Clinical Characterization and Predictive Factors for Progression in a Cohort of Patients with Interstitial Lung Disease and Features of Autoimmunity: The Need for a Revision of IPAF Classification Criteria.

Background and Objectives: The "interstitial pneumonia with autoimmune features" (IPAF) criteria have been criticized because of the exclusion of usual interstitial pneumonia (UIP) patients with a single clinical or serological feature. To classify these patients, the term UIPAF was proposed. This study aims to describe clinical characteristics and predictive factors for progression of a cohort of interstitial lung disease (ILD) patients with at least one feature of autoimmunity, applying criteria for IPAF, specific connective tissue diseases (CTD), and a definition of UIPAF when possible. Methods: We retrospectively evaluated data on 133 consecutive patients with ILD at onset associated with at least one feature of autoimmunity, referred by pulmonologists to rheumatologists from March 2009 to March 2020. Patients received 33 (16.5-69.5) months of follow-up. Results: Among the 101 ILD patients included, 37 were diagnosed with IPAF, 53 with ILD-onset CTD, and 11 with UIPAF. IPAF patients had a lower prevalence of UIP pattern compared to CTD-ILD and UIPAF patients (10.8% vs. 32.1% vs. 100%, p < 0.01). During the follow-up, 4 IPAF (10.8%) and 2 UIPAF (18.2%) patients evolved into CTD-ILD. IPAF patients presented features not included in IPAF criteria, such as sicca syndrome (8.1%), and were more frequently affected by systemic hypertension (p < 0.01). Over one year, ILD progression (greater extent of fibrosis on HRCT and/or decline in PFTs) was less frequent in the IPAF group compared to CTD-ILD and UIPAF (32.3% vs. 58.8% vs. 72.7, p = 0.02). A UIP pattern and an IPAF predicted a faster (OR: 3.80, p = 0.01) and a slower (OR: 0.28, p = 0.02) ILD progression, respectively. Conclusions: IPAF criteria help identify patients who might develop a CTD-ILD, even though a single clinical or serological feature is respected. Future revisions of IPAF criteria should include sicca syndrome and separate UIP-pattern into a different definition (UIPAF), given its association with a different prognosis, independently from ILD classification.

Transbronchial lung cryobiopsy and pulmonary fibrosis: A never-ending story?

Background: The diagnostic process of pulmonary fibrosis (PF) is often challenging, requires a collaborative effort of several experts, and often requires bioptic material, which can be difficult to obtain, both in terms of quality and technique. The main procedures available to obtain such samples are transbronchial lung cryobiopsy (TBLC) and surgical lung biopsy (SLB). Objective: The purpose of this paper is to review the evidence for the role of TBLC in the diagnostic-therapeutic process of PF. Methods: A comprehensive review was performed to identify articles to date that addressed the role of TBLC in the diagnostic-therapeutic process of PF using the PubMed® database. Results: The reasoned search identified 206 papers, including 21 manuscripts (three reviews, one systematic review, two guidelines, two prospective studies, three retrospective studies, one cross-sectional study, one original article, three editorials, three clinical trials, and two unclassifiable studies), which were included in the final review. Conclusions: TBLC is gaining increasing efficacy and improving safety profile; however, there are currently no clear data demonstrating its superiority over SLB. Therefore, the two techniques should be considered with careful rationalization on a case-by-case basis. Further research is needed to further optimize and standardize the procedure and to thoroughly study the histological and molecular characteristics of PF.

High resolution propagation-based lung imaging at clinically relevant X-ray dose levels.

