A retrospective analysis of simultaneous bilateral uniportal thoracoscopic surgeries for multiple primary bilateral pulmonary nodules.

BACKGROUND: There are no standard treatment options for bilateral multiple pulmonary nodules requiring resection. This study aimed to summarize the experience of simultaneous bilateral uniportal video-assisted thoracoscopic surgery for the treatment of bilateral multiple primary pulmonary nodules. METHODS: The clinical data of 65 cases of simultaneous bilateral uniportal thoracoscopic surgery for bilateral multiple primary pulmonary nodules treated were retrospectively analyzed. These cases were treated within The Ninth Medical Center of PLA General Hospital between January 2018 and November 2020. Parameters related to the surgery, perioperative aspects, surgical techniques, pathology results, and postoperative complications were examined. RESULTS: All surgeries were conducted through uniportal video-assisted thoracoscopic surgery, with no instances of intraoperative conversion to thoracotomy. Fifty-three patients further underwent CT-guided Hookwire localization for the localization of pulmonary nodules. A total of 189 nodules were resected using multiple surgical procedures, with a malignancy rate of 86.2%. The average operation time was 226 ± 77.4 min, the average thoracic drainage duration was 3.1 ± 1.5 days, the average 24 h pleural drainage was 385.9 ± 157.4 mL, the average postoperative hospital stay was 8.6 ± 2.4 days, and the average blood loss was 77.2 ± 33.8 mL. Post-surgery, all patients were transferred to the ward safely within 12 h. 15.38% of patients have prolonged drainage time, and 12.31% of patients experience complications such as lung infection, arrhythmia, and venous thrombosis. CONCLUSION: The selected cases undergoing simultaneous bilateral uniportal video-assisted thoracoscopic surgery for the management of bilateral multiple primary pulmonary nodules demonstrated favorable outcomes. Our observations indicate the safety and feasibility of this procedure, providing an individualized and precise treatment approach for affected patients.

Lemierre's Syndrome: An Atypical Case of Fusobacterium necrophorum Bacteraemia in the Absence of Internal Jugular Vein Thrombosis.

Lemierre's syndrome primarily affects healthy adolescents and young adults as a complication of oropharyngeal infection, most commonly pharyngitis or peritonsillar abscess. Fusobacterium necrophorum is the principal pathogen, and the infection presents with classic symptoms including fever, sore throat, and neck tenderness. However, atypical presentations can pose diagnostic challenges. This report discusses a patient in her early 60s, contrary to the typical demographic, who presented with a one-week history of varied symptoms including sore throat, pleuritic chest pain, and haemoptysis. Examination revealed mild neck tenderness and lung crepitations. Laboratory tests indicated leucocytosis, thrombocytopenia, and elevated C-reactive protein (CRP). Imaging revealed pulmonary infiltrates with cavitation. F. necrophorum was detected in blood culture, promoting a CT scan of the neck, which confirmed soft tissue swelling and a small peritonsillar collection, leading to the diagnosis of Lemierre's syndrome. The classical feature of jugular vein thrombus was absent, further underscoring the atypical nature of this case. The patient received immediate initiation of intravenous antibiotics, piperacillin/tazobactam, followed by meropenem. This was complemented by a carefully tailored 21-day intravenous course, followed by an eight-week regimen of oral antibiotics consisting of amoxicillin and metronidazole. The patient demonstrated significant clinical improvement in pulmonary complications. Follow-up imaging showed minor residual changes, and the patient remained asymptomatic. Lemierre's syndrome presents a diagnostic challenge due to diverse clinical manifestations. Key diagnostic markers include deep neck infections, septicemia, and metastatic infections. Timely utilization of diagnostic tools, such as blood cultures and imaging, aid in confirmation. Early diagnosis is crucial for prompt treatment and prevention of complications. This case emphasizes the importance of maintaining a high index of suspicion for Lemierre's syndrome, especially in atypical presentations. Increased awareness among healthcare providers is vital for timely diagnosis and optimal patient outcomes.

Pulmonary Langerhans cell histiocytosis with multiple cavitary nodules after lung cancer surgery.

