign prostatic hyperplasia, erectile dysfunction, etc.).

Comparison of operative and functional outcomes of laparoscopic radical prostatectomy and radical retropubic prostatectomy: single surgeon experience.

OBJECTIVES: To compare radical retropubic prostatectomy (RRP) and laparoscopic radical prostatectomy (LRP) outcomes in a contemporary series. METHODS: A total of 70 LRP patients operated on between 2001 and 2002 with at least 18 months of follow-up were selected. These patients were compared with a matched cohort of 70 patients who had undergone RRP by the same surgeon from 1999 to 2001. The baseline patient characteristics, perioperative and histologic parameters, recovery time, complications, and 18-month functional data were compared. RESULTS: No significant differences were found in the preoperative characteristics. The mean operative time was 181.8 +/- 18.7 minutes for RRP and 246.4 +/- 46.1 minutes for LRP (P <0.0001). The mean estimated blood loss was 563.2 mL for RRP and 275.8 mL for LRP (P <0.0001). The positive margin rate was 20% and 15.7% for the RRP and LRP groups, respectively (P = NS). The mean pain score on postoperative day 1 was 4.5 in the LRP group and 7.8 in the RRP group on an analog pain score of 0 to 10 (P = 0.02). Full recovery was achieved at 33 +/- 17 days and 45 +/- 20 days for the LRP and RRP groups, respectively (P <0.001). The total perioperative complication rate for LRP and RRP was comparable at 18.5% and 15.7%, respectively. The diurnal continence rate (no pads) for the LRP and RRP groups was 70%, 90%, and 92.8% and 71.4%, 87.6%, and 92% at 6, 12, and 18 months, respectively (P = NS). The potency rate after bilateral neurovascular preservation with or without sildenafil for the LRP and RRP group was 55%, 72.6%, and 79.5% and 43%, 58%, and 72.4% at 6, 12, and 18 months, respectively (P = NS). CONCLUSIONS: LRP is well tolerated and provides short-term oncologic and functional results comparable to those of RRP.

Laparoscopic partial cystectomy for treatment of adenocarcinoma of the urachus.

The treatment of choice for urachal carcinoma has traditionally been an open approach, either by radical cystectomy or the more recently adopted bladder-sparing approach of extended partial cystectomy and umbilectomy. We report for the first time a laparoscopic technique for an extended partial cystectomy with en bloc umbilectomy for the management of urachal carcinoma in a 41-year-old man.