Absorption-based clinical computed tomography (CT) is the current imaging method of choice in the diagnosis of lung diseases. Many pulmonary diseases are affecting microscopic structures of the lung, such as terminal bronchi, alveolar spaces, sublobular blood vessels or the pulmonary interstitial tissue. As spatial resolution in CT is limited by the clinically acceptable applied X-ray dose, a comprehensive diagnosis of conditions such as interstitial lung disease, idiopathic pulmonary fibrosis or the characterization of small pulmonary nodules is limited and may require additional validation by invasive lung biopsies. Propagation-based imaging (PBI) is a phase sensitive X-ray imaging technique capable of reaching high spatial resolutions at relatively low applied radiation dose levels. In this publication, we present technical refinements of PBI for the characterization of different artificial lung pathologies, mimicking clinically relevant patterns in ventilated fresh porcine lungs in a human-scale chest phantom. The combination of a very large propagation distance of 10.7 m and a photon counting detector with [Formula: see text] pixel size enabled high resolution PBI CT with significantly improved dose efficiency, measured by thermoluminescence detectors. Image quality was directly compared with state-of-the-art clinical CT. PBI with increased propagation distance was found to provide improved image quality at the same or even lower X-ray dose levels than clinical CT. By combining PBI with iodine k-edge subtraction imaging we further demonstrate that, the high quality of the calculated iodine concentration maps might be a potential tool for the analysis of lung perfusion in great detail. Our results indicate PBI to be of great value for accurate diagnosis of lung disease in patients as it allows to depict pathological lesions non-invasively at high resolution in 3D. This will especially benefit patients at high risk of complications from invasive lung biopsies such as in the setting of suspected idiopathic pulmonary fibrosis (IPF).

Accuracy of CT-Guided Core-Needle Biopsy in Diagnosis of Thoracic Lesions Suspicious for Primitive Malignancy of the Lung: A Five-Year Retrospective Analysis.

BACKGROUND: Lung cancer represents a heterogeneous group of neoplasms, with the highest frequency and mortality in both sexes combined. In a clinical scenario characterized by the widespread of multidetector-row spiral CT, core-needle biopsy under tomographic guidance is one of the main and safest methods to obtain tissue specimens, even though there are relatively high rates of pneumothorax (0-60% incidence) and pulmonary hemorrhage (4-27% occurrence rates). The aim of this retrospective study is to assess the diagnostic accuracy of CT-guided core-needle biopsy in the diagnosis of primary lung malignancies and to compare our results with evidence from the literature. MATERIALS AND METHODS: Our analysis included 350 thoracic biopsies, performed from 2017 to 2022 with a 64-row CT guidance and 16/18 G needles mounted on a biopsy gun. We included in the final cohort all samples with evidence of primary lung malignancies, precursor lesions, and atypia, as well as inconclusive and negative diagnoses. RESULTS: There was sensitivity of 90.07% (95% CI 86.05-93.25%), accuracy of 98.87% (95% CI 98.12-99.69%), positive predictive value of 100%, and negative value of 98.74% (95% CI 98.23-99.10%). Specificity settled at 100% (93.84-100%). The AUC was 0.952 (95% CI 0.924-0.972). Only three patients experienced major complications after the procedure. Among minor complications, longer distances from the pleura, the presence of emphysema, and the lower dimensions of the lesions were correlated with the development of pneumothorax after the procedure, while longer distances from the pleura and the lower dimensions of the lesions were correlated with intra-alveolar hemorrhage. Immunohistochemistry analysis was performed in 51% of true positive cases, showing TTF-1, CK7, and p40 expression, respectively, in 26%, 24%, and 10% of analyzed samples. CONCLUSIONS: The CT-guided thoracic core-needle biopsy is an extremely accurate and safe diagnostic procedure for the histological diagnosis of lung cancer, a first-level interventional radiology exam for peripheral and subpleural lesions of the lung, which is also able to provide adequate samples for advanced pathologic assays (e.g., FISH, PCR) to assess molecular activity and genetic sequencing.

Contrast-Enhanced CT Texture Analysis in Colon Cancer: Correlation with Genetic Markers.

