Computed tomography scoring system for discriminating between parapneumonic effusions eventually drained and those cured only with antibiotics.

BACKGROUND AND OBJECTIVE: Due to limited data, we aimed to develop and validate a computed tomography (CT)-based scoring system for identifying those parapneumonic effusions (PPEs) requiring drainage. METHODS: A retrospective review of all patients with PPE who underwent thoracentesis and a chest CT scan before any attempt to place a tube thoracostomy, if applicable, over an 8-year period was conducted. Eleven chest CT characteristics were compared between 90 patients with complicated PPEs (CPPEs), defined as those which eventually required chest drainage, and 60 with non-complicated effusions (derivation sample). A scoring system was devised with those CT findings identified as independent predictors of CPPE in a logistic regression analysis, and further validated in an independent population of 59 PPE patients. RESULTS: CT scores predicting CPPE were pleural contrast enhancement (3 points), pleural microbubbles, increased extrapleural fat attenuation and fluid volume ≥400 mL (1 point each). A sum score of ≥4 yielded 84% sensitivity (95% CI: 62-85%), 75% specificity (95% CI: 62-85%), 81% diagnostic accuracy (95% CI: 73-86%), likelihood ratio (LR) positive of 3.4 (95% CI: 2.1-5.4), LR negative of 0.22 (95% CI: 0.13-0.36) and area under the receiver operating characteristic curve (AUC) of 0.829 (95% CI: 0.754-0.904) for labelling CPPE in the derivation set. These results were reproduced in the validation sample. The CT grading scale also exhibited a fair ability to identify patients who needed surgery or would die from the pleural infection (AUC: 0.76, 95% CI: 0.61-0.9). CONCLUSION: A novel CT scoring system for adults with PPE may allow clinicians to predict the need for chest tube drainage with good accuracy.

Intrapleural Fibrinolysis with Urokinase Versus Alteplase in Complicated Parapneumonic Pleural Effusions and Empyemas: A Prospective Randomized Study.

BACKGROUND: Pleurofibrinolysis has been reported to be potentially beneficial in the management of complicated parapneumonic effusions (CPPE) and empyemas in the adult population. METHODS: Prospective, controlled, randomized, and double-blind study, to evaluate intrapleural alteplase 10 mg (initially 20 mg was considered but bleeding events forced dose reduction) versus 100,000 UI urokinase every 24 h for a maximum of 6 days in patients with CPPE or empyemas. The primary aim was to evaluate the success rate of each fibrinolytic agent at 3 and 6 days. Success of therapy was defined as the presence of both clinical and radiological improvement, making additional fibrinolytic doses unnecessary, and eventually leading to resolution. Secondary outcomes included the safety profile of intrapleural fibrinolytics, referral for surgery, length of hospital stay, and mortality. RESULTS: A total of 99 patients were included, of whom 51 received alteplase and 48 urokinase. Success rates for urokinase and alteplase at 3 and 6 days were not significantly different, but when only the subgroup of CPPE was considered, urokinase resulted in a high proportion of cures. There were no differences in mortality or surgical need (overall, 3 %). Five (28 %) patients receiving 20 mg of alteplase and 4 (12 %) receiving 10 mg presented serious bleeding events. CONCLUSIONS: If intrapleural fibrinolytics are intended to be used, urokinase may be more effective than alteplase in patients with non-purulent CPPE and have a lower rate of adverse events.

Learning from the pulmonary veins.

