Quantitative CT Texture Analysis of COVID-19 Hospitalized Patients during 3-24-Month Follow-Up and Correlation with Functional Parameters.

BACKGROUND: To quantitatively evaluate CT lung abnormalities in COVID-19 survivors from the acute phase to 24-month follow-up. Quantitative CT features as predictors of abnormalities' persistence were investigated. METHODS: Patients who survived COVID-19 were retrospectively enrolled and underwent a chest CT at baseline (T0) and 3 months (T3) after discharge, with pulmonary function tests (PFTs). Patients with residual CT abnormalities repeated the CT at 12 (T12) and 24 (T24) months after discharge. A machine-learning-based software, CALIPER, calculated the CT percentage of the whole lung of normal parenchyma, ground glass (GG), reticulation (Ret), and vascular-related structures (VRSs). Differences (Δ) were calculated between time points. Receiver operating characteristic (ROC) curve analyses were performed to test the baseline parameters as predictors of functional impairment at T3 and of the persistence of CT abnormalities at T12. RESULTS: The cohort included 128 patients at T0, 133 at T3, 61 at T12, and 34 at T24. The GG medians were 8.44%, 0.14%, 0.13% and 0.12% at T0, T3, T12 and T24. The Ret medians were 2.79% at T0 and 0.14% at the following time points. All Δ significantly differed from 0, except between T12 and T24. The GG and VRSs at T0 achieved AUCs of 0.73 as predictors of functional impairment, and area under the curves (AUCs) of 0.71 and 0.72 for the persistence of CT abnormalities at T12. CONCLUSIONS: CALIPER accurately quantified the CT changes up to the 24-month follow-up. Resolution mostly occurred at T3, and Ret persisting at T12 was almost unchanged at T24. The baseline parameters were good predictors of functional impairment at T3 and of abnormalities' persistence at T12.

Mortality surrogates in combined pulmonary fibrosis and emphysema.

BACKGROUND: Idiopathic pulmonary fibrosis (IPF) with coexistent emphysema, termed combined pulmonary fibrosis and emphysema (CPFE) may associate with reduced forced vital capacity (FVC) declines compared to non-CPFE IPF patients. We examined associations between mortality and functional measures of disease progression in two IPF cohorts. METHODS: Visual emphysema presence (>0% emphysema) scored on computed tomography identified CPFE patients (CPFE/non-CPFE: derivation cohort n=317/n=183, replication cohort n=358/n=152), who were subgrouped using 10% or 15% visual emphysema thresholds, and an unsupervised machine-learning model considering emphysema and interstitial lung disease extents. Baseline characteristics, 1-year relative FVC and diffusing capacity of the lung for carbon monoxide (D LCO) decline (linear mixed-effects models), and their associations with mortality (multivariable Cox regression models) were compared across non-CPFE and CPFE subgroups. RESULTS: In both IPF cohorts, CPFE patients with ≥10% emphysema had a greater smoking history and lower baseline D LCO compared to CPFE patients with <10% emphysema. Using multivariable Cox regression analyses in patients with ≥10% emphysema, 1-year D LCO decline showed stronger mortality associations than 1-year FVC decline. Results were maintained in patients suitable for therapeutic IPF trials and in subjects subgrouped by ≥15% emphysema and using unsupervised machine learning. Importantly, the unsupervised machine-learning approach identified CPFE patients in whom FVC decline did not associate strongly with mortality. In non-CPFE IPF patients, 1-year FVC declines ≥5% and ≥10% showed strong mortality associations. CONCLUSION: When assessing disease progression in IPF, D LCO decline should be considered in patients with ≥10% emphysema and a ≥5% 1-year relative FVC decline threshold considered in non-CPFE IPF patients.

Long-term lung ultrasound follow-up in patients after COVID-19 pneumonia hospitalization: A prospective comparative study with chest computed tomography.

