Feasibility of a New Lung Ultrasound Protocol to Determine the Extent of Lung Injury in COVID-19 Pneumonia.

BACKGROUND: Lung ultrasound (LUS) scanning is useful to diagnose and assess the severity of pulmonary lesions during COVID-19-related ARDS (CoARDS). A conventional LUS score is proposed to measure the loss of aeration during CoARDS. However, this score was validated during the pre-COVID-19 era in patients with ARDS in the ICU and does not consider the differences with CoARDS. An alternative LUS method is based on grading the percentage of extension of the typical signs of COVID-19 pneumonia on the lung surface (LUSext). RESEARCH QUESTION: Is LUSext feasible in patients with COVID-19 at the onset of disease, and does it correlate with the volumetric measure of severity of COVID-19 pneumonia lesions at CT scan (CTvol)? STUDY DESIGN AND METHODS: This observational study enrolled a convenience sampling of patients in the ED with confirmed COVID-19 whose condition demonstrated pneumonia at bedside LUS and CT scan. LUSext was visually quantified. All CT scan studies were analyzed retrospectively by a specifically designed software to calculate the CTvol. The correlation between LUSext and CTvol, and the correlations of each score with Pao2/Fio2 ratio were calculated. RESULTS: We analyzed data from 179 patients. Feasibility of LUSext was 100%. Time to perform LUS scan was 5 ± 1.5 mins. LUSext and CTvol were correlated positively (R = 0.67; P < .0001). Both LUSext and CTvol showed negative correlation with Pao2/Fio2 ratio (R = -0.66 and R = -0.54; P < .0001, respectively). INTERPRETATION: LUSext is a valid measure of the severity of the lesions when compared with the CT scan. Not only are LUSext and CTvol correlated, but they also have similar inverse correlation with the severity of respiratory failure. LUSext is a practical and simple bedside measure of the severity of pneumonia in CoARDS, whose clinical and prognostic impact need to be investigated further.

Correlation between CT findings and thoracoscopic diagnosis in diffuse pleural disease.

OBJECTIVE: Computed Tomography (CT) is considered part of the routine diagnostic workup for pleural malignancy. The definitive diagnosis of pleural malignancy depends upon histological confirmation by pleural biopsy. The aim of this study is to assess the sensitivity and specificity of CT, in view of the latest imaging technologies, in detecting pleural malignancy compared to definitive histology achieved via thoracoscopy (VATS). MATERIALS AND METHODS: We included in this retrospective study 90 patients (36 F, 54 M) with suspected pleural malignancy  evaluated in our Institution with CT scan who received a definitive diagnosis after VATS biopsy. Unaware of histopathologic diagnoses CT scans were evaluated by a junior and two experts thoracic radiologist. Conclusions were reached by consensus. RESULTS: We evaluated all CT signs suggestive for malignant pleural diseases: pleural thickening > 10 mm (Se 0,41 , Sp 0,79); nodular thickening (Se 0,86, Sp 0,75); circumferential thickening (Se 0,79, Sp 0,69); irregular pleural thickening (Se 0,77, Sp 0,91); mediastinal involvement (Se 0,88, Sp 0,64); costal involvement (Se 0,89, Sp 0,60); diaphragmatic involvement (Se 0,88, Sp 0,53). Furthermore, the diagnostic performance of additional CT features was evaluated: concomitant costal, mediastinal and diaphragmatic pleura lesions (Se 0,84, Sp 0,69); nodular/irregular thickening with mediastinal pleural involvement (Se 0,83, Sp 0,90); nodular/irregular thickening with diaphragmatic pleural involvement (Se 0,81, Sp 0,90). CONCLUSIONS: CT confirms its central role in the pleura malignancy. The high sensibility, respect to previous studies, especially in the presence of nodular pleural thickening, may lead to reconsider at least partly the diagnostic pathway of diffuse pleural disease, avoiding the use of VATS in patients not eligible for surgery, in favor of US or CT guided core biopsy.

"Sigmoid diverticulitis mimicking cholecystitis" a clinical challenge.

Diverticular disease is a common disorder and its incidence increases with ageing. Pathophysiology is multifactorial. Lifestyle, including smoking, alcohol intake, decreased dietary fibres and lack of physical activity, plays a predominant role. Genetics seems also to contribute specifically for right-sided diverticular disease (RSD). The majority of the patients with diverticular disease are asymptomatic. Diverticulitis is the inflammation of the diverticula usually presenting with abdominal pain associated to nausea, vomiting, rectal bleeding, diarrhoea and fever. When the inflammation process affects the diverticula in the ascending colon, the condition represents a clinical challenge as it can be easily misdiagnosed with other acute abdominal emergencies. We reported a case of a 70-year-old female who presented to our Emergency Department (ED) with right upper quadrant pain and an initial clinical suspicion of cholecystitis. Ultrasound (US) and Computed Tomography (CT) demonstrated an anatomical variation of the sigmoid colon diverticulitis. This clinical report demonstrates that ultrasound plays a relevant part as first-step approach to the acute abdominal conditions and its accuracy increases together with other diagnostic tools such as Computer Tomography.