The purpose of this article is to review the basic embryology and anatomy of the pulmonary veins and the various imaging techniques used to evaluate the pulmonary veins, as well as the radiologic findings in diseases affecting these structures. Specific cases highlight the clinical importance of the imaging features, particularly the findings obtained with multidetector computed tomography (CT). Pulmonary vein disease can be broadly classified into congenital or acquired conditions. Congenital disease, which often goes unnoticed until patients are adults, mainly includes (a) anomalies in the number or diameter of the vessels and (b) abnormal drainage or connection with the pulmonary arterial tree. Acquired disease can be grouped into (a) stenosis and obstruction, (b) hypertension, (c) thrombosis, (d) calcifications, and (e) collateral circulation. Pulmonary vein stenosis or obstruction, which often has important clinical repercussions, is frequently a result of radiofrequency ablation complications, neoplastic infiltration, or fibrosing mediastinitis. The most common cause of pulmonary venous hypertension is chronic left ventricular failure. This condition is difficult to differentiate from veno-occlusive pulmonary disease, which requires a completely different treatment. Pulmonary vein thrombosis is a rare, potentially severe condition that can have a local or distant cause. Calcifications have been described in rheumatic mitral valve disease and chronic renal failure. Finally, the pulmonary veins can act as conduits for collateral circulation in cases of obstruction of the superior vena cava. Multidetector CT is an excellent modality for imaging evaluation of the pulmonary veins, even when the examination is not specifically tailored for their assessment.

Migrating azygos vein and vanishing azygos lobe: MDCT findings.

OBJECTIVE: The purpose of this study was to describe six cases of migrating azygos vein and to explain the etiologic factors that contribute to the migration. Six patients with migrating azygos vein were studied by MDCT before and after migration. Five patients had right pneumothorax. All patients had repeated episodes of cough, vomiting, and a short mesoazygos. CONCLUSION: Pneumothorax, increased intrathoracic pressure, and a short mesoazygos, in combination or alone, are the main factors in azygos vein migration.

New opacities in lung allograft after transbronchial cryobiopsy.

BACKGROUND: The occurrence of radiological opacities post-transbronchial cryobiopsy may pose serious difficulties in differential diagnosis and management of lung allografts. This prospective study evaluated the frequency, characteristics, and evolution of new lung opacities after performing transbronchial cryobiopsy. METHODS: From February 2018 to June 2018, 22 of 51 consecutive patients with an indication for transbronchial cryobiopsy underwent computed tomography (CT) of the thorax before and at 1, 4, and 8 weeks post-cryobiopsy. New CT images, required by the transplant team, were also evaluated during the next 6 months. Histological findings of transbronchial cryobiopsy and microbiological studies on bronchoalveolar lavage were evaluated as risk factors for opacities. RESULTS: After obtaining 112 cryobiopsy samples, 46 opacities >10 mm, including ground-glass, solid, cavitated, or a combination of these lesions were observed in 20 (91%) patients on post-cryobiopsy CT. All ground-glasses opacities on CT disappeared at 4 weeks. A single cavitated opacity persisted at 6 months. The remaining opacities disappeared or were decreased to <10 mm by 8 weeks. No correlations of the number, type, or evolution of opacities with the number or volume of cryobiopsy samples obtained, or with the histological diagnosis, type of transplant, or microbiologic culture results were observed. CONCLUSION: New pulmonary opacities >10 mm occur frequently after transbronchial cryobiopsy; a few may persist beyond 6 months. CT studies are recommended before implementing transbronchial cryobiopsy, whenever possible.

Biomarkers predictive value for early diagnosis of Stroke-Associated Pneumonia.

To confirm the diagnostic accuracy of candidate biomarkers in stroke-associated pneumonia (SAP), we prospectively enrolled ischemic stroke patients with NIHSS ≥ 10 on admission from March-2016 to August-2017. Blood samples were collected at baseline, 24 and 48 h after stroke onset. Biomarkers (MR-proADM, suPAR, SAA) were determined by immunoassays. Regarding biomarkers, MR-proADM at 24 h (P = 0.04) and both suPAR and SAA at 48 h (P = 0.036 and P = 0.057) were associated with pneumonia. The combination of SAA > 25.15 mg/dL and suPAR> 3.14 ng/mL at 48 h had 80% sensitivity and 95.8% specificity when both biomarkers were above the cut-off. The evaluated biomarkers represent promising tools to be evaluated in future large, prospective studies on SAP. An accurate SAP diagnosis by thorax CT might help to reduce variability in such studies.

Radiological findings of unilateral tuberculous lung destruction.

