Research Progress in 3D-reconstruction Based Imaging Analysis in Partial Solid Pulmonary Nodule / 中国肺癌杂志

The incidence and mortality of lung cancer rank first among all malignant tumors in China. With the popularization of high resolution computed tomography (CT) in clinic, chest CT has become an important means of clinical screening for early lung cancer and reducing the mortality of lung cancer. Imaging findings of early lung adenocarcinoma often show partial solid nodules with ground glass components. With the development of imaging, the relationship between the imaging features of some solid nodules and their prognosis has attracted more and more attention. At the same time, with the development of 3D-reconstruction technology, clinicians can improve the accuracy of diagnosis and treatment of such nodules.This article focuses on the traditional imaging analysis of partial solid nodules and the imaging analysis based on 3D reconstruction, and systematically expounds the advantages and disadvantages of both.
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Valor del PET/CT semicuantitativo (SUVmax) en el estudio de nódulo pulmonar sólido / Value of Semiquantitative PET/CT (SUVmax) in study of solid lung nodule

OBJETIVO: Determinar el rendimiento diagnóstico del PET/CT en el estudio de nódulo pulmonar (NP) utilizando SUVmax. MÉTODO: Se revisó la base de datos de PET/CT, seleccionando aquellos solicitados para estudio de NP sólido. Se incluyeron sólo aquellos NP confirmados como malignos o benignos. Se excluyó NP subsólidos, masas pulmonares (> 3 cm), y pacientes con metástasis conocidas. Se midió SUVmax de las lesiones, determinando mejores valores de corte para malignidad y benignidad. RESULTADOS: De los 140 NP estudiados, el 60% (84/140) fueron confirmados como malignos y el 40% como benignos (100% y 59,6% de confirmación histológica, respectivamente). Un SUVmax ≤ 1,0 mostró sensibilidad 98,8%, valor predictivo negativo (VPN) 96,2%, y Likelihood ratio negativo (LR -) 0,027. Un SUVmax ≤ 2,5 no fue capaz de asegurar razonablemente benignidad con VPN 69,4%, y LR - 0,295. Valores de SUV > 2,5 y 5,0 se asociaron a malignidad en 83% y 93% de los casos, respectivamente (LR+ 3,333 y 8,889). CONCLUSIÓN: El PET/CT presenta alto rendimiento diagnóstico en estimar la naturaleza de un NP Un valor de SUVmax ≤ 1 es altamente predictivo de benignidad, y un valor de SUVmax ≥ 2,5 de malignidad. Valores entre 1,0 y 2,5 no permiten caracterizar eficientemente los NP.

AIM: To establish the diagnostic accuracy of PET/CT in study of solid lung nodule (LN) using SUVmax index. METHOD: We revised PET/CT data base, selecting those scans asked to evaluate a solid LN. Only confirmed malign o benign LN were included. Subsolid LN, lung masses (> 3 cm), and known or suspected lung metastases were excluded. SUVmax was measured in each LN, and best cutoff for malignant and benign lesion was calculated. RESULTS: Of the whole group of 140 LN, 60% were confirmed as malignant, and 40% as benign (100% and 59,6% of histological confirmation, respectively). SUVmax ≤ 1,0 showed sensibility of 98,8%, negative predictive value (NPV) of 96,2%, and negative likelihood ratio (LR —) of 0,027. SUVmax ≤ 2,5 was not able to guarantee reasonably benign nature of LN, showing NPV of 69,4% and LR - of 0,295. SUVmax > 2,5 and > 5,0 was associated to malign lesion in 83% and 93% of cases, respectively (LR + of 3,333 and 8,889). CONCLUSION: PET/CT shows high accuracy estimating the nature of solid LN. SUVmax ≤ 1,0 is highly predictive of benignity, and SUVmax ≥ 2,5 is highly predictive of malignancy. SUVmax values between 1,0 and 2,5 were not able to characterize efficiently LN.

Marcación de nódulos pulmonares con lipiodol bajo tomografía computada: experiencia local y correlación anatomopatológica / Marking of pulmonary nodules with lipiodol by computerized tomography: local experience and anatomopathological correlation

El objetivo de este estudio es la descripción de la novedosa y poco invasiva técnica de marcación de pequeños nódulos pulmonares con lipiodol, guiado con TAC para su posterior resección por cirugía videotoracoscópica con apoyo radioscópico. Se trata de un estudio retrospectivo que incluye 51 pacientes consecutivos en un tiempo comprendido entre junio del 2012 a septiembre del 2017, obteniendo el diagnóstico final mediante la correlación anatomopatológica, representando los procesos malignos el 81% y los benignos el 19%. Mediante esta técnica se lograron identificar y extraer con éxito el 100% de los nódulos marcados, demostrándose la efectividad y seguridad del procedimiento por las mínimas complicaciones relacionadas.

