Radiological Assessment in Idiopathic Pulmonary Fibrosis (IPF) Patients According to MUC5B Polymorphism.

The MUC5B rs35705950 mutant T allele is the strongest genetic risk factor for familial and sporadic IPF. We sought to determine whether MUC5B genotype influences radiological patterns of IPF at diagnosis, as well as their change over time, in patients on antifibrotic therapy. Among eighty-eight IPF patients, previously genotyped for MUC5B rs35705950, we considered seventy-eight patients who were evaluated for radiological quantification of the following features both at treatment initiation (HRCT1) and after 1 year (HRCT2): ground glass opacities (AS), reticulations (IS) and honeycombing (HC). Of the evaluated patients, 69% carried at least one copy of the T allele (TT/TG). Carriers of the T allele displayed similar FVC loss in the first year of treatment as GG carriers, but overall survival at the end of follow-up was longer in the TT/TG group, compared to the GG group. In the GG group, both the AS and HC increased significantly, whereas in the TT/TG group only HC increased over the first year of treatment. MUC5B rs35705950 GG carriers are associated with increased ground glass and honeycombing extent over time and worse survival than T allele carriers. Longitudinal HRCT may help define the prognostic role of the MUC5B rs35705950 genotype.

Impact of the COVID-19 pandemic on the selection of chest imaging modalities and reporting systems: a survey of Italian radiologists.

PURPOSE: Chest imaging modalities play a key role for the management of patient with coronavirus disease (COVID-19). Unfortunately, there is no consensus on the optimal chest imaging approach in the evaluation of patients with COVID-19 pneumonia, and radiology departments tend to use different approaches. Thus, the main objective of this survey was to assess how chest imaging modalities have been used during the different phases of the first COVID-19 wave in Italy, and which diagnostic technique and reporting system would have been preferred based on the experience gained during the pandemic. MATERIAL AND METHODS: The questionnaire of the survey consisted of 26 questions. The link to participate in the survey was sent to all members of the Italian Society of Medical and Interventional Radiology (SIRM). RESULTS: The survey gathered responses from 716 SIRM members. The most notable result was that the most used and preferred chest imaging modality to assess/exclude/monitor COVID-19 pneumonia during the different phases of the first COVID-19 wave was computed tomography (51.8% to 77.1% of participants). Additionally, while the narrative report was the most used reporting system (55.6% of respondents), one-third of participants would have preferred to utilize structured reporting systems. CONCLUSION: This survey shows that the participants' responses did not properly align with the imaging guidelines for managing COVID-19 that have been made by several scientific, including SIRM. Therefore, there is a need for continuing education to keep radiologists up to date and aware of the advantages and limitations of the chest imaging modalities and reporting systems.

Management of incidental pulmonary nodule in CT: a survey by the Italian College of Chest Radiology.

OBJECTIVES: The aim of this study is to present the results of the Italian survey on the management of pulmonary nodules incidentally identified at computed tomography (CT). MATERIALS AND METHODS: An online electronic survey, consisting of 23 multiple-choice questions, was created using the SurveyMonkey web-based tool. The questionnaire was developed by the Board of the Italian College of Chest Radiology of the Italian Society of Medical and Interventional Radiology (SIRM) and by an experienced group of Italian Academic Chest Radiologists. The link to the online electronic survey was submitted by email to all the SIRM members. RESULTS: A total of 767 radiologists, corresponding to 7.5% of all the SIRM members, participated in the online survey. The majority of participants (92%) routinely describe the attenuation of pulmonary nodules in the report, and 84.1% recommend the further follow-up, with 92.7% of respondents taking CT nodule morphological features into consideration. The 57.7% of participants adhere to the Fleischner Society guidelines for the management of incidental pulmonary nodules. However, 56.6% and 75.6% of respondents have a more cautious approach than that recommended by the guidelines and tend to use a shorter follow-up for both solid and ground-glass nodules, respectively. Finally, 94.5% of participants favor congresses and refresher courses dedicated to insights on lung nodule diagnosis and management. CONCLUSIONS: This survey demonstrates that the management of pulmonary nodules incidentally detected on CT is still complex and controversial. The majority of SIRM members express a need for an update on this topic.