During COVID-19 pandemic, lung ultrasound (LUS) proved to be of great value in the diagnosis and monitoring of patients with pneumonia. However, limited data exist regarding its use to assess aeration changes during follow-up (FU). Our study aims to prospectively evaluate 232 subjects who underwent a 3-month-FU program after hospitalization for COVID-19 at the University Hospital of Pisa. The goals were to assess the usefulness of standardized LUS compared with the gold standard chest computed tomography (CT) to evaluate aeration changes and to verify LUS and CT agreement at FU. Patients underwent in the same day a standardized 16-areas LUS and high-resolution chest CT reported by expert radiologists, assigning interpretative codes. Based on observations distribution, LUS score cut-offs of 3 and 7 were selected, corresponding to the 50th and 75th percentile, respectively. Patients with LUS scores above both these thresholds were older and with longer hospital stay. Patients with a LUS score ≥3 had more comorbidities. LUS and chest CT showed a high agreement in identifying residual pathological findings, using both cut-off scores of 3 (OR 14,7; CL 3,6-64,5, Sensitivity 91%, Specificity 49%) and 7 (OR 5,8; CL 2,3-14,3, Sensitivity 65%, Specificity 79%). Our data suggest that LUS is very sensitive in identifying pathological findings at FU after a hospitalization for COVID-19 pneumonia, compared to CT. Given its low cost and safety, LUS could replace CT in selected cases, such as in contexts with limited resources or it could be used as a gate-keeper examination before more advanced techniques.

Quantitative texture-based analysis of pulmonary parenchymal features on chest CT: comparison with densitometric indices and short-term effect of changes in smoking habit.

PURPOSE: To investigate the correlations between densitometric and Computer Aided Lung Informatics for Pathology Evaluation and Rating (CALIPER)-derived indices of pulmonary emphysema and their change in the short-term period for groups of patients with different smoking habits. METHOD: This retrospective study included 284 subjects from the ITALUNG trial (198 men and 86 women; mean±sd age 60±4 years) who underwent low-dose chest computed tomography at baseline and 2-year follow-up. Subjects were divided into four groups (persistent smokers, restarters, quitters and former smokers) according to their smoking habit at baseline and follow-up. Densitometric and texture analyses were performed, using CALIPER software. A correlation analysis was conducted between CALIPER-derived low-attenuation areas (LAAs) and densitometric indices, including the 15th percentile of the whole-lung attenuation histogram (Perc15) and the relative areas with density ≤-950 HU (RA950). Densitometric indices and LAAs were evaluated at baseline and variation assessed longitudinally with comparisons between groups with different smoking habit. Further analysis of parenchymal changes per pulmonary zone was performed. RESULTS: LAAs were strongly correlated with Perc15 (rs=0.81; p<0.001) and RA950 (rs=0.905; p<0.001). At baseline, the group of smokers showed higher Perc15, lower RA950, lower LAAs (particularly mild sub-class of LAAs) than the group of ex-smokers (p<0.001). At 2-year follow-up, densitometric indices and LAAs increased in persistent smokers, former smokers and quitters (p<0.05). The progression was larger and statistically more significant in quitters (p<0.001). CONCLUSION: CALIPER texture analysis provides an objective measure comparable to traditional density/histogram features to assess the lung parenchymal changes in relation to different smoking habits.

Evaluation of Interstitial Lung Disease in Idiopathic Inflammatory Myopathies Through Semiquantitative and Quantitative Analysis of Lung Computed Tomography.