The purpose of this study is describing a novel and minimally invasive technique of CT-guided marking of small pulmonary nodules with lipiodol prior to resection by videothoracoscopic surgery with radioscopic support. This is a retrospective study that includes 51 consecutive patients between June 2012 and September 2017, with the final diagnosis confirmed by pathology. Malignant nodules represented 81% of the cases with the remaining 19% being benign nodules. Through this technique, 100% of the marked nodules were successfully identified and extracted with few procedure related complications and no adverse clinical outcome, demonstrating the effectiveness and safety of the procedure.

CT-guided percutaneous core needle biopsy of pulmonary nodules smaller than 2 cm: technical aspects and factors influencing accuracy / Biópsia percutânea com agulha grossa, guiada por TC, de nódulos pulmonares menores que 2 cm: aspectos técnicos e fatores que influenciam a precisão

ABSTRACT Objective: To evaluate the diagnostic accuracy of CT-guided percutaneous core needle biopsy (CT-CNB) of pulmonary nodules ≤ 2 cm, as well as to identify factors influencing the accuracy of the procedure and its morbidity. Methods: This was a retrospective, single-center study of 170 consecutive patients undergoing CT-CNB of small pulmonary nodules (of ≤ 2 cm) between January of 2010 and August of 2015. Results: A total of 156 CT-CNBs yielded a definitive diagnosis, the overall diagnostic accuracy being 92.3%. Larger lesions were associated with a higher overall accuracy (OR = 1.30; p = 0.007). Parenchymal hemorrhage occurring during the procedure led to lower accuracy rates (OR = 0.13; p = 0.022). Pneumothorax was the most common complication. A pleura-to-lesion distance > 3 cm was identified as a risk factor for pneumothorax (OR = 16.94), whereas performing a blood patch after biopsy was a protective factor for pneumothorax (OR = 0.18). Conclusions: Small nodules (of < 2 cm) represent a technical challenge for diagnosis. CT-CNB is an excellent diagnostic tool, its accuracy being high.

RESUMO Objetivo: Avaliar a precisão diagnóstica da biópsia percutânea com agulha grossa, guiada por TC - doravante denominada BAG-TC - de nódulos pulmonares ≤ 2 cm, bem como identificar fatores que influenciam a precisão do procedimento e sua morbidade. Métodos: Estudo retrospectivo, realizado em um único centro, com 170 pacientes consecutivos submetidos a BAG-TC de nódulos pulmonares pequenos (≤ 2 cm) entre janeiro de 2010 e agosto de 2015. Resultados: Do total de biópsias, 156 resultaram em diagnóstico definitivo, com precisão diagnóstica global de 92,3%. Lesões maiores estiveram relacionadas com maior precisão global (OR = 1,30; p = 0,007). A presença de hemorragia parenquimatosa durante o procedimento resultou em menor precisão (OR = 0,13; p = 0,022). Pneumotórax foi a complicação mais comum. Uma distância > 3 cm entre a lesão e a pleura foi identificada como fator de risco de pneumotórax (OR = 16,94), ao passo que a realização de tampão sanguíneo após a biópsia foi um fator de proteção contra o pneumotórax (OR = 0,18). Conclusões: O diagnóstico de nódulos pequenos (< 2 cm) é um desafio do ponto de vista técnico. A BAG-TC é uma excelente ferramenta diagnóstica, cuja precisão é alta.

Differential Diagnosis of Solitary Pulmonary Inflammatory Lesions and Peripheral Lung Cancers with Contrast-enhanced Computed Tomography

OBJECTIVES: To clarify differences between solitary pulmonary inflammatory lesions and peripheral lung cancers with contrast-enhanced computed tomography. METHODS: In total, 64 and 132 patients with solitary pulmonary inflammatory masses/nodules and peripheral lung cancers, respectively, were enrolled in this study. Their computed tomographic findings were summarized and compared retrospectively. RESULTS: Compared with the peripheral lung cancers, the inflammatory lesions were located closer to the pleura (p<0.0001). The majority of the inflammatory lesions were patchy and oval-shaped (82.8%), whereas most of the tumors were lobulated (82.6%). Almost all the inflammatory cases were unclear (93.8%), whereas most of the tumors had spiculated margins (72.7%). Computed tomography values were significantly higher for the inflammatory lesions than for the cancers (p<0.0001). More than half of the inflammatory lesions had defined necrosis (59.3%). Furthermore, 49.2% of the cancers enhanced inhomogeneously, but only 24.6% had ill-defined necrosis or cavities. The peripheral zones of 98.4% of the inflammatory lesions and 72.7% of the tumors were unclear, with peripheral scattered patches (92.2%) and beam-shaped opacity (66.7%) being the most common findings, respectively. Adjacent pleural thickening was more frequent for the inflammatory lesions than the cancers (95.3% vs. 21.1%, p<0.0001), whereas pleural indentation was found in 67.4% of the subjects with cancer. In addition, hilar (p=0.034) and mediastinal (p=0.003) lymphadenopathy were more commonly detected in the cancers than in the inflammatory cases. CONCLUSIONS: Contrast-enhanced computed tomography findings for pulmonary inflammatory lesions and peripheral lung cancers were significantly different in many aspects. Developing a comprehensive understanding of these differences is helpful for directing their management.