Background: The purpose of the study was to determine whether contrast-enhanced CT texture features relate to, and can predict, the presence of specific genetic mutations involved in CRC carcinogenesis. Materials and methods: This retrospective study analyzed the pre-operative CT in the venous phase of patients with CRC, who underwent testing for mutations in the KRAS, NRAS, BRAF, and MSI genes. Using a specific software based on CT images of each patient, for each slice including the tumor a region of interest was manually drawn along the margin, obtaining the volume of interest. A total of 56 texture parameters were extracted that were compared between the wild-type gene group and the mutated gene group. A p-value of <0.05 was considered statistically significant. Results: The study included 47 patients with stage III-IV CRC. Statistically significant differences between the MSS group and the MSI group were found in four parameters: GLRLM RLNU (area under the curve (AUC) 0.72, sensitivity (SE) 77.8%, specificity (SP) 65.8%), GLZLM SZHGE (AUC 0.79, SE 88.9%, SP 65.8%), GLZLM GLNU (AUC 0.74, SE 88.9%, SP 60.5%), and GLZLM ZLNU (AUC 0.77, SE 88.9%, SP 65.8%). Conclusions: The findings support the potential role of the CT texture analysis in detecting MSI in CRC based on pre-treatment CT scans.

Chronic Thromboembolic Pulmonary Hypertension: An Observational Study.

Background and Objectives: Chronic thromboembolic pulmonary hypertension (CTEPH) has a high mortality. The treatment of CTEPH could be balloon pulmonary angioplasty (BPA), medical (MT) or pulmonary endarterectomy (PEA). This study aims to assess the clinical characteristics of CTEPH patients, surgically or medically treated, in a pulmonology referral center. Materials and Methods: A total of 124 patients with PH with suspected CTEPH (53 male subjects and 71 female subjects; mean age at diagnosis 67 ± 6) were asked to give informed consent and then were evaluated. The presence of CTEPH was ascertained by medical evaluations, radiology and laboratory tests. Results: After the evaluation of all clinical data, 65 patients met the inclusion criteria for CTEPH and they were therefore enrolled (22 males and 43 females; mean age at diagnosis was 69 ± 8). 26 CTEPH patients were treated with PEA, 32 with MT and 7 with BPA. There was a statistically significant age difference between the PEA and MT groups, at the time of diagnosis, the PEA patients were younger than the MT patients, whereas there was no statistically significant difference in other clinical characteristics (e.g., smoking habit, thrombophilia predisposition), as well as functional and hemodynamic parameters (e.g., 6-min walk test, right heart catheterization). During three years of follow-up, no patients in the PEA groups died; conversely, eleven patients in the MT group died during the same period (p < 0.05). Furthermore, a significant decrease in plasma BNP values and an increase in a meter at the six-minute walk test, 1 and 3 years after surgery, were observed in the PEA group (p < 0.05). Conclusions: This study seems to confirm that pulmonary endarterectomy (PEA) can provide an improvement in functional tests in CTEPH.

Gastroesophageal Reflux Disease in Idiopathic Pulmonary Fibrosis: Viewer or Actor? To Treat or Not to Treat?

BACKGROUND: Idiopathic pulmonary fibrosis (IPF) is a rare and severe disease with a median survival of ∼3 years. Several risk factors have been identified, such as age, genetic predisposition, tobacco exposure, and gastro-oesophageal reflux disease (GERD). Prevalence of GERD in IPF is high and may affect 87% of patients, of whom only half (47%) report symptoms. Objective: The aim of this study is to review current evidence regarding the correlation between GERD and IPF and to evaluate the current studies regarding treatments for GERD-IPF. Methods: A review to identify research papers documenting an association between GERD and IPF was performed. Results: We identified several studies that have confirmed the association between GERD and IPF, with an increased acid exposure, risk of gastric aspiration and bile acids levels in these patients. Few studies focused their attention on GERD treatment, showing how antiacid therapy was not able to change IPF evolution. Conclusions: This review investigating the correlation between GERD and IPF has confirmed the hypothesized association. However, further large prospective studies are needed to corroborate and elucidate these findings with a focus on preventative and treatment strategies.

Chronic Thromboembolic Pulmonary Hypertension: An Update.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare disease observed in a small proportion of patients after acute pulmonary embolism (PE). CTEPH has a high morbidity and mortality rate, related to the PH severity, and a poor prognosis, which mirrors the right ventricular dysfunction involvement. Pulmonary endarterectomy (PEA) reduces pulmonary vascular resistance, making it the treatment of choice and should be offered to operable CTEPH patients, as significant symptomatic and prognostic improvement has been observed. Moreover, these patients may also benefit from the advances made in surgical techniques and pulmonary hypertension-specific medication. However, not all patients are eligible for PEA surgery, as some have either distal pulmonary vascular obstruction and/or significant comorbidities. Therefore, surgical candidates should be carefully selected by an interprofessional team in expert centers. This review aims at making an overview of the risk factors and latest developments in diagnostic tools and treatment options for CTEPH.