PURPOSE: To perform a semiquantitative and quantitative analysis of interstitial lung disease (ILD), through computed tomography (CT), in different serological subgroups of idiopathic inflammatory myopathies (IIM) patients, to find radiologic and clinical differences of disease related to serology. MATERIALS AND METHODS: This was a prospective study, which included 98 IIM patients, divided into serological subgroups: anti-aminoacyl-transfer-RNA-synthetases (anti-ARS) positive and myositis-specific autoantibodies (MSA) negative.For each baseline CT the total semiquantitative score of Warrick (WS) and the automated software (Computer-Aided Lung Informatics for Pathology Evaluation and Rating) quantitative scores interstitial lung disease % (ILD%) and vascular-related structure % (VRS%) were calculated. Pulmonary function tests included total lung capacity % (TLC%), forced vital capacity % (FVC%), and diffusing capacity of the lung for carbon monoxide % (DLCO%). RESULTS: Inverse correlations ( P <0.001) between the radiologic scores and the functional scores DLCO% and TLC% were found, the most relevant being between ILD% and DLCO% (ρ=-0.590), VRS% and DLCO% (ρ=-0.549), and WS and DLCO% (ρ=-0.471).Positive correlations between ILD% and VRS% (ρ=0.916; P <0.001), WS and ILD% (ρ=0.663; ρ<0.001), and WS and VRS% (ρ=0.637; P <0.001) were obtained.Statistically significant higher values of WS, ILD%, and VRS% were found in the anti-ARS group (WS=15; ILD%=11; VRS%=3.5) compared with the MSA negative one (WS=2.5; ILD%=0.84; VRS%=2.2).The nonspecific interstitial pneumonia pattern was dominant. No statistically significant differences emerged at pulmonary function tests. CONCLUSIONS: In this study, ILD in anti-ARS-positive and MSA-negative groups was defined through semiquantitative and quantitative analysis of lung CT. The inverse correlations between the radiologic scores and TLC% and DLCO% ( P <0.001) confirm the role of lung CT in the evaluation of ILD in IIM.

The Use of Chest Magnetic Resonance Imaging in Malignant Pleural Mesothelioma Diagnosis.

In recent years, many articles have demonstrated that magnetic resonance imaging (MRI) may be performed successfully in the study of the chest. The aim of this study was to evaluate the potential role of MRI in the differentiation of benign from malignant pleural disease with a special focus on malignant pleural mesothelioma and on MRI protocols. A systematic literature search was performed to find original articles about chest MRI in patients with either benign or malignant pleural disease. We retrieved 1246 papers and 17 studies were finally identified as being in accordance with our purpose. For a morphologic assessment, T1-weighted and T2-weighted sequences were usually performed, eventually associated with T1 post-contrast sequences for better detection of pleural lesions. Functional sequences such as Diffusion Weighting Imaging (DWI), associated with the evaluation of Apparent Diffusion Coefficient (ADC) maps, were lately and gradually introduced in chest MRI protocols and their potentiality in differentiating benign from malignant disease has been investigated by many authors. Many progresses have been performed to improve quality images and diagnostic performances of MRI. A better and early identification of pleural disease may be obtained, providing MRI as a possible tool that can differentiate malignant from benign pleural disease without using invasive procedures.

Lung vessel volume evaluated with CALIPER software is an independent predictor of mortality in COVID-19 patients: a multicentric retrospective analysis.

INTRODUCTION: Computer-Aided Lung Informatics for Pathology Evaluation and Ratings (CALIPER) software has already been widely used in the evaluation of interstitial lung diseases (ILD) but has not yet been tested in patients affected by COVID-19. Our aim was to use it to describe the relationship between Coronavirus Disease 2019 (COVID-19) outcome and the CALIPER-detected pulmonary vascular-related structures (VRS). MATERIALS AND METHODS: We performed a multicentric retrospective study enrolling 570 COVID-19 patients who performed a chest CT in emergency settings in two different institutions. Fifty-three age- and sex-matched healthy controls were also identified. Chest CTs were analyzed with CALIPER identifying the percentage of VRS over the total lung parenchyma. Patients were followed for up to 72 days recording mortality and required intensity of care. RESULTS: There was a statistically significant difference in VRS between COVID-19-positive patients and controls (median (iqr) 4.05 (3.74) and 1.57 (0.40) respectively, p = 0.0001). VRS showed an increasing trend with the severity of care, p < 0.0001. The univariate Cox regression model showed that VRS increase is a risk factor for mortality (HR 1.17, p < 0.0001). The multivariate analysis demonstrated that VRS is an independent explanatory factor of mortality along with age (HR 1.13, p < 0.0001). CONCLUSION: Our study suggests that VRS increases with the required intensity of care, and it is an independent explanatory factor for mortality. KEY POINTS: • The percentage of vascular-related structure volume (VRS) in the lung is significatively increased in COVID-19 patients. • VRS showed an increasing trend with the required intensity of care, test for trend p< 0.0001. • Univariate and multivariate Cox models showed that VRS is a significant and independent explanatory factor of mortality.