Resección toracoscópica de nódulo pulmonar solitario en escolar / Thoracoscopic resection of solitary pulmonary nodule school

La cirugía mínima invasiva constituye uno de los grandes avances de la medicina en las tres últimas décadas. La cirugía pediátrica no ha escapado a este progreso, y hoy en día son muchas las indicaciones de esta técnica en el niño. El nódulo pulmonar solitario se define como una lesión esférica rodeada por parénquima sano, no asociada a atelectasia y sin adenopatías mediastinales, Se reporta el caso deescolar femenino de 9 años de edad quien presentó evidencia radiológica de nódulo pulmonar solitario ubicado a nivel de la base del campo pulmonar derecho. Se realizó resección toracoscópica del mismo. Fueron descartadas patologías oncológicas, tuberculosis, micosis y enfermedades de depósito. Únicamente fue positiva la serología para Chlamydia pneumoniae (IgM), sin embargo, la pacientenunca presento clínica de infección respiratoria baja antes de su ingreso. La biopsia evidenció una lesión inflamatoria encapsulada inespecífica. Se concluye que la toracoscópia debe ser el método de primera elección ante cualquier lesión torácica y a cualquier edad enpediatría

Minimally invasive surgery constitutes one of the greatest advances of medicine in the last three decades. Pediatric surgery has not escaped this progress; in fact, nowadays there are many indications to perform this technique on children. Solitary pulmonary nodule is defined as a spherical lesion surrounded by healthy parenchyma, not associated with atelectasia and without mediastinallymphadenopathy. We present a nine-year-old girl, with radiological evidence of a solitary pulmonary nodule located at base of the right lung field. A thoracoscopic resection was performed. Oncological pathologies, tuberculosis, mycosis and deposit illnesses werediscarded. The only positive serology was for Chlamydia pneumoniae (IgM); however, the patient never presented clinical lower respiratory infection before her admission. The biopsy determined an encapsulated nonspecific inflammatory lesion. We conclude thatthoracoscopy should be the method of choice for any thoracic injury in children

Análise e validação de modelos probabilísticos de malignidade de nódulo pulmonar solitário em uma população no Brasil / Analysis and validation of probabilistic models for predicting malignancy in solitary pulmonary nodules in a population in Brazil

OBJETIVO: Analisar características clínicas e radiográficas que influenciaram o diagnóstico anatomopatológico de nódulo pulmonar solitário (NPS) e comparar/validar dois modelos probabilísticos de malignidade do NPS em pacientes com NPS no Brasil. MÉTODOS: Análise retrospectiva de 110 pacientes com diagnóstico de NPS submetidos à ressecção em um hospital terciário no período entre 2000 e 2009. As características clínicas estudadas foram gênero, idade, presença de comorbidades sistêmicas, história de neoplasia maligna ao diagnóstico de NPS, diagnóstico histopatológico do NPS, tabagismo, carga tabágica e tempo de cessação do tabagismo. As características radiográficas avaliadas em relação ao NPS foram presença de margens espiculadas, tamanho do maior diâmetro transversal e localização anatômica do NPS. Foram utilizados dois modelos matemáticos, criados em 1997 e 2007, respectivamente, para determinar a probabilidade de malignidade do NPS. RESULTADOS: Houve associações significantes entre malignidade do NPS e idade (p = 0,006; OR = 5,70 para idade >70 anos), presença de margens espiculadas (p = 0,001) e diâmetro maior do NPS (p = 0,001; OR = 2,62 para diâmetro >20 mm). O modelo probabilístico de 1997 mostrou-se superior ao de 2007 - área sob a curva [ASC] ROC = 0,79 ± 0,44 (IC95%: 0,70-0,88) vs. ASC = 0,69 ± 0,50 (IC95%: 0,59-0,79). CONCLUSÕES: Idade elevada, maior diâmetro do NPS e presença de margens espiculadas tiveram associações significantes ao diagnóstico de malignidade do NPS. Nossa análise mostrou que, embora os dois modelos matemáticos sejam eficazes na determinação de malignidade do NPS nessa população, o modelo de 1997 mostrou-se superior.