OBJECTIVES: The aim of this report is to identify the radiological findings of unilateral tuberculous lung destruction (UTLD). MATERIALS AND METHODS: Thirteen patients with (UTLD) were reviewed from 1999 to 2014. Only patients with radiological evidence of absence of pulmonary parenchyma preserved were included. Clinical and demographic data were obtained and radiological studies (chest radiograph and CT) were retrospectively reviewed. RESULTS: The left lung was more commonly involved (85%). The following radiological findings were found in all cases: a decrease in the diameter of the pulmonary vessels of the affected lung, herniation of the contralateral lung and hypertrophy of the ribs and/or thickening of extrapleural fat. Two radiological patterns were identified: UTLD with cystic bronchiectasis (85%) and UTLD without residual cystic bronchiectasis (15%). Forty-six per cent of cases had respiratory infection symptoms with presence of air-fluid levels in the affected lung as the most common finding in these patients. CONCLUSIONS: Total unilateral post-tuberculous lung destruction is an irreversible complication with the following main radiological features: predominantly left-sided location, decreases in the diameter of the ipsilateral pulmonary vessels, herniation of the contralateral lung and hypertrophy of the ribs and/or thickening of extrapleural fat. TEACHING POINTS: • Unilateral tuberculous lung destruction is an irreversible complication of tuberculosis. • Left-side predominance and herniation of the contralateral lung are characteristic. • Decreased diameter of the ipsilateral pulmonary vessels occurred in all patients. • The pattern with residual cystic bronchiectasis is the most frequent. • Superimposed non-tuberculous infections may affect the destroyed lung.

Predictors of pleural malignancy in patients with pleural effusion undergoing thoracoscopy.

STUDY OBJECTIVES: Thoracoscopic pleural biopsy is highly accurate in the diagnosis of pleural malignancy. However, no scientific evidence is currently available to guide the physician's decision as to when and in which patients with pleural effusion thoracoscopy is indicated. The application of predictive criteria of malignancy might improve the indication of thoracoscopy in patients with undiagnosed pleural effusion. METHODS: Prospective study of 93 patients referred for thoracoscopy at a tertiary hospital. Clinical variables were obtained prior to thoracoscopy by clinical history and review of previous data, patient interview, and physical examination. Radiologic variables were obtained by evaluation of chest radiograph and chest CT images by two independent readers. After thoracoscopy, all patients without a diagnosis were sent for long-term follow-up. RESULTS: Thoracoscopy demonstrated 94% sensitivity and 100% specificity in the diagnosis of pleural malignancy. Variables, which in a multivariate model are associated with pleural malignancy, include a symptomatic period > 1 month, absence of fever, blood-tinged pleural fluid, and chest CT scan findings suggestive of malignancy. Receiver operating characteristic analysis showed that the use of these four criteria offered adequate classification in 95% of patients. Twenty-eight patients had all four criteria, and all had malignancy; 21 patients had at most one criterion, and none had malignancy. CONCLUSION: Clinical and radiologic criteria of patients with pleural effusion permit different risk levels for pleural malignancy to be distinguished. Consequently, application of the four proposed criteria permits better indication of thoracoscopy in patients with undiagnosed pleural effusion.

Immunoglobulin therapy to control lung damage in patients with common variable immunodeficiency.

BACKGROUND: Lung damage progression is the most frequent condition in patients with common variable immunodeficiency (CVID). Appropriate immunoglobulin dose adjustments and follow-up guidelines to evaluate this have not been well established. OBJECTIVE: To assess the evolution of lung damage once stable residual serum levels of IgG over 600 mg/dl had been achieved. METHODS: A prospective study was conducted in 24 adult patients consecutively diagnosed with CVID, with no previous intravenous immunoglobulin (IVIG) treatment. IVIG dose, total serum IgG level, bacterial infection rate, pulmonary function tests (PFTs) and high resolution computed tomography (HRCT) of the thorax were monitored over 2 years. Moreover, outcome data were determined by measurement of chronic pulmonary disease (CPD). RESULTS: IVIG dose variability (205-372 mg/kg/21 days) to obtain the required serum IgG levels was determined. Patients with CPD needed higher doses than those without CPD (p=0.045). A significant reduction in severe and mild infections/patient-year was observed during treatment. Overall, there were no changes in PFTs and HRCT scores in patients without CPD, but both improved in patients with CPD. An increase of over 15% in overall HRCT score was detected in two patients without evidence of impairment in either clinical status or PFT values. CONCLUSIONS: Residual levels of total IgG over 600 mg/dl may help prevent progression of lung damage in patients with CVID. Levels of IgG, clinical manifestations and PFTs seem sufficient for routine follow-up. HRCT examination of the thorax, at least biennially, may help to identify patients in whom lung injury is progressing even though they may remain symptom-free and with stable PFTs.