Pulmonary Langerhans cell histiocytosis (PLCH) is a subtype of Langerhans cell histiocytosis, a rare neoplastic disease characterized by lung involvement. Here, we present a case involving a patient with multiple cavitary nodules who was diagnosed with PLCH during surveillance after lung cancer surgery. A 74-year-old woman underwent right upper lobe resection surgery for right upper lobe lung adenocarcinoma, pStage IIA, 5 years ago. The patient underwent surveillance without adjuvant chemotherapy. During the fifth year of follow-up, multiple nodules with cavitation were observed on computed tomography in both lung fields. Chemotherapy was considered to address the suspected recurrence of lung cancer; however, video-assisted thoracoscopic surgery was performed due to the need for biomarker testing. Pathological examination led to the diagnosis of PLCH. This case emphasizes the importance of a proactive histological diagnosis to determine the appropriate treatment strategy, even in situations where lung cancer recurrence is clinically suspected.

Diffuse pulmonary meningotheliomatosis: A case report.

A 57-year-old female presented with chest discomfort and exertional dyspnea but no other respiratory symptoms or history of malignancy. Chest CT revealed multifocal centrilobular nodules with ground-glass opacity in both lungs. Thoracoscopic wedge resection was done, and histological examination confirmed interstitial meningothelial-like nodules, consistent with diffuse meningotheliomatosis. The patient was discharged without complications and showed no disease progression on follow-up CT at 3 months, maintaining stability during 6 months of outpatient observation. Diffuse pulmonary meningotheliomatosis is an exceedingly rare condition, but this may be one of the causative etiologies in patients with diffuse bilateral pulmonary nodules.

Caplan Syndrome Mimicking Progressive Massive Fibrosis on CT: A Case Report.

This report presents a unique case of Caplan syndrome that mimicked accelerated progressive massive fibrosis. The patient, a former coal miner, had been diagnosed with coal worker's pneumoconiosis 15 years prior and had been treated for rheumatoid arthritis for over 20 years. Accelerated progressive massive fibrosis and the development of multiple nodules with cavitation in the basal lungs were subsequently observed on serial CT scans. Here, the CT manifestations of Caplan syndrome are highlighted in a case in which Caplan syndrome mimicked accelerated progressive massive fibrosis.

Speed and efficiency: evaluating pulmonary nodule detection with AI-enhanced 3D gradient echo imaging.

OBJECTIVES: Evaluating the diagnostic feasibility of accelerated pulmonary MR imaging for detection and characterisation of pulmonary nodules with artificial intelligence-aided compressed sensing. MATERIALS AND METHODS: In this prospective trial, patients with benign and malignant lung nodules admitted between December 2021 and December 2022 underwent chest CT and pulmonary MRI. Pulmonary MRI used a respiratory-gated 3D gradient echo sequence, accelerated with a combination of parallel imaging, compressed sensing, and deep learning image reconstruction with three different acceleration factors (CS-AI-7, CS-AI-10, and CS-AI-15). Two readers evaluated image quality (5-point Likert scale), nodule detection and characterisation (size and morphology) of all sequences compared to CT in a blinded setting. Reader agreement was determined using the intraclass correlation coefficient (ICC). RESULTS: Thirty-seven patients with 64 pulmonary nodules (solid n = 57 [3-107 mm] part-solid n = 6 [ground glass/solid 8 mm/4-28 mm/16 mm] ground glass nodule n = 1 [20 mm]) were analysed. Nominal scan times were CS-AI-7 3:53 min; CS-AI-10 2:34 min; CS-AI-15 1:50 min. CS-AI-7 showed higher image quality, while quality remained diagnostic even for CS-AI-15. Detection rates of pulmonary nodules were 100%, 98.4%, and 96.8% for CS-AI factors 7, 10, and 15, respectively. Nodule morphology was best at the lowest acceleration and was inferior to CT in only 5% of cases, compared to 10% for CS-AI-10 and 23% for CS-AI-15. The nodule size was comparable for all sequences and deviated on average < 1 mm from the CT size. CONCLUSION: The combination of compressed sensing and AI enables a substantial reduction in the scan time of lung MRI while maintaining a high detection rate of pulmonary nodules. CLINICAL RELEVANCE STATEMENT: Incorporating compressed sensing and AI in pulmonary MRI achieves significant time savings without compromising nodule detection or characteristics. This advancement holds clinical promise, enhancing efficiency in lung cancer screening without sacrificing diagnostic quality. KEY POINTS: Lung cancer screening by MRI may be possible but would benefit from scan time optimisation. Significant scan time reduction, high detection rates, and preserved nodule characteristics were achieved across different acceleration factors. Integrating compressed sensing and AI in pulmonary MRI offers efficient lung cancer screening without compromising diagnostic quality.