[Pulmonary tuberculosis in diagnostic imaging: the great mime.] / La tubercolosi polmonare nella diagnostica per immagini: il grande mimo.

Pulmonary tuberculosis (TB) is nowadays one of the most common causes of infectious disease-related morbility and mortality worldwide. The differential diagnosis between TB and some others conditions is an emerging problem, particularly challenging when TB imaging mimicks sarcoidosis, lymphoproliferative disorders and pulmonary neoplasms. In these cases, the correct diagnoses can be made with certainty only with trans-bronchial or CT guided biopsy.

Computed tomography of solitary fibrous tumor of the pleura abutting the mediastinum: A diagnostic challenge.

BACKGROUND: Solitary fibrous tumor of the pleura (SFTP) arising from the mediastinal pleura may be confused with primary mediastinal tumors. We studied the computerized tomographic (CT) findings of patients with SFTP that could suggest a diagnosis of SFTP. MATERIALS AND METHODS: At our hospital from January 1995 to June 2012, 39 patients with histologically confirmed SFTP were surgically treated; seven of them abutting the mediastinal pleura. The study group included seven patients aged between 53 and 81 years. Baseline CT scans were retrospectively reviewed to identify radiological findings suggestive of SFTP including: (1) smooth and sharply delineated contours; (2) obtuse, acute, or tapering angles between the lesion and the mediastinum depending on the size; (3) homogeneous soft-tissue attenuation; (4) "geographic pattern" due to the contemporary presence of large vessels, necrosis, and calcifications; (5) displacement of the lung parenchyma; (6) presence of a cleavage plane; and (7) absence of lymphadenopathy or pleural methastasis. RESULTS: All tumors formed acute angles with the pleura. Six out of the seven presented smoothly tapering margins, three had a "geographic pattern" of attenuation and displaced the anterior junction line; one showed an outside junction line development. Four cases had a clear pleural origin. CONCLUSIONS: The possibility of SFTP should be taken into account when a mass abuts the mediastinum projecting inside the thoracic cavity in the presence of an intense and "geographical pattern" of enhancement without lymphoadenopathy or pleural metastasis. These findings assume greater significance in the presence of discrepancy between the size of the lesion and the clinical presentation.

Diagnostic Imaging and workup of Malignant Pleural Mesothelioma.

Malignant pleural mesothelioma is the most frequent primary neoplasm of the pleura and its incidence is still increasing.This tumor has a strong association with exposure to occupational or environmental asbestos, often after a long latent period of 30-40 years.Plain chest radiography (CXR) is usually the first-line radiologic examination, but the radiographic findings are nonspecific due to its limited contrast resolution and they need to be complemented by other imaging modalities such as computed tomography (CT), magnetic resonance Imaging (MRI), Positron emission tomography-computed tomography (PET-CT) and ultrasound (US).The aim of this paper is to describe the imaging  features of this malignancy, underlining the peculiarity of CXR, CT, MRI, PET-CT and US and also focusing on diagnostic workup, based on the literature evidence and according to our experience.

Radiological contribution to the diagnosis of early postoperative complications after lung resection for primary tumor: a revisional study.

In the post-operative course of the interventions of lung resection for primary tumor, complications of different nature and severity can arise, recognizing different pathogenetic mechanisms and differing according to the type of resection performed and to the time elapsed after surgery. The low diagnostic accuracy of chest radiography requires a thorough knowledge of the radiologist about all radiographic findings, both normal and pathological, which can be found in the immediate post-operative period (within 30 days after surgery). This article aims to describe the incidence, the clinical features and the radiological aspects of immediate complications following pulmonary resections, with specific reference to those in which the diagnostic imaging provides a fundamental contribution.

[Diffuse benign pleural diseases: clinical and radiological correlation]. / Correlazione clinico-radiologica delle patologie diffuse benigne della pleura.

The aim of this paper is to provide an effective and comprehensive summary of the main inflammatory pleural diseases, providing the radiologist an overview of key points in CXR, CT and US, and their main aspects in the differential diagnosis. The diffuse benign pleural diseases are frequently found during the first-level radiological diagnostic approach, but they are often difficult to classify because of their poor characterization. Pleural effusion or thickening can have a benign or malignant cause and use of the appropriate imaging techniques is crucial to a correct diagnosis. The clinical features of pleural disease are often nonspecific and may require complex imaging and histology for diagnosis. The integration of informations derived from different methods (CXR, CT and US) is extremely important to an appropriate diagnosis.

