Vascular tree-in-bud sign in Pulmonary Tumour Thrombotic Microangiopathy (PTTM): CT findings for a difficult radiological early antemortem diagnosis.

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Immune-Checkpoint-Inhibitor-Related Lung Toxicity: A Multicentre Real-Life Retrospective Portrait from Six Italian Centres.

BACKGROUND: Immune checkpoint inhibitors (ICIs) have revolutionized the therapeutic horizons of various cancers. However, immune-related adverse events have been reported, including interstitial lung diseases. Our aim was to describe the clinical and radiological features and survival of a multicentre cohort of patients who developed ICI-related lung toxicity. METHODS: Six Italian centres were involved in the study. Patients who were treated with anti-PD-1/PD-L1 and CTLA-4 mAbs and developed ICI-related lung toxicity were recruited retrospectively to study clinical, radiological, immunological and survival data. RESULTS: A total of 41 patients (25 males, 66.8 ± 9.9 years) were enrolled. Lung toxicity occurred after 204.3 ± 208.3 days of therapy, with ground glass opacities being the most common HRCT pattern (23 cases). Male sex, lung cancer and acute respiratory failure were associated with a shorter latency of toxicity (p = 0.0030, p = 0.0245 and p = 0.0390, respectively). Patients who required high-flow oxygen therapy showed significantly worse survival (p = 0.0028). CONCLUSIONS: Our cohort showed heterogeneous clinical and radiological aspects of ICI-related lung toxicity, with a latency not limited to the first year of treatment. Severity was mainly mild to moderate, although life-threatening events did occur. Our data indicate that strict long-term follow-up is needed to enable early diagnosis and appropriate management.

A practical overview of CT and MRI features of developmental, inflammatory, and neoplastic lesions of the sphenoid body and clivus.

The sphenoid bone is an unpaired bone that contributes to the formation of the skull base. Despite the enormous progress in transnasal endoscopic visualisation, imaging techniques remain the cornerstones to characterise any pathological condition arising in this area. In the present review, we offer a bird's-eye view of the developmental, inflammatory, and neoplastic alterations affecting the sphenoid body and clivus, with the aim to propose a practical diagnostic aid for radiologists based on clinico-epidemiological, computed tomography, and magnetic resonance imaging features.

Low-dose CT for lung cancer screening: position paper from the Italian college of thoracic radiology.

Smoking is the main risk factor for lung cancer (LC), which is the leading cause of cancer-related death worldwide. Independent randomized controlled trials, governmental and inter-governmental task forces, and meta-analyses established that LC screening (LCS) with chest low dose computed tomography (LDCT) decreases the mortality of LC in smokers and former smokers, compared to no-screening, especially in women. Accordingly, several Italian initiatives are offering LCS by LDCT and smoking cessation to about 10,000 high-risk subjects, supported by Private or Public Health Institutions, envisaging a possible population-based screening program. Because LDCT is the backbone of LCS, Italian radiologists with LCS expertise are presenting this position paper that encompasses recommendations for LDCT scan protocol and its reading. Moreover, fundamentals for classification of lung nodules and other findings at LDCT test are detailed along with international guidelines, from the European Society of Thoracic Imaging, the British Thoracic Society, and the American College of Radiology, for their reporting and management in LCS. The Italian College of Thoracic Radiologists produced this document to provide the basics for radiologists who plan to set up or to be involved in LCS, thus fostering homogenous evidence-based approach to the LDCT test over the Italian territory and warrant comparison and analyses throughout National and International practices.

CT findings of non-neoplastic central airways diseases.

Non-neoplastic lesions of central airways are uncommon entities with different etiologies, with either focal or diffuse involvement of the tracheobronchial tree. Clinical symptoms of non-neoplastic tracheobronchial diseases are non-specific, and diagnosis is difficult, especially in the early stages. Three-dimensional computed tomography (3D-CT) is an evaluable tool as it allows to assess and characterize tracheobronchial wall lesions and meanwhile it enables the evaluation of airways surrounding structures. Multiplanar reconstructions (MPR), minimum intensity projections (MinIP), and 3D Volume Rendering (VR) (in particular, virtual bronchoscopy) also provide information on the site and of the length of airway alterations. This review will be discussed about (1) primary airway disorders, such as relapsing polychondritis, tracheobronchophathia osteochondroplastica, and tracheobronchomegaly, (2) airway diseases, related to granulomatosis with polyangiitis, Chron's disease, Behcet's disease, sarcoidosis, amyloidosis, infections, intubation and transplantation, (3) tracheobronchial malacia, and (4) acute tracheobronchial injury. 3D-CT findings, especially with MPR and 3D VR reconstructions, allows us to evaluate tracheobronchial disease morphologically in detail.