Intravascular Large B-cell Lymphoma in a Young Southeast Asian Male With Recurrent Strokes and Pulmonary Ground Glass Opacities With a Normal Chest Radiograph.

Intravascular large B-cell lymphoma (IVLBCL) is a rare form of extranodal large B-cell lymphoma characterized by the growth of lymphoma cells within lumina of blood vessels, especially capillaries, which aggregate to form clots, resulting in organ ischemia. In Caucasians, it predominantly involves the central nervous system (CNS) and the skin, with the cutaneous variant carrying a better prognosis. Whereas in Asians it preferentially involves the bone marrow, liver, and spleen and is associated with hemophagocytic syndrome. We report a case of a young Asian male with neurological, pulmonary, and hepatosplenic involvement. He presented with recurrent strokes, chronic cough, and unintentional weight loss. The chest radiograph (CXR) on admission was clear. Magnetic resonance imaging (MRI) of the brain showed acute multifocal infarcts, and a whole-body computed tomography (CT) scan revealed upper-lobe predominant pulmonary ground glass opacities (GGOs) with mediastinal lymphadenopathy. Interestingly, a CXR performed one week after the CT scan remained clear. The positron emission tomography-computed tomography (PET-CT) showed hepatosplenic and adrenal involvement. The diagnosis was confirmed via a bronchoscopic approach. The patient received chemotherapy consisting of MR-CHOP (methotrexate, rituximab, cyclophosphamide, adriamycin, vincristine, and prednisolone), high-dose methotrexate, and intrathecal cytarabine, which led to complete remission. Subsequently, he underwent an autologous peripheral blood stem cell transplant. At the time of writing this case report, the patient is still in complete remission for three years after the initial diagnosis. As IVLBCL has a non-specific clinicoradiological presentation, it is important to suspect IVLBCL in patients with an atypical neurological and pulmonary presentation in the presence of raised serum lactate dehydrogenase (LDH) and to consider a CT scan of the thorax if CXR is normal.

Effect of emphysema on AI software and human reader performance in lung nodule detection from low-dose chest CT.

BACKGROUND: Emphysema influences the appearance of lung tissue in computed tomography (CT). We evaluated whether this affects lung nodule detection by artificial intelligence (AI) and human readers (HR). METHODS: Individuals were selected from the "Lifelines" cohort who had undergone low-dose chest CT. Nodules in individuals without emphysema were matched to similar-sized nodules in individuals with at least moderate emphysema. AI results for nodular findings of 30-100 mm3 and 101-300 mm3 were compared to those of HR; two expert radiologists blindly reviewed discrepancies. Sensitivity and false positives (FPs)/scan were compared for emphysema and non-emphysema groups. RESULTS: Thirty-nine participants with and 82 without emphysema were included (n = 121, aged 61 ± 8 years (mean ± standard deviation), 58/121 males (47.9%)). AI and HR detected 196 and 206 nodular findings, respectively, yielding 109 concordant nodules and 184 discrepancies, including 118 true nodules. For AI, sensitivity was 0.68 (95% confidence interval 0.57-0.77) in emphysema versus 0.71 (0.62-0.78) in non-emphysema, with FPs/scan 0.51 and 0.22, respectively (p = 0.028). For HR, sensitivity was 0.76 (0.65-0.84) and 0.80 (0.72-0.86), with FPs/scan of 0.15 and 0.27 (p = 0.230). Overall sensitivity was slightly higher for HR than for AI, but this difference disappeared after the exclusion of benign lymph nodes. FPs/scan were higher for AI in emphysema than in non-emphysema (p = 0.028), while FPs/scan for HR were higher than AI for 30-100 mm3 nodules in non-emphysema (p = 0.009). CONCLUSIONS: AI resulted in more FPs/scan in emphysema compared to non-emphysema, a difference not observed for HR. RELEVANCE STATEMENT: In the creation of a benchmark dataset to validate AI software for lung nodule detection, the inclusion of emphysema cases is important due to the additional number of FPs. KEY POINTS: • The sensitivity of nodule detection by AI was similar in emphysema and non-emphysema. • AI had more FPs/scan in emphysema compared to non-emphysema. • Sensitivity and FPs/scan by the human reader were comparable for emphysema and non-emphysema. • Emphysema and non-emphysema representation in benchmark dataset is important for validating AI.