Structured reporting for fibrosing lung disease: a model shared by radiologist and pulmonologist.

OBJECTIVES: To apply the Delphi exercise with iterative involvement of radiologists and pulmonologists with the aim of defining a structured reporting template for high-resolution computed tomography (HRCT) of patients with fibrosing lung disease (FLD). METHODS: The writing committee selected the HRCT criteria-the Delphi items-for rating from both radiology panelists (RP) and pulmonology panelists (PP). The Delphi items were first rated by RPs as "essential", "optional", or "not relevant". The items rated "essential" by < 80% of the RP were selected for the PP rating. The format of reporting was rated by both RP and PP. RESULTS: A total of 42 RPs and 12 PPs participated to the survey. In both Delphi round 1 and 2, 10/27 (37.7%) items were rated "essential" by more than 80% of RP. The remaining 17/27 (63.3%) items were rated by the PP in round 3, with 2/17 items (11.7%) rated "essential" by the PP. PP proposed additional items for conclusion domain, which were rated by RPs in the fourth round. Poor consensus was observed for the format of reporting. CONCLUSIONS: This study provides a template for structured report of FLD that features essential items as agreed by expert thoracic radiologists and pulmonologists.

Indeterminate lung nodules in cancer patients: pretest probability of malignancy and the role of 18F-FDG PET/CT.

OBJECTIVE: The purpose of this study was to determine likelihood of malignancy for indeterminate lung nodules identified on CT comparing two standardized models with (18)F-FDG PET/CT. MATERIALS AND METHODS: Fifty-nine cancer patients with indeterminate lung nodules (solid tumors; diameter, ≥5 mm) on CT had FDG PET/CT for lesion characterization. Mayo Clinic and Veterans Affairs Cooperative Study models of likelihood of malignancy were applied to solitary pulmonary nodules. High probability of malignancy was assigned a priori for multiple nodules. Low (<5%), intermediate (5-60%), and high (>60%) pretest malignancy probabilities were analyzed separately. Patients were reclassified with PET/CT. Histopathology or 2-year imaging follow-up established diagnosis. Outcome-based reclassification differences were defined as net reclassification improvement. A null hypothesis of asymptotic test was applied. RESULTS: Thirty-one patients had histology-proven malignancy. PET/CT was true-positive in 24 and true-negative in 25 cases. Negative predictive value was 78% and positive predictive value was 89%. On the basis of the Mayo Clinic model (n=31), 18 patients had low, 12 had intermediate, and one had high pretest likelihood; on the basis of the Veterans Affairs model (n=26), 5 patients had low, 20 had intermediate, and one had high pretest likelihood. Because of multiple lung nodules, 28 patients were classified as having high malignancy risk. PET/CT showed 32 negative and 27 positive scans. Net reclassification improvements respectively were 0.95 and 1.6 for Mayo Clinic and Veterans Affairs models (both p<0.0001). Fourteen of 31 (45.2%) and 12 of 26 (46.2%) patients with low and intermediate pretest likelihood, respectively, had positive findings on PET/CT for the Mayo Clinic and Veterans Affairs models, respectively. Of 15 patients with high pretest likelihood and negative findings on PET/CT, 13 (86.7%) did not have lung malignancy. CONCLUSION: PET/CT improves stratification of cancer patients with indeterminate pulmonary nodules. A substantial number of patients considered at low and intermediate pretest likelihood of malignancy with histology-proven lung malignancy showed abnormal PET/CT findings.

Extrapleural and cardiophrenic lymph nodes: prevalence, clinical significance and diagnostic value.

PURPOSE: The aim of this study was to evaluate the prevalence, clinical meaning and diagnostic value of extrapleural and cardiophrenic nodes occasionally observed on computed tomography (CT) scans of the chest. MATERIALS AND METHODS: We included 750 consecutive patients who underwent CT of the chest for different clinical purposes (340 nonneoplastic patients, 270 with extrathoracic neoplasms, 120 with intrathoracic neoplasms, 20 with pleural metastasis) and 91 patients with histologically proven malignant pleural mesothelioma (MPM). For each group of patients, we analysed the presence of extrapleural and cardiophrenic nodes, their number (single or multiple) and their size. RESULTS: The prevalence of cardiophrenic nodes between 6 and 10 mm and >10 mm was significantly higher in patients with MPM (28.6 and 26.4 %, respectively) than in all other categories of patients, except for patients with pleural metastasis (30 and 25 %, respectively). The prevalence of extrapleural nodes, independently from their size, was significantly higher in patients with MPM (68 %) compared with all other groups, including patients with pleural metastasis (5 %; p < 0.0001). CONCLUSIONS: Cardiophrenic nodes >5 mm and extrapleural nodes of any size have a significant diagnostic value in malignant pleural disease, either primary or secondary, whereas they are extremely rare in other neoplastic or nonneoplastic diseases.