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.

New Updates of the Imaging Role in Diagnosis, Staging, and Response Treatment of Malignant Pleural Mesothelioma.

Malignant pleural mesothelioma is a rare neoplasm with poor prognosis. CT is the first imaging technique used for diagnosis, staging, and assessment of therapy response. Although, CT has intrinsic limitations due to low soft tissue contrast and the current staging system as well as criteria for evaluating response, it does not consider the complex growth pattern of this tumor. Computer-based methods have proven their potentiality in diagnosis, staging, prognosis, and assessment of therapy response; moreover, computer-based methods can make feasible tasks like segmentation that would otherwise be impracticable. MRI, thanks to its high soft tissue contrast evaluation of contrast enhancement and through diffusion-weighted-images, could replace CT in many clinical settings.

Mortality in combined pulmonary fibrosis and emphysema patients is determined by the sum of pulmonary fibrosis and emphysema.

In patients with combined pulmonary fibrosis and emphysema, emphysema and fibrosis do not have a synergistic effect that results in worsened survival when compared to IPF patients without emphysema https://bit.ly/35EJMo6.

Combining liquid biopsy and radiomics for personalized treatment of lung cancer patients. State of the art and new perspectives.

Lung cancer has become a paradigm for precision medicine in oncology, and liquid biopsy (LB) together with radiomics may have a great potential in this scenario. They are both minimally invasive, easy to perform, and can be repeated during patient's follow-up. Also, increasing evidence suggest that LB and radiomics may provide an efficient way to screen and diagnose tumors at an early stage, including the monitoring of any change in the tumor molecular profile. This could allow treatment optimization, improvement of patients' quality of life, and healthcare-related costs reduction. Latest reports on lung cancer patients suggest a combination of these two strategies, along with cutting-edge data analysis, to decode valuable information regarding tumor type, aggressiveness, progression, and response to treatment. The approach seems more compatible with clinical practice than the current standard, and provides new diagnostic companions being able to suggest the best treatment strategy compared to conventional methods. To implement radiomics and liquid biopsy directly into clinical practice, an artificial intelligence (AI)-based system could help to link patients' clinical data together with tumor molecular profiles and imaging characteristics. AI could also solve problems and limitations related to LB and radiomics methodologies. Further work is needed, including new health policies and the access to large amounts of high-quality and well-organized data, allowing a complementary and synergistic combination of LB and imaging, to provide an attractive choice e in the personalized treatment of lung cancer.

Radioguided Surgery, a Cost-Effective Strategy for Treating Solitary Pulmonary Nodules: 20-Year Experience of a Single Center.

INTRODUCTION: Surgical resection with minimally invasive approach is the gold standard for both definitive diagnosis and treatment of solitary pulmonary nodules (SPNs); however, it can be difficult to pinpoint small, deep, or subsolid nodes without palpating lung parenchyma. The primary endpoint of this study is showing that radioguided surgery is a cost-effective strategy to improve the effectiveness of video-thoracoscopic localization/resection of SPNs/ground-glass opacities (GGOs). Secondary endpoints are analyzing the morbidity of this technique and tips and tricks to better manage this method. METHODS: SPN smaller than 20 mm and/or with a distance from the visceral pleura ≥5 mm underwent minimally invasive resection after computed tomography-guided injection of a solution composed of 0.1/0.2 mL of 99Tc-labeled human serum albumin microspheres and 0.1 mL of nonionic contrast. In the operating theater, a collimated probe connected to a gamma ray detector allowed localization of the target area. RESULTS: Between 1997 and 2018, a total of 451 patients with SPN/GGO underwent minimally invasive surgery with a radioguided technique at our hospital. The mean SPN diameter was 13 mm (range, 5-20 mm), and the mean distance from the visceral pleura was 15 mm (range, 6-29 mm). The mean time to a localizing nodule was 3 minutes (range, 1-5 minutes). No significant injection-related complications were reported; only 3.3% of patients (15 of 451) developed pneumothorax. Both 30- to 60-day and 90-day mortality were 0%. The rate of postoperative complications was 2.53% (prolonged air leak). The conversion rate to thoracotomy was 1.55% (7 of 451). CONCLUSIONS: Our 20-year experience shows that radioguided thoracoscopic surgery is a safe and feasible strategy to treat suspicious SPN/GGO, with a success rate of 98%.