Structured Reporting of Lung Cancer Staging: A Consensus Proposal.

BACKGROUND: Structured reporting (SR) in radiology is becoming necessary and has recently been recognized by major scientific societies. This study aimed to build CT-based structured reports for lung cancer during the staging phase, in order to improve communication between radiologists, members of the multidisciplinary team and patients. MATERIALS AND METHODS: A panel of expert radiologists, members of the Italian Society of Medical and Interventional Radiology, was established. A modified Delphi exercise was used to build the structural report and to assess the level of agreement for all the report sections. The Cronbach's alpha (Cα) correlation coefficient was used to assess internal consistency for each section and to perform a quality analysis according to the average inter-item correlation. RESULTS: The final SR version was built by including 16 items in the "Patient Clinical Data" section, 4 items in the "Clinical Evaluation" section, 8 items in the "Exam Technique" section, 22 items in the "Report" section, and 5 items in the "Conclusion" section. Overall, 55 items were included in the final version of the SR. The overall mean of the scores of the experts and the sum of scores for the structured report were 4.5 (range 1-5) and 631 (mean value 67.54, STD 7.53), respectively, in the first round. The items of the structured report with higher accordance in the first round were primary lesion features, lymph nodes, metastasis and conclusions. The overall mean of the scores of the experts and the sum of scores for staging in the structured report were 4.7 (range 4-5) and 807 (mean value 70.11, STD 4.81), respectively, in the second round. The Cronbach's alpha (Cα) correlation coefficient was 0.89 in the first round and 0.92 in the second round for staging in the structured report. CONCLUSIONS: The wide implementation of SR is critical for providing referring physicians and patients with the best quality of service, and for providing researchers with the best quality of data in the context of the big data exploitation of the available clinical data. Implementation is complex, requiring mature technology to successfully address pending user-friendliness, organizational and interoperability challenges.

Correlation between Potential Risk Factors and Pulmonary Embolism in Sarcoidosis Patients Timely Treated.

BACKGROUND: Some studies with inconclusive results have reported a link between sarcoidosis and an increased risk of pulmonary embolism (PE). This study aimed at assessing a possible correlation between potential risk factors and PE in sarcoidosis patients. METHODS: A total of 256 sarcoidosis patients (84 males and 172 females; mean age at diagnosis 49 ± 13) were enrolled after giving written informed consent. Clinical evaluations, laboratory and radiology tests were performed to evaluate the presence of pulmonary embolism. RESULTS: Fifteen sarcoidosis patients with PE (4 males and 11 females; mean age at diagnosis 50 ± 11), diagnosed by lung scintigraphy and 241 sarcoidosis patients without PE (80 males and 161 females; mean age at diagnosis 47 ± 13), were observed. There was a statistically significant increase of the presence of antiphospholipid antibodies in the sarcoidosis group with pulmonary embolism. There was no statistically significant difference between the two groups as to smoking habit, obesity or hereditary thrombophilia frequency (p > 0.05, respectively). CONCLUSIONS: This study demonstrates a significant correlation between the presence of antiphospholipid antibody positivity and the pulmonary embolism events in our sarcoidosis patients. Furthermore, we propose screening for these antibodies and monitoring, aimed at timely treatment.

The History and Mystery of Alveolar Epithelial Type II Cells: Focus on Their Physiologic and Pathologic Role in Lung.