Under-reporting of cardiovascular findings on chest CT.

PURPOSE: It is unclear whether (and, to what extent) radiologists look at and report cardiovascular abnormalities on non-cardio-synchronized standard chest computed tomography (CT). In this study, the frequency and the reporting rate of cardiovascular findings in chest CT examinations were retrospectively assessed. MATERIALS AND METHODS: This study was approved by the institutional review board of each participating center. Four academic centers provided data on 447 subjects who underwent non-ECG-synchronized chest CT examinations for evaluating pulmonary fibrosis (161/447, 36 %), suspected pulmonary embolism (140/447, 31.3 %), or lung cancer staging (146/447, 32.7 %). A total of 220/447 (53.7 %) and 227/447 CT (46.3 %) examinations were evaluated and reported by junior and senior chest radiologists, respectively. Two radiologists with training in cardiac imaging reviewed the same chest CT images looking for the presence of incidental cardiovascular abnormalities using a preformatted score sheet. Inter-observer agreement was assessed using the kappa coefficient of agreement (k). RESULTS: Inter-observer agreement between the study reviewers was moderate to good (0.4-0.73) for most of the incidental cardiovascular findings. At least one incidental cardiovascular finding not documented in the original report was identified by the study reviewers in 225/409 (55 %) of chest CT examinations. A total of 168/266 (63.2 %) potentially clinically significant cardiovascular findings were unreported in the original reports of 177/447 (39.6 %) subjects (p < 0.0001). Senior radiologists tended to more frequently report coronary artery calcification (p = 0.0006), cardiac valves calcification (p = 0.0003), and ascending aorta enlargement (p = 0.01) compared to junior radiologists. CONCLUSIONS: Several cardiovascular abnormalities can be reliably identified on standard chest CT. Yet, they are often under-reported, even when they might be relevant to the patient's work-up.

The imaging spectrum of pulmonary tuberculosis.

Tuberculosis has still an important impact on public health because it is an important cause of death, particularly in developing countries. On the other hand recent studies have shown that tuberculosis is again becoming concentrated in big cities of Western Europe, especially among immigrants, drug addicts, poor people, and the homeless, despite progress in reducing national rates of the disease. Diagnostic imaging is challenging for radiologists because signs of tuberculosis may easily mimic other diseases such as neoplasms or sarcoidosis. Clinical signs and symptoms in affected adults can be non-specific and a high level of pre-test clinical suspicion based on history is fundamental in the diagnostic work-up. Impact of tuberculosis in the world is extremely important considering the high incidence estimated during 2011 that was 8.7 million cases. This article gives a review of imaging patterns of chest tuberculosis as may be detected on conventional radiography and computerized tomography (CT). The main aim is to improve radiologist's familiarity with the spectrum of imaging features of this disease and facilitate timely diagnosis. Furthermore, we consider the emerging role of alternative methods of imaging, such as magnetic resonance imaging (MRI), that can be helpful and highly accurate for a better definition of some signs of tuberculosis.

Multiphasic multidetector computed tomography study of a rare tracheal tumor: granular cell tumor.

Our aim is to present the case report of a woman affected by tracheal granular cell tumor analysed by multiphasic contrast-enhanced multidetector CT. The tumor presents as polypoid lesion (diameter 13 mm), with smooth and well-defined margins, elevated contrast enhancement in arterial phase, and a modest release of contrast in venous phase. This pattern is quite different from the other tracheal tumours. We have performed a comprehensive review of literature to assess all cases of granular cell tumors of the trachea; only 40 cases are reported. Of these, no one focused on the contrast enhancement aspect, so our work is the first showing a specific pattern in multidetector computed tomography (MDCT) of the tracheal granular cell tumour and may help in differential diagnosis.

Pathophysiology, clinical features and radiological findings of differentiation syndrome/all-trans-retinoic acid syndrome.

In acute promyelocytic leukemia, differentiation therapy based on all-trans-retinoic acid can be complicated by the development of a differentiation syndrome (DS). DS is a life-threatening complication, characterized by respiratory distress, unexplained fever, weight gain, interstitial lung infiltrates, pleural or pericardial effusions, hypotension and acute renal failure. The diagnosis of DS is made on clinical grounds and has proven to be difficult, because none of the symptoms is pathognomonic for the syndrome without any definitive diagnostic criteria. As DS can have subtle signs and symptoms at presentation but progress rapidly, end-stage DS clinical picture resembles the acute respiratory distress syndrome with extremely poor prognosis; so it is of absolute importance to be conscious of these complications and initiate therapy as soon as it was suspected. The radiologic appearance resembles the typical features of cardiogenic pulmonary edema. Diagnosis of DS remains a great skill for radiologists and haematologist but it is of an utmost importance the cooperation in suspect DS, detect the early signs of DS, examine the patients' behaviour and rapidly detect the complications.