Shape-Sensing Robotic-Assisted Bronchoscopy in the Multiple Pulmonary Nodule Diagnosis during a Single Anesthetic Event.

INTRODUCTION: The widespread use of computed tomography as a screening tool for early lung cancer has increased detection of pulmonary lesions. It is common to encounter patients with more than one peripheral pulmonary nodule (PPN) of uncertain etiology. Shape-sensing robotic-assisted bronchoscopy (ssRAB) emerges as a potential alternative to biopsy multiple PPN, in addition to mediastinal staging in single anesthetic procedure. METHODS: This is a single-center, retrospective review of 22 patients who underwent ssRAB for evaluation of two or more PPN, between November 2021 and April 2023 at Mayo Clinic, FL, USA. RESULTS: A total of 46 PPNs were biopsied in 22 patients. All lesions were ≤2 cm with a median minimum and maximum cross-sectional lesion size of 1.40 cm and 1.05 cm, respectively. Diagnostic yield was 86.9% (n = 40), and target reach was 91.3% (n = 42). Most lesions were in the upper lobes, a solid pattern was found in 78.3% (n = 36), bronchus sign was present in 82.6% of cases (n = 38), 54.4% (n = 25) were malignant nodules, and 32.6% (n = 15) were benign. Fourteen patients had at least one malignant lesion out of two or more nodules sampled, and 10 patients had a malignant diagnosis for all sampled lesions. The complication rate was 9% (n = 2) with one case of bleeding and one of pneumothorax. CONCLUSION: This study is, to our knowledge, the first to assess the use and safety of ssRAB for diagnosis of multiple PPN in a single anesthetic event. This procedure will mainly impact management decisions and subsequently shorten the time from diagnosis to treatment.

Mucinous Adenocarcinoma of the Prostate With Normal Prostate-Specific Antigen Levels, Pulmonary Metastasis, and the Absence of Nodal Disease: A Case Report.

A 74-year-old man was suffering from nine months of perineal pain and progressive worsening of urinary symptoms including nocturia and urgency. His prostate-specific antigen (PSA) levels were 1.48 ng/mL at the time of referral. Initially, a differential diagnosis of prostatitis or seminal vesicle inflammation was made, and four weeks of antibiotics were prescribed, which were later extended to six weeks due to failure of symptoms to resolve. Magnetic resonance imaging (MRI) of the prostate was then conducted. The impression was that there was ejaculatory duct obstruction caused by enlarged seminal vesicles with no evidence of significant prostate cancer. The prostate-specific antigen density (PSAd) was 0.04, and the prostate imaging reporting and data system (PIRADS) score was I-II. A CT chest with contrast was conducted for further investigation of pulmonary nodules found on the CT urogram. It revealed multiple calcified pulmonary nodules which were suspicious of malignancy. A CT-guided biopsy of one of the pulmonary nodules was taken, and histopathological analysis revealed a mucinous adenocarcinoma. A transurethral resection of the prostate (TURP) was then performed. Histopathological analysis of the prostatic surgical specimen revealed invasive mucinous adenocarcinoma. Based on the findings, a diagnosis of mucinous adenocarcinoma of the prostate with atypical lung metastasis without osseous or regional lymph node involvement was made, stage T4 N0 M1a. The patient is currently on a treatment regimen consisting of carboplatin, pemetrexed, and pembrolizumab.

Multiple pulmonary nodules with diffuse idiopathic pulmonary neuroendocrine cell hyperplasia and minute pulmonary meningothelial-like nodules.