OBJECTIVE: To analyze clinical and radiographic findings that influence the pathological diagnosis of solitary pulmonary nodule (SPN) and to compare/validate two probabilistic models for predicting SPN malignancy in patients with SPN in Brazil. METHODS: This was a retrospective study involving 110 patients diagnosed with SPN and submitted to resection of SPN at a tertiary hospital between 2000 and 2009. The clinical characteristics studied were gender, age, presence of systemic comorbidities, history of malignancy prior to the diagnosis of SPN, histopathological diagnosis of SPN, smoking status, smoking history, and time since smoking cessation. The radiological characteristics studied, in relation to the SPN, were presence of spiculated margins, maximum transverse diameter, and anatomical location. Two mathematical models, created in 1997 and 2007, respectively, were used in order to determine the probability of SPN malignancy. RESULTS: We found that SPN malignancy was significantly associated with age (p = 0.006; OR = 5.70 for age > 70 years), spiculated margins (p = 0.001), and maximum diameter of SPN (p = 0.001; OR = 2.62 for diameters > 20 mm). The probabilistic model created in 1997 proved to be superior to that created in 2007-area under the ROC curve (AUC), 0.79 ± 0.44 (95% CI: 0.70-0.88) vs. 0.69 ± 0.50 (95% CI: 0.59-0.79). CONCLUSIONS: Advanced age, greater maximum SPN diameter, and spiculated margins were significantly associated with the diagnosis of SPN malignancy. Our analysis shows that, although both mathematical models were effective in determining SPN malignancy in our population, the 1997 model was superior.

Doença de Castleman: uma apresentação pouco frequente / Castleman's disease: an unusual presentation

A doença de Castleman é uma doença linfoproliferativa rara, com envolvimento ganglionar localizado ou sistêmico, raramente atingindo o parênquima pulmonar. Relatamos o caso de um paciente imunocompetente, assintomático, com a variante histológica mais rara da doença, com apresentação nodular parenquimatosa. O paciente foi submetido a lobectomia, com evolução benigna. Nos últimos 10 anos, somente cinco casos de doença de Castleman com apresentação na forma de nódulo pulmonar único foram descritos na literatura. Este caso reforça a necessidade de inclusão da doença de Castleman no diagnóstico diferencial dos nódulos do pulmão, embora ela seja rara.

Castleman's disease is a rare lymphoproliferative disorder, with focal or systemic lymph node involvement, which rarely affects the lung parenchyma. We report the case of an asymptomatic immunocompetent male patient who had the rarest histological variant of the disease, a nodular parenchymal presentation. The patient underwent lobectomy, and the postoperative evolution was favorable. In the last 10 years, there have been only five reports of Castleman's disease presenting as a solitary pulmonary nodule. This case underscores the fact that Castleman's disease, albeit rare, should be included in the differential diagnosis of pulmonary nodules.

A Computer-Aided Diagnosis for Evaluating Lung Nodules on Chest CT: the Current Status and Perspective

As the detection and characterization of lung nodules are of paramount importance in thoracic radiology, various tools for making a computer-aided diagnosis (CAD) have been developed to improve the diagnostic performance of radiologists in clinical practice. Numerous studies over the years have shown that the CAD system can effectively help readers identify more nodules. Moreover, nodule malignancy and the response of malignant lung tumors to treatment can also be assessed using nodule volumetry. CAD also has the potential to objectively analyze the morphology of nodules and enhance the workflow during the assessment of follow-up studies. Therefore, understanding the current status and limitations of CAD for evaluating lung nodules is essential to effectively apply CAD in clinical practice.

Fatores de risco de complicações pulmonares em pacientes com sarcoma após toracotomia para a ressecção de nódulos pulmonares / Risk factors for pulmonary complications in patients with sarcoma after the resection of pulmonary nodules by thoracotomy

OBJETIVO: Identificar os fatores de risco para complicações pulmonares em pacientes com sarcoma após serem submetidos a toracotomia para a ressecção de nódulos pulmonares. MÉTODOS: Estudo de coorte retrospectivo com 68 pacientes consecutivos com diagnóstico de sarcomas e submetidos a 174 toracotomias para a ressecção de nódulos pulmonares. A variável dependente foi definida como a ocorrência de qualquer complicação pulmonar pós-operatória. As variáveis independentes foram relacionadas com o paciente, o diagnóstico de base e o tipo de procedimento cirúrgico. Os dados foram analisados segundo um modelo multivariado de estimação de equações generalizadas, com uma função de ligação logística e uma estrutura de correlação simétrica. RESULTADOS: Houve 24 complicações (13,8 por cento; IC95 por cento: 9,0-19,8), incluindo um óbito. Os pacientes que apresentaram complicações pós-operatórias tiveram um tempo médio de internação duas vezes superior àqueles sem complicações (18,8 ± 10,0 dias vs. 8,6 ± 6,0 dias; p < 0,05). As variáveis que se correlacionaram com o desfecho foram o tipo de ressecção (em cunha ou anatômica; OR = 3,6; IC95 por cento: 1,5-8,8), necessidade de transfusão sanguínea (OR = 9,8; IC95 por cento: 1,6-60,1) e número de nódulos ressecados (OR = 1,1; IC95 por cento: 1,0-1,1). O modelo multivariado obtido exibiu uma área sob a curva ROC de 0,75 (IC95 por cento: 0,65-0,85). CONCLUSÕES: As complicações pulmonares pós-operatórias após a ressecção de nódulos pulmonares em pacientes com sarcoma não foram raras, ocorrendo em cerca de 10 por cento dos procedimentos. A ocorrência dessas complicações pode ser antecipada pelo uso de ressecção não em cunha, necessidade de hemotransfusão e maior número de nódulos ressecados. Assim, já no pós-operatório imediato, é possível identificar pacientes de risco, que devem ser estritamente monitorizados durante o período pós-operatório imediato. Para esses pacientes, todas as medidas preventivas devem ser tomadas.