Moderate-severe coronary calcification predicts long-term cardiovascular death in CT lung cancer screening: The ITALUNG trial.

PURPOSE: Coronary artery calcifications (CAC) are very strong indicators for increased cardio-vascular (CV) risk and can be evaluated also in low-dose computed tomography (LDCT) for lung cancer screening. We assessed whether a simple and fast CAC visual score is associated with CV mortality. METHODS: CAC were retrospectively assessed by two observers using a 4-score (absent, mild, moderate and severe) scale in baseline LDCT obtained in 1364 participants to the ITALUNG trial who had 55-69 years of age and a smoking history ≥20 pack-years. Correlations with CV risk factors at baseline and with CV mortality after 11 years of follow-up were investigated. RESULTS: CAC were absent in 470 (34.5%), mild in 433 (31.7%), moderate in 357 (26.2%) and severe in 104 (7.6%) subjects. CAC severity correlated (≤0.001) with age, male sex, pack-years, history of arterial hypertension or diabetes, obesity and treated hypercholesterolemia. Twenty-one CV deaths occurred. Moderate or severe CAC were significantly associated with higher CV mortality after adjustment for all other known risk factors (ARR = 2.72; 95 %CI:1.04-7.11). Notably, also in subjects with none or one only additional CV risk factor, the presence of moderate-severe CAC allowed to identify a subgroup of subjects with higher CV death risk (RR = 3.66; CI95%:1.06-12.6). CONCLUSIONS: Moderate or severe CAC visually assessed in LDCT examinations for lung cancer screening are independently associated with CV mortality.

Prognostic value of CT pulmonary angiography parameters in acute pulmonary embolism.

OBJECTIVES: Computed tomographic pulmonary angiography (CTPA) is the first-line test in acute pulmonary embolism (APE) diagnostic algorithm, but its correlation with short-term outcome remains not clear at all. The aim is to determine whether CTPA findings can predict 30-day mortality of patients with APE in Emergency Department. METHODS: This retrospective monocentric study involved 780 patients with APE diagnosed at the Emergency Department of our institution (period 2010-2019). These CTPA findings were evaluated: embolic obstruction burden score (Qanadli score), common pulmonary artery trunk diameter, right-to-left ventricular ratio, azygos vein and coronary sinus diameters. Comorbidities and fatal/nonfatal adverse outcomes within 30 days were recorded. Troponin I values were correlated with angiographic parameters with multiple logistic regression analysis. RESULTS: The all-cause and APE-related 30-day mortality rates were 5.9% and 3.6%, respectively. Patients who died within 30 days were older with higher prevalence rates of malignancy. Qanadli score and all CTPA parameters correlate with Troponin I level and the presence of RVD at echocardiography (p values < 0.0001). Instead, RV/LV ratio and coronary sinus diameter correlate with 30-day mortality (p values < 0.05). At the multivariate logistic regression analysis, only coronary sinus and RVD remained significant with an HR = 2.5 (95% CI 1.1-5.6) and HR = 1.9 (95% CI 0.95-3.7), respectively. CONCLUSION: CTPA quantification of right ventricular strain is an accurate predictor of 30-day mortality. In particular, it seems that a dilated coronary sinus (>9 mm) has an additional prognostic value in association with echocardiographic signs of right-heart disfunction and high Troponin I levels.

Exogenous lipoid pneumonia: when radiologist makes the difference.