Alveolar type II (ATII) cells are a key structure of the distal lung epithelium, where they exert their innate immune response and serve as progenitors of alveolar type I (ATI) cells, contributing to alveolar epithelial repair and regeneration. In the healthy lung, ATII cells coordinate the host defense mechanisms, not only generating a restrictive alveolar epithelial barrier, but also orchestrating host defense mechanisms and secreting surfactant proteins, which are important in lung protection against pathogen exposure. Moreover, surfactant proteins help to maintain homeostasis in the distal lung and reduce surface tension at the pulmonary air-liquid interface, thereby preventing atelectasis and reducing the work of breathing. ATII cells may also contribute to the fibroproliferative reaction by secreting growth factors and proinflammatory molecules after damage. Indeed, various acute and chronic diseases are associated with intensive inflammation. These include oedema, acute respiratory distress syndrome, fibrosis and numerous interstitial lung diseases, and are characterized by hyperplastic ATII cells which are considered an essential part of the epithelialization process and, consequently, wound healing. The aim of this review is that of revising the physiologic and pathologic role ATII cells play in pulmonary diseases, as, despite what has been learnt in the last few decades of research, the origin, phenotypic regulation and crosstalk of these cells still remain, in part, a mystery.

The Treatment of Lung Involvement in Systemic Sclerosis.

Systemic sclerosis (SSc) patients are often affected by interstitial lung disease (ILD) and, although there have been recent treatment advances, it remains the leading cause of death among SSc, with a 10-year mortality up to 40%. African Americans and subjects with diffuse cutaneous SSc or anti-topoisomerase 1 antibodies are most commonly affected. Currently, early ILD diagnosis can be made, and it is pivotal to improve the prognosis. The diagnostic mainstay test for SSc-ILD is high-resolution computed tomography for the morphology and pulmonary function tests for the functional aspects. Treatment planning and intensity are guided by the disease severity and risk of progression. Traditionally, therapy has depended on combinations of immunosuppressants, particularly cyclophosphamide and mycophenolate mofetil, which can be supplemented by targeted biological and antifibrotic therapies. Benefits have been observed in trials on hematopoietic autologous stem cell transplantation for patients with progressive SSc, whilst lung transplantation is reserved for refractory SSc-ILD cases. Herein, recent advances in SSc-ILD treatment will be explored.

Potential links between COVID-19-associated pulmonary aspergillosis and bronchiectasis as detected by high resolution computed tomography.

PURPOSE: The aim of this observational study was to highlight high resolution CT scan characteristics of COVID-19-associated pulmonary aspergillosis (CAPA) with a focus on the detection of de-novo appeared or evolved bronchiectasis. METHODS: From March 2020 to May 2021, we enrolled 350 consecutive mechanically ventilated ICU patients with COVID-19. Patients with CAPA and at least one chest CT scan performed within 15 days from the diagnosis were included. Two radiologists were asked to identify typical and atypical signs of COVID-19 pneumonia. Bronchiectasis locations were described and a modified Reiff score was calculated, as severity score. A total of 19 CAPA patients (median age 71.0, Interquartile range (IQR) 62.5-75.0; male 16, 84.2%) were included. RESULTS: According to the 2020 ECMM/ISHAM criteria, 18 patients had probable CAPA and one had proven CAPA. The median time between hospital admission and CT scan was 21 days (IQR 14.5-25.0). The incidence of bronchiectasis in the study population was 57.9% (n = 11). Tubular bronchiectasis was detected in 10 patients and were scored as follows: three patients had a score of 1, three patients had a score of score 2, one patient had a score of 5 and four patients had a score of 6. Eight patients had a previous CT scan (performed at hospital admission), among them: 5 patients developed de-novo bronchiectasis, while 2 patients demonstrated a volumetric increase of bronchiectasis. At the 6-months follow-up, the mortality rate for patients with CAPA was >60%. CONCLUSION: the radiologic detection of de-novo appearance or volumetric increase of bronchiectasis in COVID-19 should lead clinicians to search for fungal superinfections.

CT Urography Findings of Upper Urinary Tract Carcinoma and Its Mimickers: A Pictorial Review.

Urothelial carcinoma (UC) is the fourth most frequent tumor in Western countries and upper tract urothelial carcinoma (UTUC), affecting pyelocaliceal cavities and ureter, accounts for 5-10% of all UCs. Computed tomography urography (CTU) is now considered the imaging modality of choice for diagnosis and staging of UTUC, guiding disease management. Although its specificity is very high, both benign and malignant diseases could mimic UTUCs and therefore have to be well-known to avoid misdiagnosis. We describe CTU findings of upper urinary tract carcinoma, features that influence disease management, and possible differential diagnosis.