Typical and atypical pattern of pulmonary sarcoidosis at high-resolution CT: relation to clinical evolution and therapeutic procedures.

AIM: This study was done to evaluate the importance of high-resolution CT (HRCT) in defining pattern and extent of disease and establishing the clinical and therapeutic pathway in sarcoidosis. MATERIALS AND METHODS: A retrospective analysis of 56 patients with pulmonary involvement of sarcoidosis was performed. Two groups were identified: 39 patients exhibiting a typical HRCT pattern and 17 patients with an atypical pattern. Inclusion criteria were the presence of radiological documentation (HRCT) of disease, clinical and radiological follow-up of 1 year and the beginning of any therapy within 1 month from the diagnosis. RESULTS: Among subjects not receiving therapy, the comparison between the two groups showed that the radiological findings remained stable in subjects with a typical pattern, while they worsened in more than 70% of cases with atypical appearance. Therapy was more effective in patients with a typical pattern. Recurrences occurred in both groups, but more often in patients with a typical pattern. One patient not receiving treatment experienced clinical worsening. Re-evaluation of HRCT within 1 year revealed no correlation between clinical deterioration and radiological changes. CONCLUSIONS: The findings of this study suggest that persistence of the inflammatory process rather than the radiological pattern at onset is a prognostic factor for recurrence.

Endobronchial solitary fibrous tumors: An enigma for diagnosis.

Solitary fibrous tumors (SFTs) are rare mesenchymal neoplasms constituting less than 2% of all soft tissue tumors. They typically originate in the thoracic cavity, mainly in the pleura, but can also occur in other various sites such as lung parenchyma, pericardium, and bronchus. In this study, a 49-year-old non-smoking female with a history of allergies presented to our pulmonary clinic with a chronic cough. An explorative bronchoscopy revealed an intrabronchial mass in the left superior bronchi, and a 68 Ga-DOTATOC positron emission computed tomography suggested a carcinoid tumor. Subsequent pulmonary segmentectomy unveiled a well-circumscribed polypoid lesion diagnosed as a low-grade bronchus SFT through histopathological and immunohistochemical assessments. The patient was asymptomatic after surgical excision and showed no other lesion during the 6-month follow-up. The endobronchial location of SFT is uncommon, with only a few reported cases in the literature, underscoring the necessity of considering various differential diagnoses, including carcinoid, mucoepidermoid carcinoma, endobronchial pleomorphic adenoma, hamartoma, leiomyoma, and metastasis, depending on location and imaging features. This report underscores the importance of careful histological and immunohistochemical evaluation in understanding and appropriately stratifying the risk associated with polypoid lesions.

Intrathymic Localization of Melanoma: A Brief Report of Two Cases and a Review of the Literature.

Intrathymic localizations of melanoma represent a very rare entity, with fewer than ten cases of intrathymic melanoma described in the literature. Herein, we describe two cases of patients who underwent surgical removal of a thymic mass at our thoracic surgery department between 2015 and 2022. The final pathological examination revealed a malignant melanoma in both cases; we therefore carried out a literature review to identify such rare and similar cases. In the first case, the intrathymic localization of melanoma was the first manifestation of the disease, posing a dilemma regarding the metastatic and primitive nature of the neoplasm. The second case described a thymic metastasis from a known previous cutaneous melanoma, for which the patient had successfully been treated six years earlier. After carefully reviewing the literature, we identified only six cases of verified primary intrathymic melanomas and one case of intrathymic metastasis resulting from melanoma previously described. Pathologists should be aware of the occurrence of this rare entity and mindful of the differential diagnoses. Several tools, including immunostaining of melanocytic markers and molecular investigations, are mandatory for final pathological diagnosis.