A 78-year-old woman presented with multiple pulmonary nodules, mixed with solid and ground-glass nodules. We pathologically confirmed that the multiple pulmonary nodules were a combination of diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) and multiple pulmonary meningothelial-like nodules (MPMNs). This is the first case report of concurrent DIPNECH and MPMNs.

Enhancing a deep learning model for pulmonary nodule malignancy risk estimation in chest CT with uncertainty estimation.

OBJECTIVE: To investigate the effect of uncertainty estimation on the performance of a Deep Learning (DL) algorithm for estimating malignancy risk of pulmonary nodules. METHODS AND MATERIALS: In this retrospective study, we integrated an uncertainty estimation method into a previously developed DL algorithm for nodule malignancy risk estimation. Uncertainty thresholds were developed using CT data from the Danish Lung Cancer Screening Trial (DLCST), containing 883 nodules (65 malignant) collected between 2004 and 2010. We used thresholds on the 90th and 95th percentiles of the uncertainty score distribution to categorize nodules into certain and uncertain groups. External validation was performed on clinical CT data from a tertiary academic center containing 374 nodules (207 malignant) collected between 2004 and 2012. DL performance was measured using area under the ROC curve (AUC) for the full set of nodules, for the certain cases and for the uncertain cases. Additionally, nodule characteristics were compared to identify trends for inducing uncertainty. RESULTS: The DL algorithm performed significantly worse in the uncertain group compared to the certain group of DLCST (AUC 0.62 (95% CI: 0.49, 0.76) vs 0.93 (95% CI: 0.88, 0.97); p < .001) and the clinical dataset (AUC 0.62 (95% CI: 0.50, 0.73) vs 0.90 (95% CI: 0.86, 0.94); p < .001). The uncertain group included larger benign nodules as well as more part-solid and non-solid nodules than the certain group. CONCLUSION: The integrated uncertainty estimation showed excellent performance for identifying uncertain cases in which the DL-based nodule malignancy risk estimation algorithm had significantly worse performance. CLINICAL RELEVANCE STATEMENT: Deep Learning algorithms often lack the ability to gauge and communicate uncertainty. For safe clinical implementation, uncertainty estimation is of pivotal importance to identify cases where the deep learning algorithm harbors doubt in its prediction. KEY POINTS: • Deep learning (DL) algorithms often lack uncertainty estimation, which potentially reduce the risk of errors and improve safety during clinical adoption of the DL algorithm. • Uncertainty estimation identifies pulmonary nodules in which the discriminative performance of the DL algorithm is significantly worse. • Uncertainty estimation can further enhance the benefits of the DL algorithm and improve its safety and trustworthiness.

Pathological diagnosis and immunohistochemical analysis of minute pulmonary meningothelial-like nodules: A case report.

BACKGROUND: Minute Pulmonary Meningothelial-like Nodules (MPMNs) are rare benign pulmonary nodules, which are more common in elderly women and have a higher detection rate in lung tissues of patients with lung malignant diseases. Its origin is not yet clear. At present, there are few reports on the diagnostic methods such as imaging and pathological manifestations of MPMNs. This article reports a 70-year-old female patient with pulmonary adenocarcinoma combined with MPMNs and reviews of the relevant literature. CASE SUMMARY: A 70-year-old women was admitted to our institution with feeling sour in her back and occasional cough for more than 2 mo. Computerized electronic scanning scan and 3D reconstruction images in our institution showed there were multiple ground-glass nodules in both of her two lungs. The biggest one was in the apicoposterior segment of left upper lobe, about 2.5 mm × 9 mm in size. We performed thoracoscopic resection of the left upper lung apicoposterior segment of the patient, and the final pathological report was minimally invasive adenocarcinoma. Re-examination of high resolution computed tomography 21 mo after surgery showed multiple ground-glass nodules in both lungs, and a new ground-glass nodule was found in the superior segment of the right lower lobe. We took pathological biopsy of the right upper lung and right lower lung nodules for the patient under thoracoscopy. The histomorphology of the right lower lobe nodule showed multiple lesions in the lung tissue, and the small foci in the alveolar septum were distributed in mild form of the aggregation of short spindle cells. The immunohistochemistry showed that the lesion was epithelial membrane antigen (EMA) (+), somatostatin receptor 2a (SSTR2a) (+), S-100 (-), chromogranin A (-), Syn (-), cytokeratin (-) and HMB-45 (-). The final diagnosis was minimally invasive adenocarcinoma, accompanied by MPMNs. We recommend that patients continue to receive treatment after surgery and to do regular follow-up observations. CONCLUSION: The imaging manifestations of MPMNs are atypical, histomorphology and immunohistochemistry can assist in its diagnosis. This article reviews the relevant literature of MPMNs immunohistochemistry and shows that MPMNs are positive for EMA, SSTR2a, and progesterone receptor.