Good outcome of interstitial lung disease in patients with scleroderma associated to anti-PM/Scl antibody.

OBJECTIVE: The objective of this article was to establish the clinical course of interstitial lung disease (ILD) in scleroderma related to the presence of anti-PM/Scl antibody compared with anti-Scl-70 in a Spanish cohort. Furthermore, no study has thoroughly investigated the outcome of pulmonary function test in the first group of patients. METHODS: A total of 63 Spanish patients with scleroderma and ILD were selected in a retrospective observational study. Among them, 14 were positive for anti-PM/Scl antibodies and 49 for anti-Scl-70. Clinical assessments, including pulmonary function test, were collected. Variations equal or greater than 10% in forced vital capacity (FVC) were considered significant. Progression-free survival of disease was defined as the period of stable illness since pulmonary fibrosis diagnosis. RESULTS: Anti-Scl-70 patients had a higher frequency of diffuse SSc subset, peripheral vasculopathy, and gastrointestinal involvement. Inflammatory myopathy was associated to anti-PM/Scl antibody. Anti-PM/Scl patients presented more improvement in FVC during follow-up, 30.8% compared to a 7.1% in Scl-70 group (P = 0.04), with less worsening of this parameter (15.4% vs 52.4% in Scl-70 patients, P = 0.01), and secondary less frequency of severe restrictive pattern (FVC < 50%) (7.7% compared to 42.9% in the other group, P = 0.02). Regarding treatment, more anticalcineurinics were used in anti-PM/Scl patients, while cyclophosphamide and mycophenolate were mainly used in anti-Scl-70 patients. The progression-free survival of disease was higher in anti-PM/Scl patients, with 76% at 10 years from diagnosis of ILD against a 29% in the Scl-70 group. CONCLUSIONS: Several features and prognosis of ILD in SSc may be modified depending on the identified immunological profile.

Quality of life, pulmonary function, and tomographic scan abnormalities after ARDS.

BACKGROUND: ARDS can produce a loss of lung function with persistent sequelae. This study aimed to evaluate health-related quality of life (HRQL) in survivors of ARDS compared with a healthy reference population and to determine the middle/long-term radiographic abnormalities and functional status, as well as their relation to observed HRQL, in these patients. METHODS: This was a prospective study carried out in three ICUs. HRQL in patients was determined with the Nottingham Health Profile immediately after ARDS diagnosis and 6 months after diagnosis. Patients underwent complete respiratory function testing, chest CT scan study, and the 6-min walk test. RESULTS: Follow-up was conducted in 38 patients with ARDS. Survivors of ARDS presented a poorer overall HRQL vs the general population, mainly because of lower scores in the dimensions related to mobility, energy, and social isolation. Limitations in daily life activities were documented in 40%. Respiratory function was altered in 67%, with a restrictive respiratory pattern in 58%. Radiologic study disclosed alterations in 76% (mainly reticular pattern). Patients were able to cover only 366 m (318-411 m) in the 6-min walk test and had a minimum pulse oximetry of 93% (90%-94%). A significant correlation was documented between the overall quality of life at first and at 6 months (r = 0.68, P < .01). CONCLUSIONS: Survivors of ARDS after 6 months had a poorer HRQL than the healthy population and showed mild radiographic and functional involvement. Early HRQL study in these patients enabled early detection of those who would present more long-term HRQL morbidity.

Computed tomography (CT) predicts accurately the pathologic tumour size in stage I non-small-cell lung cancer (NSCLC).