High-Resolution CT Change over Time in Patients with Idiopathic Pulmonary Fibrosis on Antifibrotic Treatment.

Antifibrotic treatment slows down functional decline and disease progression in idiopathic pulmonary fibrosis (IPF). High-resolution computed tomography (HRCT) is useful to diagnose IPF; however, little is known about whether and to what extent HRCT changes reflect functional changes during antifibrotic therapy. The aim of this study was, therefore, to assess HRCT change over time after 1 year of treatment and to evaluate whether these changes correlate with functional decline over the same period of time. Sixty-eight IPF patients on antifibrotic treatment (i.e., pirfenidone or nintedanib) were functionally categorized as stable or progressors based on whether (or not) they had a decline in forced vital capacity (FVC) >5% predicted/year, and their HRCT were scored blindly and independently by two expert thoracic radiologists at treatment initiation (HRCT1) and after 1 year of treatment (HRCT2). Ground glass opacities (Alveolar Score, AS), reticulations (Interstitial Score, IS) and honeycombing (HC) were quantified and correlated with FVC decline between HRCT1 and HRCT2. At treatment initiation, HRCT scores were similar in both stable patients and progressors. After one year of treatment, in the entire population, AS and HC increased significantly, while IS did not. However, when stratified by the rate of functional decline, in stable patients, HC increased significantly while AS and IS did not. On the other hand, among progressors AS and HC increased significantly whereas IS did not. In the entire population, the combined score of fibrosis (IS + HC) correlated significantly with FVC decline. In conclusion, IPF patients on antifibrotic treatment exhibit different patterns of HRCT change over time based on their rate of functional decline. HRCT data should be integrated to lung function data when assessing response to antifibrotic treatment in patients with IPF.

High-Resolution Computed Tomography (HRCT) Reflects Disease Progression in Patients with Idiopathic Pulmonary Fibrosis (IPF): Relationship with Lung Pathology.

High-Resolution Computed Tomography (HRCT) plays a central role in diagnosing Idiopathic Pulmonary Fibrosis (IPF) while its role in monitoring disease progression is not clearly defined. Given the variable clinical course of the disease, we evaluated whether HRCT abnormalities predict disease behavior and correlate with functional decline in untreated IPF patients. Forty-nine patients (with HRCT1) were functionally categorized as rapid or slow progressors. Twenty-one had a second HRCT2. Thirteen patients underwent lung transplantation and pathology was quantified. HRCT Alveolar (AS) and Interstitial Scores (IS) were assessed and correlated with Forced Vital Capacity (FVC) decline between HRCT1 and HRCT2. At baseline, AS was greater in rapids than in slows, while IS was similar in the two groups. In the 21 subjects with HRCT2, IS increased over time in both slows and rapids, while AS increased only in rapids. The IS change from HRCT1 to HRCT2 normalized per month correlated with FVC decline/month in the whole population, but the change in AS did not. In the 13 patients with pathology, the number of total lymphocytes was higher in rapids than in slows and correlated with AS. Quantitative estimation of HRCTs AS and IS reflects the distinct clinical and pathological behavior of slow and rapid decliners. Furthermore, AS, which reflects the immune/inflammatory infiltrate in lung tissue, could be a useful tool to differentiate rapid from slow progressors at presentation.

Conflicting or complementary role of computed tomography (CT) and positron emission tomography (PET)/CT in the assessment of thymic cancer and thymoma: our experience and literature review.