[Feasibility and safety of one-stage bilateral video-assisted thoracic surgery for resection of bilateral multiple pulmonary nodules].

OBJECTIVE: To evaluate the feasibility and safety of one- stage bilateral video-assisted thoracic surgery (VATS) for resection of bilateral multiple pulmonary nodules (BMPNs). METHODS: We analyzed the clinical characteristics, pathological features, perioperative outcomes and follow-up data of 41 patients with BMPNs undergoing one-stage bilateral VATS from July, 2011 to August, 2021. RESULTS: One-stage bilateral VATS was performed uneventfully in 40 of the patients, and conversion to open surgery occurred in 1 case. The surgical approaches included bilateral lobectomy (4.9%), lobar-sublobar resection (36.6%) and sublobar-sublobar resection (58.5%) with a mean operative time of 196.3±54.5 min, a mean blood loss of 224.6±139.5 mL, a mean thoracic drainage duration of 4.7±1.1 days and a mean hospital stay of 14±3.8 days. Pathological examination revealed bilateral primary lung cancer in 15 cases, unilateral primary lung cancer in 21 cases and bilateral benign lesions in 5 cases. A total of 112 pulmonary nodules were resected, including 67 malignant and 45 benign lesions. Postoperative complications included pulmonary infection (5 cases), respiratory failure (2 cases), asthma attack (2 cases), atrial fibrillation (2 cases), and drug-induced liver injury (1 case). No perioperative death occurred in these patients, who had a 1-year survival rate of 97.6%. CONCLUSION: With appropriate preoperative screening and perioperative management, one-stage bilateral VATS is feasible and safe for resection of BMPNs.

[Clinical diagnosis and treatment of multiple pulmonary nodules].

CT screening has markedly reduced the lung cancer mortality in high-risk population and increased the detection of early-stage pulmonary neoplasms, including multiple pulmonary nodules, especially those with a ground-glass appearance on CT. Multiple primary lung cancer (MPLC) constitutes a specific subtype of lung cancer with indolent biological behaviors, which is predominantly early-stage adenocarcinoma. Although MPLC progresses slowly with rare lymphatic metastasis, existence of synchronous lesions and distributed location of these nodules still pose difficulty for the management of such patients. One single operation is usually insufficient to eradicate all neoplastic lesions, whereas repeated surgical procedures bring about another dilemma: whether clinical benefits of surgical treatment outweigh loss of pulmonary function following multiple operations. Therefore, despite the anxiety for treatment among MPLC patients, whether and how to treat the patient should be assessed meticulously. Currently there is a heated discussion upon the timing of clinical intervention, operation mode and the application of local therapy in MPLC. Based on clinical experience of our multiple disciplinary team, we have summarized and commented on the evaluation, surgical treatment, non-surgical local treatment, targeted therapy and immunotherapy of MPLC in this article to provide further insight into this field.

Trends in the incidence of pulmonary nodules in chest computed tomography: 10-year results from two Dutch hospitals.