Severity of lung involvement on chest X-rays in SARS-coronavirus-2 infected patients as a possible tool to predict clinical progression: an observational retrospective analysis of the relationship between radiological, clinical, and laboratory data / Gravidade do comprometimento pulmonar em radiografias de tórax de pacientes infectados por SARS-coronavirus-2 como possível ferramenta para prever a evolução clínica: análise retrospectiva observacional da relação entre dados radiológicos, clínicos e laboratoriais

ABSTRACT Objective: To investigate the diagnostic accuracy of a chest X-ray (CXR) score and of clinical and laboratory data in predicting the clinical course of patients with SARS coronavirus 2 (SARS-CoV-2) infection. Methods: This is a pilot multicenter retrospective study including patients with SARS-CoV-2 infection admitted to the ERs in three hospitals in Italy between February and March of 2020. Two radiologists independently evaluated the baseline CXR of the patients using a semi-quantitative score to determine the severity of lung involvement: a score of 0 represented no lung involvement, whereas scores of 1 to 4 represented the first (less severe) to the fourth (more severe) quartiles regarding the severity of lung involvement. Relevant clinical and laboratory data were collected. The outcome of patients was defined as severe if noninvasive ventilation (NIV) or intubation was necessary, or if the patient died. Results: Our sample comprised 140 patients. Most of the patients were symptomatic (132/138; 95.7%), and 133/140 patients (95.0%) presented with opacities on CXR at admission. Of the 140 patients, 7 (5.0%) showed no lung involvement, whereas 58 (41.4%), 31 (22.1%), 26 (18.6%), and 18 (12.9%), respectively, scored 1, 2, 3, and 4. In our sample, 66 patients underwent NIV or intubation, 37 of whom scored 1 or 2 on baseline CXR, and 28 patients died. Conclusions: The severity score based on CXR seems to be able to predict the clinical progression in cases that scored 0, 3, or 4. However, the score alone cannot predict the clinical progression in patients with mild-to-moderate parenchymal involvement (scores 1 and 2).

RESUMO Objetivo: Investigar a acurácia diagnóstica de um escore de radiografia de tórax (RxT) e também de dados clínicos e laboratoriais na previsão da evolução clínica de pacientes com infecção por SARS coronavirus 2 (SARS-CoV-2). Métodos: Estudo piloto multicêntrico retrospectivo incluindo pacientes com infecção por SARS-CoV-2 internados nos PSs de três hospitais na Itália entre fevereiro e março de 2020. Dois radiologistas avaliaram as RxT iniciais dos pacientes de forma independente utilizando um escore semiquantitativo para determinar a gravidade do comprometimento pulmonar: escore 0 representava ausência de comprometimento pulmonar, enquanto escores de 1 a 4 representavam o primeiro (menos grave) ao quarto (mais grave) quartil de gravidade do comprometimento pulmonar. Coletaram-se dados clínicos e laboratoriais relevantes. O desfecho dos pacientes foi definido como grave se foi necessária ventilação não invasiva (VNI) ou intubação ou se o paciente faleceu. Resultados: Nossa amostra foi composta por 140 pacientes. A maioria era sintomática (132/138; 95,7%), e 133/140 (95,0%) apresentavam opacidades na RxT da admissão. Dos 140 pacientes, 7 (5,0%) não apresentavam comprometimento pulmonar, enquanto 58 (41,4%), 31 (22,1%), 26 (18,6%) e 18 (12,9%), respectivamente, receberam escore 1, 2, 3 e 4. Em nossa amostra, 66 pacientes foram submetidos a VNI ou intubação, 37 dos quais receberam escore 1 ou 2 na RxT inicial, e 28 pacientes faleceram. Conclusões: O escore de gravidade baseado em RxT parece ser capaz de prever a evolução clínica em casos com escore 0, 3 ou 4. No entanto, o escore isoladamente não consegue prever a evolução clínica de pacientes com comprometimento leve a moderado do parênquima (escores 1 e 2).

Imaging Review of the Lung Parenchymal Complications in Patients with IPF.