BACKGROUND: To evaluate the role of computed tomography (CT) and positron emission tomography (PET)/CT in patients with thymic cancer and thymoma at initial staging. METHODS: We retrospectively reviewed CT and PET/CT scans of 26 patients with a thymic cancer (n = 9) or thymoma (n = 17). Chest CT findings documented were qualitative and quantitative. Both qualitative and semiquantitative data were recovered by PET/CT. The comparisons among histological entities, outcome, and qualitative data from CT and PET/CT were made by non-parametric analysis. RESULTS: PET/CT resulted positive in 15/17 patients with thymoma. CT was available in 5/9 (56%) patients with thymic cancer and in 3/17 with thymoma. All quantitative CT parameters were significantly higher in patients with thymic cancer than thymoma (maximum axial diameter: 45 vs. 20 mm, maximum longitudinal diameter: 69 vs. 21 mm and volume: 77.91 vs. 4.52 mL; all P < 0.05). Conversely, only metabolic tumor volume (MTV) and total lesion glycolysis were significantly different in patients with thymic cancer than thymoma (126.53 vs. 6.03 cm3 and 246.05 vs. 20.32, respectively; both P < 0.05). After a median follow-up time of 17.45 months, four recurrences of disease occurred: three in patients with thymic cancer and one with a type B2 thymoma. CT volume in patients with recurrent disease was 102.19 mL versus a median value of 62.5 mL in six disease-free patients. MTV was higher in the recurrent than disease-free patient subset (143.3 vs. 81.13 cm(3)), although not statistically significant (P = 0.075). CONCLUSION: Our preliminary results demonstrated that both morphological and metabolic volume could be useful from a diagnostic and prognostic point of view in thymic cancer and thymoma patients. A large multi-center clinical trial experience for confirming the findings of this study seems mandatory.

A 72-Year-Old Woman With Previous Pulmonary Metastasis and New Peripheral Nodule.

A 72-year-old female nonsmoker was admitted to our Thoracic Surgery Unit in 2013 because of a lesion detected on chest CT scan during oncologic follow-up. Her medical history was significant for the development of a single pulmonary metastasis discovered 1 year after sigmoidectomy for colic adenocarcinoma. At that time, the patient was treated with six cycles of neoadjuvant chemotherapy followed by left lower lobectomy. Histologic examination demonstrated a pulmonary metastasis of colic adenocarcinoma with diffuse necrotic areas. The patient underwent subsequent adjuvant chemotherapy with capecitabine and was followed annually with biohumoral oncologic screening (carcinoembryonic antigen, carbohydrate antigen 19-9), chest-abdomen CT scan, and colonoscopy.

Imaging of pancreatic metastases from renal cell carcinoma.

BACKGROUND: To describe the main imaging characteristics of pancreatic metastases from renal cell carcinoma (RCC) with particular attention to CT features, underlining possible criteria for a differential diagnosis. METHODS: 15 patients have been included in this study. 14 patients underwent multislice CT with triphasic acquisition (unenhanced, pancreatic parenchymal and portal venous phases). In 9 cases a delayed phase (120 sec) was also acquired. 5 patients underwent MRI, before and after administration of gadolinium. RESULTS: The mean time interval between nephrectomy and recurrence was 7.5 years (range 1-17 years). On CT metastases avidly enhanced in the parenchymal phase and then demonstrated a significant wash-out, approaching isodensity to the normal pancreatic parenchyma in the portal phase. In the portal phase 20 of the 25 lesions found in the arterial phase were recognizable. On non-enhanced scans, only 13 of the 25 lesions were detected. CONCLUSION: Renal Cell Carcinomas require a prolonged CT or MRI follow-up.

Necrotizing sarcoid granulomatosis with an uncommon manifestation: clinicopathological features and review of literature.

We report a rare case of an incidental diagnosis of necrotizing sarcoid granulomatosis (NSG) in a 60-y-old non-smoking male. The patient was admitted to the hospital for sudden back pain. Chest x-ray revealed areas of parenchymal consolidation and high-resolution computed tomography demonstrated a pulmonary nodular pattern with no lymph node enlargement. All laboratory and pulmonary function tests were normal. Bronchoscopy with bronchoalveolar lavage showed no sign of infection or specific inflammation. The diagnosis of NSG was made by histopathological examination of a surgical lung biopsy and by excluding other causes of granulomatous disease. In paucisymptomatic/asymptomatic patients, as in our case, therapy is not necessary, with a good prognosis and complete recovery. NSG is a rare systemic disease similar to sarcoidosis and Wegener's granulomatosis with a benign clinical course and should always be considered for patients with nodular pulmonary lesions even with subclinical or uncommon features.

An unusual mediastinal outline.

Thymoma is the most common primary neoplasm of the anterior mediastinum. We describe the case of a 40-year-old man with asymptomatic thymoma involving the right atrium, and the diagnostic pathway.