OBJECTIVE: To identify the risk factors for pulmonary complications after thoracotomy for the resection of pulmonary nodules in patients with sarcoma. METHODS: A retrospective cohort study involving 68 consecutive patients diagnosed with sarcoma and submitted to a total of 174 thoracotomies for the resection of pulmonary nodules. The dependent variable was defined as the occurrence of any postoperative pulmonary complications. The independent variables were related to the patient, underlying diagnosis, and type of surgical procedure. We analyzed the data using a multivariate generalized estimating equations model with logistic link function and a symmetric correlation structure. RESULTS: Complications were observed in 24 patients (13.8 percent, 95 percent CI: 9.0-19.8), and there was one death. The mean length of hospital stay was twice as long in the patients with postoperative complications as in those without (18.8 ± 10.0 days vs. 8.6 ± 6.0 days; p < 0.05). The variables that correlated with the outcome measure were the type of resection (wedge vs. anatomic; OR = 3.6; 95 percent CI: 1.5-8.8), the need for blood transfusion (OR = 9.8; 95 percent CI: 1.6-60.1), and the number of nodules resected (OR = 1.1; 95 percent CI: 1.0-1.1). The multivariate model showed an area under the ROC curve of 0.75 (95 percent CI: 0.65-0.85). CONCLUSIONS: Postoperative pulmonary complications were common after pulmonary nodule resection in patients with sarcoma, occurring in approximately 10 percent of the procedures. The occurrence of such complications can be expected when techniques other than wedge resection are employed, when blood transfusion is required, and when a great number of nodules are resected. Therefore, it is possible to identify patients at risk for pulmonary complications, who should be closely monitored in the immediate postoperative period. In such patients, all preventive measures should be taken.

calcified lung nodule: what does it mean?

The aim of this review is to present a pictorial essay emphasizing the various patterns of calcification in pulmonary nodules [PN] to aid diagnosis and the pathogenesis where it is known. The imaging evaluation of PN is based on clinical history, size, distribution and the gross appearance of the nodule as well as feasibility of obtaining a tissue diagnosis. Imaging is instrumental in the management of PN and one should strive not only to identify small malignant tumors with high survival rates but to spare patients with benign PN from undergoing unnecessary surgery. The review emphasizes how to achieve these goals. One of the most reliable imaging features of a benign lesion is a benign pattern of calcification and periodic follow-up with computed tomography showing no growth for 2 years. Calcification in PN is generally considered as a pointer toward a possible benign disease. However, as we show here, calcification in PN as a criterion to determine benign nature is fallacious and can be misleading. The differential considerations of a calcified lesion include calcified granuloma, harmartome, carcinoid, osteosarcoma, chondrosarcoma and lung metastases or a primary bronchogenic carcinoma among others. We describe and illustrate different patterns of calcification as seen in PN on imaging

Incidencia de lesiones benignas en pacientes sometidos a resecciones pulmonares por sospecha de neoplasias malignas / Benign pulmonary nodules excised for suspicion of malignancy: experience in 140 patients

Background: The management of incidental pulmonary nodules discovered during imaging studies may range from clinical observation, percutaneous needle aspiration to open surgery. The predictive value for malignancy of imaging studies is low. Aim: To report our experience with nodular pulmonary lesions suggestive of lung cancer and subsequently proven benign on histological examination. Material and Methods: A retrospective analysis of the medical records of 140 patients aged 59 +/- 15 years (107 males) in whom a focal pulmonary lesion was excised at our institution from October 1984 to august 2007. Computed tomography and pathology reports were reviewed for all patients. Fluorine-18-flurodeoxyglucose positron emission tomography studies were performed on 43 patients. Lesions were excised by thoracotomy and video-assisted thoracoscopy, and sternotomy. All lesions were diagnosed as benign on pathology. Results: One patient died in the postoperative period. Pathologic diagnoses of the surgical pieces were granulomatous inflammation in 65 percent, hamartomas in 12 percent, pneumonia or pneumonitis in 10 percent, fibrosis in 4 percent and other in 9 percent. Fluorine-18 fluorodeoxyglucose positron emission tomography imaging suggested malignancy in 22 of 43 patients. Conclusions: Despite thorough clinical assessment, advanced imaging technology, and needle biopsy, many patients continue to undergo surgery for benign diseases. Aggressive attempts to diagnose and treat early stage lung cancer must be tempered with understanding.