Automated Computed Tomography analysis in the assessment of Idiopathic Pulmonary Fibrosis severity and progression.

PURPOSE: To investigate the role of a quantitative analysis software (CALIPER) in identifying HRCT thresholds predicting IPF patients' survival and lung function decline and its role in detecting changes of HRCT abnormalities related to treatment and their correlation with Forced Vital Capacity (FVC). METHODS: This retrospective study included 105 patients with a multidisciplinary diagnosis of IPF for whom one HRCT at baseline and concomitant FVC were available. HRCTs were evaluated with CALIPER and the correlation between FVC and radiological features were assessed. Radiological thresholds for survival prediction and functional decline were calculated for all patients. Fifty-nine patients with at least 2 serial HRCTs were classified into two groups based on treatment. For patients for whom a FVC within 3 months of the HRCT was available (n = 44), the correlation of radiological and clinical progression was evaluated. RESULTS: The correlation between FVC and CALIPER-derived features at baseline was significant and strong. A baseline CALIPER-derived interstitial lung disease (ILD%) extent higher than 20 % and pulmonary vascular related structures (PVRS%) score greater than 5 % defined a worse prognosis. A significant progression of CALIPER-derived features in all patients was found with a faster increase in untreated patients. ILD% and PVRS% changes during follow-up demonstrated strong correlations with FVC changes. CONCLUSIONS: CALIPER quantification of fibrosis and vascular involvement could distinguish disease progression in treated versus untreated patients and predict the survival. The changes in CALIPER-derived variables over time were significantly correlated to changes in FVC.

Integrating Liquid Biopsy and Radiomics to Monitor Clonal Heterogeneity of EGFR-Positive Non-Small Cell Lung Cancer.

BACKGROUND: EGFR-positive Non-small Cell Lung Cancer (NSCLC) is a dynamic entity and tumor progression and resistance to tyrosine kinase inhibitors (TKIs) arise from the accumulation, over time and across different disease sites, of subclonal genetic mutations. For instance, the occurrence of EGFR T790M is associated with resistance to gefitinib, erlotinib, and afatinib, while EGFR C797S causes osimertinib to lose activity. Sensitive technologies as radiomics and liquid biopsy have great potential to monitor tumor heterogeneity since they are both minimally invasive, easy to perform, and can be repeated over patient's follow-up, enabling the extraction of valuable information. Yet, to date, there are no reported cases associating liquid biopsy and radiomics during treatment. CASE PRESENTATION: In this case series, seven patients with metastatic EGFR-positive NSCLC have been monitored during target therapy. Plasma-derived cell free DNA (cfDNA) was analyzed by a digital droplet PCR (ddPCR), while radiomic analyses were performed using the validated LifeX® software on computed tomography (CT)-images. The dynamics of EGFR mutations in cfDNA was compared with that of radiomic features. Then, for each EGFR mutation, a radiomic signature was defines as the sum of the most predictive features, weighted by their corresponding regression coefficients for the least absolute shrinkage and selection operator (LASSO) model. The receiver operating characteristic (ROC) curves were computed to estimate their diagnostic performance. The signatures achieved promising performance on predicting the presence of EGFR mutations (R2 = 0.447, p <0.001 EGFR activating mutations R2 = 0.301, p = 0.003 for T790M; and R2 = 0.354, p = 0.001 for activating plus resistance mutations), confirmed by ROC analysis. CONCLUSION: To our knowledge, these are the first cases to highlight a potentially promising strategy to detect clonal heterogeneity and ultimately identify patients at risk of progression during treatment. Together, radiomics and liquid biopsy could detect the appearance of new mutations and therefore suggest new therapeutic management.