Indeterminate pulmonary nodules on CT images in breast cancer patient: the additional value of 18F-FDG PET/CT.

AIM: To assess the potential role of 18F-Fluorodeoxiglucose (FDG) Positron Emission Tomography (PET)/Computed Tomography (CT) in characterizing indeterminate lung nodules detected at CT scan in patients previously treated for a breast cancer (BC). MATERIALS AND METHODS: Twenty-nine consecutive BC patients (28 females, mean age 65 ± 12 years) with evidence of indeterminate lung nodules at contrast-enhanced CT (CECT) scan (lesions with axial diameter ≥8 mm) were retrospectively analysed: all patients underwent 18F-FDG PET/CT within a mean 2 ± 1 months from CECT imaging. PET/CT was considered positive in the presence of abnormal FDG uptake in the pulmonary nodules and/or in other organs. The nature of lung nodules was defined at histopathology and/or imaging follow-up. RESULTS: Fourteen (48%) patients showed negative and 15 (52%) positive PET/CT scan in the lungs: of these 15 patients, 7 (47%) had pathologic FDG-uptake in lungs only, whereas 8 (53%) showed abnormal FDG-uptake also in sites different from lungs. At histology and/or imaging follow-up, five (17%) patients were considered positive for BC lung metastases while in seven (24%) a second cancer was diagnosed. In this subset of patients, the sensitivity and specificity for FDG PET/CT in revealing lung lesions were 17% and 100%, respectively, for nodules <8 mm in diameter, and 77% and 85%, respectively, for nodules with diameter ≥8 mm. The therapeutic planning was changed to surgery in seven patients, chemotherapy in one patient and continued hormonal therapy in five. The inclusion of PET/CT in the diagnostic algorithm of the evaluated patients helped avoid unnecessary over-treatment in 12 of 29 patients. CONCLUSION: FDG PET/CT appears useful in characterizing indeterminate lung nodules found at CECT scan in BC patients, with a sensitivity that is proportional to nodule size. In addition, PET/CT helped in avoiding over-treatment in a significant proportion of patients.

Early bone marrow metastasis detection: the additional value of FDG-PET/CT vs. CT imaging.

OBJECTIVE: To assess the addition value of ¹8F-Fluorodeoxyglucose (FDG) PET/computed tomography (FDG-PET/CT) vs. CT in detecting early metastatic deposits in bone marrow (BM). METHODS: From January 2009 to December 2010, 198 consecutive patients (88 male, 110 female; median age: 64 years) were retrospectively examined. All patients underwent ¹8F-FDG-PET/CT for disease evaluation: 65 for lung cancer, 66 for breast cancer, 57 for lymphoma and 10 for multiple myeloma. All scans were reviewed by a radiologist and a specialist in nuclear medicine for the identification of bone lesions. The presence of BM metastases was confirmed by biopsy, sequential PET/CT scan or magnetic resonance imaging when available. A patient-based analysis was performed. RESULTS: Investigating the presence of skeletal metastasis, 94 (48%) patients had positive and 104 (52%) negative CT scan whereas 110 (56%) had positive and 88 (44%) negative FDG-PET/CT scan (P<0.001). The two imaging modalities were concordant in 178 (90%) patients for bone lesions; on the contrary 20 (10%) patients had discordant results (P<0.001). In 21 out of 178 concordant patients BM lesions were identified both in CT and FDG-PET, whereas nine out of the 20 discordant patients showed BM involvement at PET/CT only. Overall, PET/CT was able to identify 30 (15%) patients with BM lesions. In these latter patients, the maximum standardized uptake value (SUVmax) for BM metastases was 7.9±4.5 (range: 3.1-19.0), resulting slightly higher in patients with negative than positive CT scan (8.3±5.1 vs. 7.8±4.3, respectively; P=0.79). CONCLUSIONS: FDG-PET/CT resulted more accurate than CT in early detection of BM metastases. The FDG-PET/CT images improve the staging of about 15% of our study population. PET/CT detected BM lesions mainly on the basis of their increased metabolic activity rather than on anatomical alterations. Moreover, it provided an accurate identification of tumour viability that was useful for treatment planning and follow-up.