Idiopathic pulmonary fibrosis (IPF) is a chronic, pulmonary-limited, interstitial lung disease with a poor prognosis. This condition is characterized by different clinical scenarios, ranging from the most typical slow and progressive deterioration of symptoms to a rapid and abrupt decline of lung function. Rapid worsening of clinical course is due to superimposed complications and comorbidities that can develop in IPF patients, with a higher incidence rate compared to the general population. These conditions may require a different management of the patient and a therapy adjustment, and thus it is fundamental to recognize them. High Resolution Computed Tomography (HRCT) is sensitive, but not specific, in detecting these complications, and can evaluate the presence of radiological variations when previous examinations are available; it recognizes ground glass opacities or consolidation that can be related to a large spectrum of comorbidities, such as infection, lung cancer, or acute exacerbation. To reach the final diagnosis, a multidisciplinary discussion is required, particularly when the clinical context is related to imaging findings.

Diagnostic impact of digital tomosynthesis in oncologic patients with suspected pulmonary lesions on chest radiography.

OBJECTIVES: To assess the actual diagnostic impact of digital tomosynthesis (DTS) in oncologic patients with suspected pulmonary lesions on chest radiography (CXR). METHODS: A total of 237 patients (135 male, 102 female; age, 70.8 ± 10.4 years) with a known primary malignancy and suspected pulmonary lesion(s) on CXR and who underwent DTS were retrospectively identified. Two radiologists (experience, 10 and 15 years) analysed in consensus CXR and DTS images and proposed a diagnosis according to a confidence score: 1 or 2 = definitely or probably benign pulmonary or extrapulmonary lesion, or pseudolesion; 3 = indeterminate; 4 or 5 = probably or definitely pulmonary lesion. DTS findings were proven by CT (n = 114 patients), CXR during follow-up (n = 105) or histology (n = 18). RESULTS: Final diagnoses included 77 pulmonary opacities, 26 pulmonary scars, 12 pleural lesions and 122 pulmonary pseudolesions. DTS vs CXR presented a higher (P < 0.05) sensitivity (92 vs 15 %), specificity (91 vs 9 %), overall accuracy (92 vs 12 %), and diagnostic confidence (area under ROC, 0.997 vs 0.619). Mean effective dose of CXR vs DTS was 0.06 vs 0.107 mSv (P < 0.05). CONCLUSIONS: DTS improved diagnostic accuracy and confidence in comparison to CXR alone in oncologic patients with suspected pulmonary lesions on CXR with only a slight, though significant, increase in radiation dose. KEY POINTS: • Digital tomosynthesis (DTS) improves accuracy of chest radiography (CXR) in oncologic patients. • DTS improves confidence of CXR in oncologic patients. • DTS allowed avoidance of CT in about 50 % of oncologic patients.

Digital tomosynthesis as a problem-solving imaging technique to confirm or exclude potential thoracic lesions based on chest X-ray radiography.

RATIONALE AND OBJECTIVES: To assess the capability of digital tomosynthesis (DTS) as a problem-solving imaging technique to confirm or exclude potential thoracic lesions based on chest x-ray radiography (CXR). MATERIALS AND METHODS: Four hundred and-sixty five patients (263 male, 202 female; age, 72.47 ± 11.33 years) with suspected thoracic lesion(s) after the initial onsite analysis of CXR underwent DTS. Two independent readers prospectively analyzed in consensus CXR and DTS images on a picture archiving and communications system-integrated workstation and proposed a diagnosis according to a confidence score for each lesion: 1 or 2 = definite or probable pulmonary or pleural benign lesion or pseudolesion deserving no further diagnostic work-up; 3 = indeterminate; 4 or 5 = probable or definite pulmonary lesion deserving further diagnostic work-up by computed tomography (CT). In patients who did not undergo chest CT, the DTS findings had to be confirmed by 6 to 12 months' imaging follow-up. RESULTS: Finally, 229 pulmonary lesions (193 thoracic and 36 pleural lesions) and 236 pseudolesions were identified. Based on DTS images, readers correctly classified all pseudolesions except for 10/236 (reader 1) or 11/236 (reader 2) pseudolesions and 7 (reader 1) or 6 (reader 2) pulmonary subpleural lesions located in the anterior or posterior lung region close to the thoracic wall. Chest CT was performed in 127/465 (27%) patients, whereas in 338/465 patients (73%) CXR doubtful findings were resolved by DTS. CONCLUSIONS: DTS allowed to exclude most pseudolesions initially considered as potential thoracic lesions on the preliminary onsite assessment of CXR and allowed to exclude pulmonary lesions deserving CT assessment in about three fourths of the patients.