Clinical Impact of Radioguided Localization in the Treatment of Solitary Pulmonary Nodule: A 20-Year Retrospective Analysis.

PURPOSE: Incidental solitary pulmonary nodules (SPNs) have become an increasingly common CT finding worldwide. Although there are currently many imaging strategies for evaluating SPNs, the differential diagnosis and management of SPNs remains complex because of overlap between benign and malignant processes. Moreover, transbronchial or percutaneous CT-guided biopsies do not always allow definitive diagnoses. In such cases, video-assisted thoracic surgery (VATS) has become the preferred surgical procedure for diagnosis and, in selected cases, for treatment of indeterminate SPNs. The difficulties in localizing smaller, deeper, and ground-glass nodules have been approached with different techniques. The aim of this study was to report 20 years of experience with radioguided thoracoscopic resection of SPNs at the Regional Centre of Nuclear Medicine of Pisa. METHODS: Three hundred ninety-five patients with SPNs less than 2 cm and deeper than 5 mm below the visceral pleura underwent CT-guided injection of a suspension composed of 0.1 to 0.2 mL Tc-labeled human albumin macroaggregates (Tc-MAA) and of 0.2 to 0.3 mL of nonionic contrast medium into or adjacent to the SPN. During VATS, the pulmonary area with the highest target/background ratio identified by an 11-mm-diameter collimated thoracoscopic gamma probe was resected. RESULTS: From 1997 to 2016, approximately 395 patients with SPN underwent VATS wedge resection using the radioguided technique. Mean SPN size was 13 mm (range, 5-20 mm) with mean distance of 15 mm (range, 6-39 mm) from the visceral pleura. Mean VATS procedural time was 40 minutes (range, 20-90 minutes), with an average time of 3 minutes (range, 1-5 minutes) to localize the nodule. Neither mortality nor major perioperative complication was reported. The success rate of VATS with radioguidance in our series was 99%. Histological examination revealed 206 benign lesions (52%), 59 primary lung tumors (15%), and 130 metastatic nodules (33%). CONCLUSIONS: This study demonstrates that radioguided SPN localization by VATS is a feasible, safe, and rapid procedure with highly successful rate of SPN resection.

Idiopathic interstitial pneumonias: do HRCT criteria established by ATS/ERS/JRS/ALAT in 2011 predict disease progression and prognosis?

PURPOSE: The objective of the study was to determine whether HRCT criteria for Usual Interstitial Pneumonia (UIP), possible UIP or no-UIP pattern recommended by ATS/ERS/JRS/ALAT guidelines 2011 are able to predict progression and prognosis of the disease in a group of patients with fibrotic idiopathic interstitial pneumonia (IIP). MATERIALS AND METHODS: This was a retrospective study conducted with the approval of the ethics committee. Two radiologists at baseline HRCT distributed 70 patients with fibrotic IIP into three groups on the basis of the 2011 guidelines: UIP pattern (group 1), possible UIP pattern (group 2), inconsistent with UIP pattern (group 3). The different abnormalities (honeycombing, reticulation, ground-glass and traction bronchiectasis), fibrotic score (reticulation + honeycombing) and overall CT score were visually scored at baseline and during the follow-up (total HRCT 178). The mortality rate of the three groups was compared. The baseline abnormalities were then correlated with the mortality rate in the UIP group. RESULTS: The inter-observer agreement in the classification of the abnormalities in the three groups was almost perfect (k = 0.92). After consensus, 44 patients were classified into group 1, 13 into group 2 and 13 into group 3. During a mean follow-up of 1386 days, overall CT score, fibrotic score, honeycombing and traction bronchiectasis showed a significant progression in group 1. The mortality rate was significantly higher in group 1 (18 deaths) versus group 2 and 3 (1 death each). In group 1, baseline honeycombing rate higher than 25 %, fibrotic score higher than 30, overall CT score greater than 45 and traction bronchiectasis in more than 4 lobes defined the worst prognosis. CONCLUSION: HRCT classification based on 2011 guidelines showed high accuracy in stratifying fibrotic changes because in our study UIP, possible UIP and inconsistent with UIP pattern seem to be correlated with different disease progression and mortality rate.