PURPOSE: To report high-resolution CT (HRCT) findings in our group of patients with exogenous lipoid pneumonia (ELP), confirmed with histopathological findings and clinical-anamnestic data, in order to describe the most common radiological patterns of this rare disorder. MATERIALS AND METHODS: In this retrospective study, HRCT of 10 patients with ELP were evaluated by three radiologists. Diagnosis of ELP was made through CT, bronchiolo-alveolar lavage (BAL) and a pneumological examination associated with an accurate medical anamnesis. Five patients had a histologically proven ELP, through lung biopsy. All patients had a chronic exposition to substances made of animal fat or mineral/vegetable oils. RESULTS: In our cohort of patients with ELP, the following parenchymal patterns were observed: 8/10 patients had lung consolidation with adipose density (attenuation values < - 40 HU); 10/10 patients had multiple areas of ground glass opacity; 6/10 patients had smooth thickening of interlobular septa and ground glass opacities ("crazy-paving" pattern); 2/10 patients presented nodules > 2.5 cm with spiculated margins (tumor-like); 5/10 patients showed reactive lymph nodes enlargement. The oldest lesions were characterized by bronchiectasis and fibrosis around the lipidic consolidations. CONCLUSION: Pulmonary alterations found in HRCT exams can be confused with other lung diseases (especially lung tumors) and they are always a challenge even for the most experienced radiologist. In our experience, although non-specific, consolidation areas with low HU values and crazy-paving pattern are frequently associated in ELP. These characteristics should alert the radiologist to consider ELP among the possible differential diagnoses, always correlating the results of CT examination with appropriate clinical-laboratory evaluations and an accurate anamnesis.

Decreased cardiovascular mortality in the ITALUNG lung cancer screening trial: Analysis of underlying factors.

OBJECTIVES: In the ITALUNG lung cancer screening trial after 9.3 years of follow-up we observed an unexpected significant decrease of cardiovascular (CV) mortality in subjects invited for low-dose CT (LDCT) screening as compared to controls undergoing usual care. Herein we extended the mortality follow-up and analyzed the potential factors underlying such a decrease. MATERIALS AND METHODS: The following factors were assessed in screenes and controls: burden of CV disease at baseline, changes in smoking habits, use of CV drugs and frequency of planned vascular procedures after randomisation. Moreover, in the screenes we evaluated inclusion of presence of coronary artery calcification (CAC) in the LDCT report form that was transmitted to the participant and his/her General Practitioner. RESULTS: The 2-years extension of follow-up confirmed a significant decrease of CV mortality in the subjects of the active group compared to control subjects (15.6 vs 34.0 per 10,000; p = 0.001) that was not observed in the drops-out of the active group. None of the explaining factors we considered significantly differed between active and control group. However, the subjects of the active group with reported CAC experienced a not significantly lower CV mortality and showed a significantly higher use of CV drugs and frequency of planned vascular procedures than the control group. CONCLUSIONS: LDCT screening for lung cancer offers the opportunity for detection of CAC that is an important CV risk factor. Although the underlying mechanisms are not clear, our results suggest that the inclusion of information about CAC presence in the LDCT report may represent a candidate factor to explain the decreased CV mortality observed in screened subjects of the ITALUNG trial, possibly resulting in intervention for patient care to prevent CV deaths. Further studies investigating whether prospective reporting and rating of CAC have independent impact on such interventions and CV mortality are worthy.

Lung Cancer in Patients with Severe Idiopathic Pulmonary Fibrosis: Critical Aspects.

Idiopathic pulmonary fibrosis (IPF) is a rare interstitial lung disease limited to the lung with an undefined etiopathogenesis and a very short life expectancy (less than 5 years). IPF susceptibility has been associated with several genetic and environmental risk factors and the prognosis is conditioned by comorbidities such as gastro-esophageal reflux, depression, venous thromboembolism, pulmonary hypertension and lung cancer. At 5 years follow-up, 15% of IPF patients develop lung cancer, which can significantly reduce their survival. Because diagnostic or therapeutic procedures such as surgical, radiation or pharmacological treatments may induce acute exacerbations and increase mortality, the management of lung cancer in IPF patients is a very difficult task. This study discusses advantages and disadvantages of lung cancer treatments in patients with severe IPF, highlighting several controversial aspects on this topic, including potential nintedanib treatment.

Lung CT densitometry in systemic sclerosis: correlation with lung function, exercise testing, and quality of life.