Analysis of the impact of digital tomosynthesis on the radiological investigation of patients with suspected pulmonary lesions on chest radiography.

OBJECTIVE: To assess the impact of digital tomosynthesis (DTS) on the radiological investigation of patients with suspected pulmonary lesions on chest radiography (CXR). METHODS: Three hundred thirty-nine patients (200 male; age, 71.19 ± 11.9 years) with suspected pulmonary lesion(s) on CXR underwent DTS. Two readers prospectively analysed CXR and DTS images, and recorded their diagnostic confidence: 1 or 2 = definite or probable benign lesion or pseudolesion deserving no further diagnostic workup; 3 = indeterminate; 4 or 5 = probable or definite pulmonary lesion deserving further diagnostic workup by computed tomography (CT). Imaging follow-up by CT (n = 76 patients), CXR (n = 256) or histology (n = 7) was the reference standard. RESULTS: DTS resolved doubtful CXR findings in 256/339 (76 %) patients, while 83/339 (24 %) patients proceeded to CT. The mean interpretation time for DTS (mean ± SD, 220 ± 40 s) was higher (P < 0.05; Wilcoxon test) than for CXR (110 ± 30 s), but lower than CT (600 ± 150 s). Mean effective dose was 0.06 mSv (range 0.03-0.1 mSv) for CXR, 0.107 mSv (range 0.094-0.12 mSv) for DTS, and 3 mSv (range 2-4 mSv) for CT. CONCLUSIONS: DTS avoided the need for CT in about three-quarters of patients with a slight increase in the interpretation time and effective dose compared to CXR.

The value of digital tomosynthesis in the diagnosis of suspected pulmonary lesions on chest radiography: analysis of diagnostic accuracy and confidence.

RATIONALE AND OBJECTIVES: The aim of this study was to investigate the value of digital tomosynthesis in the diagnosis of suspected pulmonary lesions on chest radiography. MATERIALS AND METHODS: Two-hundred twenty-eight patients (133 men, 95 women; mean age, 70.8 ± 11.1 years) with suspected pulmonary lesions after initial analysis of chest radiography underwent digital tomosynthesis. Two independent readers (with 3 and 20 years of experience) prospectively analyzed the chest radiographic and digital tomosynthesis images on a picture archiving and communication system workstation and proposed a diagnostic confidence score for each lesion (1 or 2 = definitely or probably extrapulmonary lesion or pseudolesion, 3 = indeterminate, 4 or 5 = probably or definitely pulmonary lesion). Chest computed tomography was the reference standard examination. RESULTS: A total of 251 suspected pulmonary lesions were identified. In 71 patients, digital tomosynthesis and computed tomography did not confirm any lesion. In the remaining 157 patients, 180 lesions were identified, including 112 pulmonary and 68 extrapulmonary lesions. In 110 (reader 1) and 123 (reader 2) lesions, correct diagnoses were provided after analysis of the chest radiographs. All lesions were correctly classified after digital tomosynthesis except for 14 extrapulmonary lesions (both readers) that were misinterpreted as pulmonary and 10 (reader 1) and six (reader 2) pulmonary lesions that were misinterpreted as pleural. Digital radiography versus tomosynthesis differed in accuracy (reader 1, 43% vs 90%; reader 2, 49% vs 92%; P < .05) and confidence by area under the receiver-operating characteristic curve (reader 1, 0.788 vs 0.944; reader 2, 0.840 vs 0.997; P < .05). CONCLUSIONS: Digital tomosynthesis improved diagnostic accuracy and confidence in the diagnosis of suspected pulmonary lesions on chest radiography.