OBJECTIVE: To study trends in the incidence of reported pulmonary nodules and stage I lung cancer in chest CT. METHODS: We analyzed the trends in the incidence of detected pulmonary nodules and stage I lung cancer in chest CT scans in the period between 2008 and 2019. Imaging metadata and radiology reports from all chest CT studies were collected from two large Dutch hospitals. A natural language processing algorithm was developed to identify studies with any reported pulmonary nodule. RESULTS: Between 2008 and 2019, a total of 74,803 patients underwent 166,688 chest CT examinations at both hospitals combined. During this period, the annual number of chest CT scans increased from 9955 scans in 6845 patients in 2008 to 20,476 scans in 13,286 patients in 2019. The proportion of patients in whom nodules (old or new) were reported increased from 38% (2595/6845) in 2008 to 50% (6654/13,286) in 2019. The proportion of patients in whom significant new nodules (≥ 5 mm) were reported increased from 9% (608/6954) in 2010 to 17% (1660/9883) in 2017. The number of patients with new nodules and corresponding stage I lung cancer diagnosis tripled and their proportion doubled, from 0.4% (26/6954) in 2010 to 0.8% (78/9883) in 2017. CONCLUSION: The identification of incidental pulmonary nodules in chest CT has steadily increased over the past decade and has been accompanied by more stage I lung cancer diagnoses. CLINICAL RELEVANCE STATEMENT: These findings stress the importance of identifying and efficiently managing incidental pulmonary nodules in routine clinical practice. KEY POINTS: • The number of patients who underwent chest CT examinations substantially increased over the past decade, as did the number of patients in whom pulmonary nodules were identified. • The increased use of chest CT and more frequently identified pulmonary nodules were associated with more stage I lung cancer diagnoses.

A case of idiopathic multicentric Castleman disease with pulmonary hyalinizing granuloma-like multiple pulmonary nodules.

A 41-year-old man presented with chronic cough and chest pain. Laboratory tests revealed anemia, inflammation, hypoalbuminemia, polyclonal hypergammaglobulinemia, and elevated interleukin-6 levels. Computed tomography revealed diffuse bilateral pulmonary nodules and multicentric lymphadenopathy. Histopathology of the pulmonary nodule resembled pulmonary hyalinizing granuloma (PHG), whereas lymph node histopathology was consistent with idiopathic multicentric Castleman disease (iMCD). The patient was diagnosed with iMCD involving PHG-like pulmonary nodules. Little is known about the association between these two diseases, and the present case provides insights regarding the relationship between PHG and iMCD.

Robustness of pulmonary nodule radiomic features on computed tomography as a function of varying radiation dose levels-a multi-dose in vivo patient study.

OBJECTIVE: Analysis of textural features of pulmonary nodules in chest CT, also known as radiomics, has several potential clinical applications, such as diagnosis, prognostication, and treatment response monitoring. For clinical use, it is essential that these features provide robust measurements. Studies with phantoms and simulated lower dose levels have demonstrated that radiomic features can vary with different radiation dose levels. This study presents an in vivo stability analysis of radiomic features for pulmonary nodules against varying radiation dose levels. METHODS: Nineteen patients with a total of thirty-five pulmonary nodules underwent four chest CT scans at different radiation dose levels (60, 33, 24, and 15 mAs) in a single session. The nodules were manually delineated. To assess the robustness of features, we calculated the intra-class correlation coefficient (ICC). To visualize the effect of milliampere-second variation on groups of features, a linear model was fitted to each feature. We calculated bias and calculated the R2 value as a measure of goodness of fit. RESULTS: A small minority of 15/100 (15%) radiomic features were considered stable (ICC > 0.9). Bias increased and R2 decreased at lower dose, but shape features seemed to be more robust to milliampere-second variations than other feature classes. CONCLUSION: A large majority of pulmonary nodule radiomic features were not inherently robust to radiation dose level variations. For a subset of features, it was possible to correct this variability by a simple linear model. However, the correction became increasingly less accurate at lower radiation dose levels. CLINICAL RELEVANCE STATEMENT: Radiomic features provide a quantitative description of a tumor based on medical imaging such as computed tomography (CT). These features are potentially useful in several clinical tasks such as diagnosis, prognosis prediction, treatment effect monitoring, and treatment effect estimation. KEY POINTS: • The vast majority of commonly used radiomic features are strongly influenced by variations in radiation dose level. • A small minority of radiomic features, notably the shape feature class, are robust against dose-level variations according to ICC calculations. • A large subset of radiomic features can be corrected by a linear model taking into account only the radiation dose level.