Objetivos: Describir la experiencia en los nodulos pulmonares sospechosos por clínica e imagenología de malignidad, que resultaron ser benignos luego del estudio histológico de la pieza operatoria. Se realiza análisis retrospectivo en 140 pacientes con lesiones nodulares indeterminadas sometidos a resección entre octubre de 1984 a agosto 2007, en la sección de cirugía torácica Servicio, Hospital Universitario Miguel Pérez Carreño, Caracas, Venezuela. Se revisaron las historias clínicas, los estudios imagenológicos y los informes de anatomía patológica. La tomografía mediante emisión de positrones fue realizada en el 30,71 por ciento, y fue sugerente de malignidad en el 51,16 por ciento (22 casos), un estudio resultó ininterpretable (2,32 por ciento). Treinta y ocho nodulos fueron biopsiados. De estas, 29 resultaron no diagnósticas, 5 negativas, y cuatro positivas para malignidad. En relación a la técnica quirúrgica se dividieron en dos grupos. A: Cirugía abierta, B: Por videotoracoscopia. El estudio histológico reveló: granuloma infeccioso (65 por ciento), hamartomas (12 por ciento), neumonía o neumonitis en (10 por ciento), fibrosis (4 por ciento), otros (9 por ciento). No obstante la valoración clínica, la avanzada tecnología de imágenes, y la biopsia por aspiración, muchos nodulos continúan siendo sometidos a cirugía por sospecha de malignidad. En estos pacientes han de realizarse las exploraciones necesarias para establecer el diagnóstico y tratamiento en los nodulos pulmonares indeterminados, donde se sospeche malignidad, para descartar los estadios tempranos del cáncer pulmonar.

Malignant Pure Pulmonary Ground-Glass Opacity Nodules: Prognostic Implications

OBJECTIVE: This study was designed to evaluate follow-up results in terms of patient prognosis for malignant pulmonary nodules depicted as pure ground-glass opacity (GGO) lesion observed at high-resolution CT (HRCT). MATERIALS AND METHODS: Surgical removal for malignant GGO nodules was accomplished in 58 patients (26 men, 32 women; mean age, 57 years; age range, 29-78 years). Patient prognoses were assessed by patient clinical status and the presence of changes in nodule size determined after a follow-up HRCT examination. Differences in patient prognoses were compared for nodule number, size, surgical method, change in size before surgical removal, and histopathological diagnosis by use of Fisher's exact test and Pearson's chi-squared test. RESULTS: Of the 58 patients, 40 patients (69%) were confirmed to have a bronchioloalveolar carcinoma (BAC) and 18 patients (31%) were confirmed to have an adenocarcinoma with a predominant BAC component. Irrespective of nodule size, number, treatment method, change in size before surgical removal and histopathological diagnosis, neither local recurrence nor a metastasis occurred in any of these patients as determined at a follow-up period of 24 months (range; 12-65 months). Of 14 patients with multiple GGO nodules, all of the nodules were resected without recurrence in six patients. In the remaining eight patients, the remaining nodules showed no change in size in seven cases and a decrease in size in one case as determined after a follow-up CT examination. CONCLUSION: Prognoses in patients with pure GGO malignant pulmonary nodules are excellent, and not significantly different in terms of nodule number, size, surgical method, presence of size change before surgical removal and histopathological diagnosis.

Condições pulmonares simulando metástases: relato de dois casos e revisão de literatura / Pulmonary conditions mimicking metastasis: two case reports and literature review

Normalmente as metástases pulmonares apresentam-se como nódulos múltiplos, bilaterais e distribuídos perifericamente. A presença de múltiplos nódulos pulmonares assintomáticos é uma condição que, muitas vezes,impõe dificuldades quanto à investigação diagnóstica até mesmo a médicos experientes. Embora a principal hipótese frente a este quadro imaginológico seja o de doença metastática, etiologias diferentes podem levar aquadros similares, dentre elas: infecções granulomatosas, sarcoidose, granulomatose de Wegener (GW), neoplasias benignas, artrite reumatóide, síndrome de Churg-Strauss e hamartomas múltiplos. No presente trabalho, são apresentados dois casos de patologias distintas identificadas incidentalmente por exames imaginológicos que inicialmente simularam metástases pulmonares em pacientes assintomáticos. Em um deles fez-se o diagnóstico de linfangioleiomiomatose pulmonar e o tratamento vem sendo feito com tamoxifeno 20mg/dia há um ano e quatro meses, com lesões inalteradas. O segundo revelou tratar-se de vasculite linfocítica compatível com GW, sendo tratado com pulsoterapia com prednisolona, ciclofosfamida e azatioprina e encontra-se no momento com um nódulo residual calcificado.