Radio-guided thoracoscopic surgery (RGTS) of small pulmonary nodules.

BACKGROUND: The demand for adequate tissue sampling to determine individual tumor behavior is increasing the number of lung nodule resections, even when the diagnosis is already recognized. Video-assisted thoracic surgery (VATS) is the procedure of choice for diagnosis and treatment of small pulmonary nodules. Difficulties in localizing smaller and deeper nodules have been approached with different techniques. Herein we report our 13-years' experience with radio-guided thoracoscopic resection. METHODS: Patients with pulmonary nodules smaller than 1 cm and/or deeper than 1 cm, below the visceral pleura, underwent computed tomography (CT)-guided injection of a solution, composed of 0.2 ml (99)Tc-labeled human serum albumin microspheres and 0.1 ml nonionic contrast, into the nodule. During the VATS procedure, an 11-mm-diameter collimated probe connected to a gamma ray detector was introduced to scan the lung surface. The area of major radioactivity, which matched with the area of the nodule, was resected. RESULTS: From 1997 to 2009, 573 patients underwent thoracoscopic resection of small pulmonary nodules, 211 with the radio-guided technique. There were 159 men and 52 women, with an average age of 60.6 years (range = 12-83). The mean duration of the surgical procedure was 41 min (range = 20-100). The procedure was successful in 208/211 cases. Three patients (0.5%) required conversion to a minithoracotomy. The mean length of pleural drainage and hospital stay was 2.3 and 3.7 days, respectively. Histological examination showed 98 benign lesions and 113 malignant lesions (61 metastases and 52 primary lung cancers). CONCLUSION: This study confirms that radio-guided localization of small pulmonary nodules is a feasible, safe, and quick procedure, with a high rate of success. The spread of the sentinel lymph node technique has increased the availability of technology required for RGTS.

Long-term results of radiofrequency ablation treatment of stage I non-small cell lung cancer: a prospective intention-to-treat study.

INTRODUCTION: About one-fifth of patients with resectable non-small cell lung cancer (NSCLC) are unsuitable for surgical treatment. Radiofrequency ablation offers an alternative minimally invasive option. We report the result of an intention-to-treat study with long-term follow-up. METHODS: From 2001 to 2009, we performed 80 percutaneous radiofrequency ablations of 59 stage I NSCLC in 57 inoperable patients. Two patients were treated for two separate lesions. The study group consisted of 45 males and 12 females, with mean age of 74 years (range, 40-88 years). All patients had pathological evidence of NSCLC, which was in stage IA in 44 cases and in stage IB in the other 15 cases. The mean size of the lesions was 2.6 cm (range, 1.1-5 cm). Fourteen lesions were retreated up to five times. The procedure was always performed under local anesthesia and conscious sedation. Most of the procedures were performed under computed tomography guidance, with nine under ultrasonography guidance. RESULTS: In all cases, the procedure was technically successful. No mortality was recorded, and major morbidity consisted of four cases of pneumothorax requiring pleural drainage. At a mean follow-up of 47 months, the complete response rate was 59.3% (stage Ia 65.9%, stage Ib 40%, p = 0.01), with a mean local recurrence interval of 25.9 months. Median overall survival and cancer-specific survival were 33.4 and 41.4 months, respectively. Cancer-specific actuarial survival was 89% at 1 year, 59% at 3 years, and 40% at 5 years. CONCLUSIONS: Radiofrequency ablation treatment of early-stage NSCLC seems to be a effective minimally invasive therapy even in the long-term period, particularly for stage Ia tumors.