BACKGROUND: To ascertain if analysis of lung density histograms in thin-section CT was more reproducible than visual assessment of lung changes in systemic sclerosis (SSc), and if such density histogram parameters as mean lung attenuation (MLA), skewness, and kurtosis could more closely reflect pulmonary function as well as exercise and quality of life impairment. METHODS: The intraoperator and interoperator reproducibility of visual and densitometric lung CT analysis in 48 SSc patients examined with CT were evaluated by means of weighted kappa statistics. Univariate and multivariate regression analyses were applied to evaluate the relationship of visual and densitometric CT measurements with functional parameters including functional residual capacity (FRC), FVC, FEV(1), diffusion capacity of the lung for carbon monoxide (Dlco), 6-min walking testing (6MWT), and health-related quality of life questionnaire (QLQ) parameters. RESULTS: The intraoperator and interoperator reproducibility of MLA (intraobserver weighted kappa = 0.97; interobserver weighted kappa = 0.96), skewness (intraobserver weighted kappa = 0.89; interobserver weighted kappa = 0.88), and kurtosis (intraobserver weighted kappa = 0.89; interobserver weighted kappa = 0.88) were higher than those of visual assessment (intraobserver weighted kappa = 0.71; interobserver weighted kappa = 0.69). In univariate analysis, only densitometric measurements were correlated with some exercise and QLQ parameters. In multivariate analysis, MLA (square regression coefficient corrected [R(2)c] = 0.70), skewness (R(2)c = 0.78), and kurtosis (R(2)c = 0.77) were predicted by FRC, FVC, Dlco, 6MWT, and QLQ parameters, while visual assessment was associated only with FRC and FVC (R(2)c = 0.40). CONCLUSIONS: In SSc, densitometric analysis is more reproducible than visual assessment of lung changes in thin-section CT and more closely correlated to pulmonary function testing, 6MWT, and QLQ. Density histogram parameters may be useful for cross-sectional and longitudinal studies of lung involvement in SSc.

Transverse colon herniation through the foramen of Winslow presenting with unusual CT findings.

Bowel herniation through the foramen of Winslow is among the rarest of internal hernias, accounting for less than 0.8%. In its origin, a pivotal role is played by some anatomic variations, or anomalies such as the increased mobility of the right transverse colon, and maybe the exceedingly large bore of the foramen itself. The first case of hernia through the foramen of Winslow was reported by Blandin in 1834. Since then, no more that 200 new cases have been described. Diagnosis usually is established during surgery while treating a bowel obstruction. Only in an exceedingly small group of patients is diagnosis achieved preoperatively on the basis of radiological findings. We describe a preoperatively diagnosed case of transverse colon herniation through the foramen of Winslow, showing a portal vein narrowing and periportal lymphedema at computed tomography (CT). To the best of our knowledge, only a few cases of preoperative CT diagnosis of Winslow foramen hernia have been described in the past. None had the above-mentioned CT findings.

Spiral computed tomography versus ultrasound in the follow-up of cirrhotic patients previously treated for hepatocellular carcinoma: a prospective study.

BACKGROUND/AIMS: To assess the value of hepatic-arterial-phase computed tomography (HAP-CT) versus ultrasound (US) plus alpha-fetoprotein (AFP) in the surveillance of cirrhotic patients with previously treated hepatocellular carcinoma (HCC). METHODS: Thirty-six cirrhotic patients, treated for single nodular HCC <4cm with complete response and no evidence of other focal lesions, were enrolled in a prospective study and underwent simultaneous AFP/US/spiral-CT follow-up every 6 months. Focal lesions were considered recurrences when they appeared as globular enhancement areas (EA) at HAP-CT and increased in size during the follow-up. RESULTS: Fifteen of 36 patients showed at least one focal lesion for a total of 43 EA: 38/43 increased in size, four did not change and one disappeared. EA were first observed after a follow-up of 9+/-4 (range 6-18) months. At the same time, no patient had either nodular lesion at US examination or diagnostic levels of AFP. In 22 matched lesions, diagnosis by CT was 8.2+/-3.5 months earlier than by US. In 13 patients, one evolved EA was submitted to US-guided biopsy and histological examination showed HCC in all cases. CONCLUSIONS: Periodical spiral-CT examination is more effective than US-AFP in early detection of HCC recurrence in cirrhotic patients successfully treated for HCC.