Valor do FDG[18F]-PET/TC como preditor de câncer em nódulo pulmonar solitário / Value of [18F]-FDG-PET/CT as a predictor of cancer in solitary pulmonary nodule

OBJETIVO: Determinar a acurácia diagnóstica da positron emission tomography (tomografia por emissão de pósitrons)/tomografia computadorizada (PET/TC) com deoxiglicose marcada com flúor-18, conhecida como fluorodeoxiglicose (FDG[18F]), na avaliação de nódulo pulmonar solitário (NPS). MÉTODOS: Análise prospectiva de 53 pacientes consecutivos que realizaram PET/TC para avaliação de NPS, entre março de 2005 e maio de 2007. Destes 32 preencheram os critérios de inclusão. As lesões foram avaliadas quanto a sua localização e tamanho, grau de captação do radiofármaco e o standardized uptake value (SUV, valor padronizado de captação) máximo das lesões. Os achados dos estudos de FDG-PET/TC foram correlacionados com outros preditores de malignidade (idade, sexo, tabagismo, tamanho e localização do nódulo). O diagnóstico definitivo foi estabelecido por confirmação histopatológica ou acompanhamento clínico-radiológico por um período mínimo de um ano. RESULTADOS: Encontrados 14 NPS malignos. Após análise da curva ROC, o SUV de 2,5 foi considerado o melhor ponto de corte que identificou corretamente 13 dos 14 NPS malignos. Os resultados abaixo deste ponto de corte mostraram um exame falso positivo para neoplasia num total de 14. O método semiquantitativo apresentou sensibilidade de 92,9 por cento, especificidade de 72,2 por cento, valor preditivo positivo de 72,2 por cento, valor preditivo negativo de 92,9 por cento e acurácia de 81,2 por cento. Na análise multivariada, apenas a localização do nódulo nos lobos superiores (p = 0,048) e o SUV (p = 0,007) demonstraram significância estatística para malignidade no NPS. CONCLUSÕES: Os dados do estudo mostram que o SUV da FDG[18F] é um bom preditor de neoplasia em nódulos pulmonares e com alto valor preditivo negativo, o que oferece grande segurança em afastar presença de malignidade, indicando sua importância na abordagem diagnóstica do nódulo pulmonar.

OBJECTIVE: To determine the diagnostic accuracy of positron emission tomography/computed tomography (PET/CT) using fluorine-18-deoxyglucose ([18F]-FDG) for the evaluation of a solitary pulmonary nodule (SPN). METHODS: Prospective analysis of 53 consecutive patients submitted to PET/CT between March 2005 and May 2007 for the evaluation of an SPN. Of those, 32 met the criteria for inclusion in the present study. The lesions were evaluated for location, size, radiotracer uptake and maximum standardized uptake value (SUV). The FDG-PET/TC results were correlated with other predictors of malignance (age, gender, smoking status, nodule size and nodule location). The definitive diagnosis was established through histopathology or through clinical/radiological follow-up for at least one year. RESULTS: Fourteen malignant SPNs were found. Through analysis of the ROC curve, we established an SUV of 2.5 as the most appropriate cut-off point, since it correctly identified 13 of the 14 malignant SPNs. The results below that point revealed one false positive for neoplasia out of a total of 14. The semiquantitative method presented a sensitivity of 92.9 percent, specificity of 72.2 percent, positive predictive value of 72.2 percent, negative predictive value of 92.9 percent and accuracy of 81.2 percent. The multivariate analysis showed a statistically significant association with SPN malignancy only for nodule location in the upper lobes (p = 0.048) and SUV (p = 0.07). CONCLUSIONS: The results obtained suggest that the SUV of [18F]-FDG is a useful predictor of neoplasia in SPN, with a high negative predictive value, which allows malignancy to be safely ruled out, showing its relevance in the diagnostic approach to pulmonary nodules.

Nódulo pulmonar solitario: desafío diagnóstico y terapéutico / Solitary pulmonary nodule: a challenge in diagnosis and treatment

El concepto de nódulo pulmonar solitario (NPS) corresponde a una imagen radiológica aumentada de densidad, en general esférica, de bordes bien delimitados, que mide menos de 3cm de diámetro.El NPS ha sido siempre una situación de difícil manejo, que requiere de un enfoque ordenado y especializado. Es por esto, que la aproximación diagnóstica en un paciente con NPS debe basarse en una estimación de la probabilidad de tener cáncer, de esta forma, cuando la posibilidad de cáncer sea baja, el nódulo puede ser seguido por medio de tomografía computada de alta resolución cada tres meses el primer año y cada seis el segundo. En caso de alta sospecha de cáncer, la resección quirúrgica es justificada, idealmente mediante videotoracoscopía. Para pacientes con nódulos indeterminados, puede utilizarse el PET para determinar el riesgo de cáncer. A raíz de los múltiples avances de la medicina y los nuevos métodos diagnósticos disponibles hoy en día, creemos importante revisar este tema entregando herramientas actuales y concretas para el estudio de un paciente con NPS.