Clinical implications and added costs of incidental findings in an early detection study of lung cancer by using low-dose spiral computed tomography.

INTRODUCTION: To prospectively evaluate the frequency and spectrum of incidental findings (IF) in a 5-year lung cancer screening program with low-dose spiral computed tomography (CT) and to estimate the additional costs of their imaging workup incurred from subsequent radiologic follow-up evaluation. MATERIALS AND METHODS: A total of 519 asymptomatic volunteers were enrolled. All IFs were reported and were considered clinically relevant if they required further evaluations or with clinical implications if they required more than one additional diagnostic test for characterization or medical and/or surgical intervention. RESULTS: IFs were commonly found (59.2%, 307/519 participants at baseline and 5.3% per year at 5-year follow-up [123 participants of 2341 LDsCT exams performed during follow-up], with an overall rate of 26.3%). IFs were categorized as previously unknown clinically relevant in 52 (10.0%) individuals at baseline. Of these, 36 (6.9%) individuals had IFs with clinical implications (10 clinically relevant, of which 6 had clinical implications, detected during the subsequent 5-year follow-up). The most common recommendations were for additional imaging of the thyroid and kidneys. Additional imaging was mainly performed by ultrasound (43/68 [63.2%]). Subsequent surgical intervention resulted from these findings in 7 (1.5%) subjects. Six malignancies were diagnosed (rate, 0.2% per year). Costs of subsequent radiologic follow-up studies were calculated as €4644.56 [U.S. $6575.04] at baseline and €1052.30 [U.S. $1489.69] at 5-year follow-up (average added costs per participant €8.95 [U.S. $12.67] and €2.25 [U.S. $3.19], respectively). CONCLUSIONS: Low-dose spiral CT commonly detects IFs. Some of these require further investigations to assess their clinical relevance. Although such IFs add little clinical benefit to the screening intervention, moderate incremental costs are incurred based on additional radiologic procedures generated during short-term follow-up, given the potential for positive effects on patient care.

A comparison of different diagnostic tests in the bedside evaluation of pleuritic pain in the ED.

PURPOSES: Bedside lung ultrasound (LUS) is useful in detecting radio-occult pleural-pulmonary lesions. The aim of our study is to compare the value of LUS with other conventional routine diagnostic tools in the emergency department (ED) evaluation of patients with pleuritic pain and silent chest radiography (CXR). METHODS: Ninety patients consecutively admitted to the ED with pleuritic pain and normal CXR were retrospectively (n = 49) and prospectively (n = 41) studied. All patients were blindly examined by LUS and submitted to clinical examination and blood samples. The ability of blood tests and symptoms to predict any radio-occult pleural-pulmonary condition confirmed by conclusive image techniques and follow-up was evaluated and compared with LUS. RESULTS: In 57 cases, the final diagnosis was chest wall pain. The other 33 patients were diagnosed with a pleural-pulmonary condition (22 pneumonia, 2 pleuritis, 7 pulmonary embolism, 1 lung cancer, 1 pneumothorax). Lung ultrasound showed a sensitivity of 96.97% (95% confidence interval [CI], 84.68%-99.46%) and a specificity of 96.49% (95% CI, 88.08%-99.03%) in predicting radio-occult pleural-pulmonary lesions and significantly higher area under the curve (AUC) of receiver operating characteristic analysis (AUC, 0.967; 95% CI, 0.929-1.00) than d-dimer (AUC, 0.815; 95% CI, 0.720-0.911) and white blood cell count (AUC, 0.778; 95% CI, 0.678-0.858). None of the other routine tests considered or a combination between them better predicted the final diagnosis. CONCLUSIONS: Chest radiography and blood tests may be inadequate in the diagnostic process of pleuritic pain. In case of silent CXR, LUS is critical for identifying patients with pleural-pulmonary radio-occult conditions at bedside and cannot be safely replaced by other conventional methods.

Imaging of benign solitary fibrous tumor of the pleura: a pictorial essay.

Solitary fibrous tumor of the pleura (SFTP) is a mesenchymal tumor that tends to involve the pleura, and is also described in other thoracic and extrathoracic sites. SFTP usually presents as a peripheral mass abutting the pleural surface, to which it is attached by a broad base or by a pedicle that allows it to be mobile. SFTPs exist in benign and malignant forms. A precise pre-operative diagnosis can be arrived at with a cutting-needle biopsy, although most cases are diagnosed with postoperative histology and immunohistochemical analysis. In this pictorial essay, we review a large series of cases, with emphasis on the radiographic appearance of these lesions and their findings from computed tomography, magnetic resonance imaging, ultrasonography and positron emission tomography.