INTRODUCTION: In stage I non-small-cell lung cancer (NSCLC) tumour size has been the most consistent determinant of survival. The choice of therapy option is based on accurate definition of the stage. The aim of our study is to correlate tumour size by computed tomography scan (CT) with pathologic size and to determine possible prognostic factors in surgically resected pathologic stage IA and IB NSCLC patients. METHODS: Retrospective review of CT scans and medical history data from 89 pathologic stage I NSCLC patients. Clinical prognostic factors analysed were age, gender, smoking status, pulmonary function, performance status (PS), surgical procedure, histopathology, vessel invasion, pleural infi ltration, tumour size and number of lymph nodes resected. According to the new TNM classification for lung cancer, tumour size was divided into five groups (I: <2 cm, II: 2-3 cm, III: 3-5 cm, IV: 5-7 cm and V: >7 cm). RESULTS: After a median surveillance of 55.2 months, 42 patients relapsed and 55 had died. The 5-year progressionfree survival was 55.7% and 5-year overall survival (OS) 49.9% (median 58.97 months). None of the clinical parameters analysed were predictors of OS. Significant correlation was found between tumour size in CT scan and pathologic stage (Pearson 0.75). CONCLUSIONS: In our analysis with 89 surgically resected stage IA and IB NSCLC patients we found a good correlation between clinical and pathologic tumour size by CT scan. The prognoses factors analysed had no significant impact on survival.

Clinical surrogate markers of survival in advanced non-small cell lung cancer (NSCLC) patients treated with second-third line erlotinib.

BACKGROUND: Inhibition of the EGFR pathway is a useful strategy in the treatment of patients with advanced NSCLC. The aim of this study is to assess predictive clinical parameters of efficacy. METHODS AND PATIENTS: Sixty-two patients with advanced NSCLC were treated with erlotinib as second-third line (150 mg/day). Baseline patient characteristics were: performance status (PS) 1: 92%; median age, 58 years; males, 73%; adenocarcinoma, 45%; current/former smokers, 83%. During erlotinib treatment, 35% of patients had no rash, 32.3% had grade 1 rash, 26% had grade 2 rash and 6.5% patients developed grade 3 rash. RESULTS: For patients with grades 2-3 rash vs. those with grades 0-1 rash, time to tumor progression (TTP) and overall survival (OS) were 92 vs. 41 days (p=0.0381) and 244 vs. 131 days (p=0.011), respectively. For patients with non-smoking history and current/former smokers, TTP and OS were 136 vs. 42 days (p=0.0015) and 324 vs. 133 days (p=0.0242), respectively. In addition, rash grade and smoking history were found to have a highly significant impact on TTP and OS, according to the Cox model. CONCLUSIONS: Grade > or =2 rash and non-smoking history are associated with improved TTP and OS in advanced NSCLC patients treated with erlotinib.

Lymphangioleiomyomatosis: pulmonary and abdominal findings with pathologic correlation.

Lymphangioleiomyomatosis (LAM) is a rare disease characterized by pulmonary cysts at computed tomography (CT) and proliferation of abnormal smooth muscle cells at lung biopsy. Almost all patients are female, and all have pulmonary cysts at high-resolution CT. Although the presence of cysts may be suggested at conventional CT or chest radiography, high-resolution CT is superior for cyst detection and is essential for diagnosis. The cysts are typically round; in most cases, the cyst wall is barely seen at thin-section CT. They are typically diffusely distributed throughout the central and peripheral lung parenchyma. The lung bases are affected in all patients. Some patients also have increased lung attenuation or a reticular pattern. Expiratory CT shows no air trapping between the cysts, and most of the cysts decrease in size. Pneumothorax, pleural effusion, and chylothorax are complications of LAM. Certain abdominal findings may provide additional corroborative evidence of the diagnosis. Renal angiomyolipomas, the most frequent abdominal lesions, usually manifest as asymptomatic, small, bilateral tumors of fat attenuation in the renal cortex. Lymphangiomas are cystic retroperitoneal masses that occur in up to 20% of patients. Other CT findings are hypo- or hyperattenuating lymph nodes, a dilated thoracic duct, and ascites.