Volumetric Measurements of Lung Nodules with Multi-Detector Row CT: Effect of Changes in Lung Volume

OBJECTIVE: To evaluate how changes in lung volume affect volumetric measurements of lung nodules using a multi-detector row CT. MATERIALS AND METHODS: Ten subjects with asthma or chronic bronchitis who had one or more lung nodules were included. For each subject, two sets of CT images were obtained at inspiration and at expiration. A total of 33 nodules (23 nodules > or = 3 mm) were identified and their volume measured using a semiautomatic volume measurement program. Differences between nodule volume on inspiration and expiration were compared using the paired t-test. Percent differences, between on inspiration and expiration, in nodule attenuation, total lung volume, whole lung attenuation, and regional lung attenuation, were computed and compared with percent difference in nodule volume determined by linear correlation analysis. RESULTS: The difference in nodule volume observed between inspiration and expiration was significant (p or = 3 mm. The volume of nodules was measured to be larger on expiration CT than on inspiration CT (28 out of 33 nodules; 19 out of 23 nodules > or = 3 mm). A statistically significant correlation was found between the percent difference of lung nodule volume and lung volume or regional lung attenuation (p or = 3 mm. CONCLUSION: Volumetric measurements of pulmonary nodules were significantly affected by changes in lung volume. The variability in this respiration-related measurement should be considered to determine whether growth has occurred in a lung nodule.

Histoplasmoma pulmonar no Rio Grande do Sul / Pulmonary histoplasmoma in Rio Grande do Sul

Foram revisados dezesseis prontuários de pacientes que apresentavam nódulo pulmonar à radiografia de tórax diagnosticados como histoplasmoma através de achado histopatológico demonstrando elementos fúngicos compatíveis com Histoplasma capsulatum var capsulatum no Rio Grande do Sul. Revisada a literatura brasileira. Todos os pacientes eram brancos, nove eram homens, a média de idade foi de 50,8 anos. Seis (37,5 por cento) pacientes tinham história epidemiológica sugestiva de contato com fungo. Os nódulos variaram de 0,7 a 2,7 cm de diâmetro, apresentavam-se como granuloma com necrose caseosa. Doze (75 por cento) pacientes apresentavam nódulo solitário. O histoplasmoma como regra se apresenta como nódulo solitário com até três centímetros de diâmetro em paciente assintomático. O diagnóstico é realizado por exame histopatológico com coloração especial para visualização do fungo, método de Gomori-Grocott com metenamina argêntica. Cultivo ou testes soromicológicos não contribuem para o diagnóstico.

Predictors for Benign Solitary Pulmonary Nodule in Tuberculosis-Endemic Area

BACKGROUND: Solitary pulmonary nodule (SPN) may show different pre- sentation in tuberculosis (TB)-endemic countries. The aim of this study was to identify clinical and radiological predictors favoring benign or malignant SPN in TB-endemic region. METHODS: Two hundred one SPNs in 201 consecutive Korean patients were included (< 3 cm in diameter, all confirmed by pathology or bacteriology, 93 benign and 108 malignant diseases). For clinical parameters, age, sex, smoking status and amount, and past history of pulmonary tuberculosis and diabetes mellitus were investigated retrospectively. For radiological parameters, size, location, margin characteristics, presence of calcification, pleural tag, surrounding satellite nodule, cavitation, internal low attenuation, open bronchus sign, surrounding ground-glass opacity, enhancement pattern of the SPNs and mediastinal lymph node (LN) enlargement were analyzed on chest CT scans. RESULTS: Patients with a older age (60.7+/-9.6 vs 56.2+/-13.1, p=0.008) and more than 40-pack years smoking (27.8% vs 14.0%, p=0.017) were more frequently related with malignant than benign SPN. On chest CT scans, spiculated margin, contrast enhancement more than 20 Hounsfield unit and presence of pleural tag and mediastinal LN enlargement were more frequently observed in malignant than benign SPNs. In contrast to previous studies, satellite lesions (21.5% vs 1.9%, p < 0.001) and cavitation (20.4% vs 5.6%, p=0.001) were more frequently seen in benign than malignant SPN. Positive predictive values of benignity were 90.9% and 76.0%, respectively, when satellite lesions and cavitation were found in cases of SPN. CONCLUSION: Satellite lesions and cavitation on chest CT scan could be useful predictors for benign SPN in TB-endemic areas.

Pulmonary scedosporiosis

E relatado caso de nodulo solitario pulmonar por Scedosporium apiospermum (Pseudallescheria boydii). Foi feita uma revisao da literatura pertinente e, alem disso, casos com lesoes similares causadas por outros fungos oportunistas sao comentados