Basic HRCT patterns in diffuse interstitial lung disease.

The term interstitial lung disease (also called diffuse infiltrative lung disease) encompasses a heterogeneous group of processes characterized by the appearance of an inflammatory reaction in the alveolar wall that can be triggered by different antigens. This group of diseases represents a wide spectrum of processes of diverse etiologies, and sometimes the nomenclature can be confusing. High-resolution computed tomography (HRCT) is the imaging method of choice for the evaluation and diagnosis of interstitial lung diseases because it confirms the presence of lung disease and establishes the correct diagnosis for associated complications. Nevertheless, the definitive diagnosis of these entities requires the imaging findings to be interpreted together with their clinical manifestations and histological confirmation. In this group of diseases, HRCT findings play a fundamental role, being especially important for avoiding unnecessary biopsies. For these reasons, clinicians need to be familiar with the basic radiologic patterns associated with this group of lung diseases: septal, reticular, nodular, ground-glass, cystic, and consolidations. This chapter describes the features of these patterns and ways that they can present, and it reviews some of the most common interstitial lung diseases, emphasizing the predominant radiologic patterns in each of them.

Idiopathic pleuroparenchymal fibroelastosis.

The term idiopathic pleuroparenchymal fibroelastosis refers to a rare interstitial lung disease that predominantly involves the upper lobes. It has been considered a rare subtype of interstitial lung disease since 2013, when it was included in the joint consensus statement on the diagnosis of interstitial lung diseases published by the American Thoracic Society (ATS) and the European Respiratory Society (ERS). Currently, two distinct types of pleuroparenchymal fibroelastosis are recognized: the idiopathic type for cases in which it has not been possible to establish a specific etiology and a secondary type associated with a variety of different causes. The diagnosis of pleuroparenchymal fibroelastosis must be managed from a combined clinical and radiological perspective. High-resolution computed tomography (HRCT) is the imaging method of choice for the evaluation and diagnosis of pleuroparenchymal fibroelastosis. In many cases, the diagnosis will be based exclusively on the HRCT findings and histologic confirmation will be unnecessary. This article describes the clinical, radiological, and histological characteristics of pleuroparenchymal fibroelastosis, discussing the different associations with this entity and its differential diagnosis.

Ablación mediante microondas de metástasis pulmonar de sarcoma en paciente portador de marcapasos / Microwave ablation of a sarcoma lung metastasis in a patient with a pacemaker

Presentamos un caso de paciente con una metástasis pulmonar de sarcoma, portador de marcapasos, tratado con ablación mediante microondas. Aunque el tratamiento de tumores mediante microondas es una técnica mínimamente invasiva que ha demostrado su utilidad, existe preocupación acerca de si se trata de una técnica segura en pacientes portadores de marcapasos o desfibriladores. Tras la adecuada planificación por parte de radiólogos y cardiólogos, se indicó la ablación mediante microondas ya que se trata de una técnica más segura y de menor duración que la ablación mediante radiofrecuencia. La lesión fue tratada sin complicaciones. Es importante comunicar tanto los procedimientos realizados como las complicaciones en este tipo de pacientes, con el fín de permitir la formulación por parte de las sociedades científicas de guías de tratamiento apropiadas (AU)

We present the case of a patient with a pacemaker and a sarcoma lung metastasis treated with microwave ablation. Although the treatment of tumours with microwave ablation is a successful and minimally invasive approach, there are concerns about the safety of this procedure for patients with implanted cardiac devices, such as a pacemaker. After careful planning between radiology and cardiology, microwave ablation was indicated in the patient since it is safer and shorter than the radiofrequency technique. The lesion was treated without complications. It is important to communicate the procedures performed, as well as any complications in order to formulate guidelines for the use of microwave ablation in patients with pacemakers (AU)

[Microwave ablation of a sarcoma lung metastasis in a patient with a pacemaker]. / Ablación mediante microondas de metástasis pulmonar de sarcoma en paciente portador de marcapasos.

We present the case of a patient with a pacemaker and a sarcoma lung metastasis treated with microwave ablation. Although the treatment of tumours with microwave ablation is a successful and minimally invasive approach, there are concerns about the safety of this procedure for patients with implanted cardiac devices, such as a pacemaker. After careful planning between radiology and cardiology, microwave ablation was indicated in the patient since it is safer and shorter than the radiofrequency technique. The lesion was treated without complications. It is important to communicate the procedures performed, as well as any complications in order to formulate guidelines for the use of microwave ablation in patients with pacemakers.

Neumonías intersticiales idiopáticas / Idiopathic interstitial pneumonias

Las neumonías intersticiales idiopáticas son enfermedades pulmonares difusas caracterizadas por inflamación intersticial y fibrosis. La tomografía computarizada de alta resolución (TCAR) es la mejor técnica de imagen para estudiar las enfermedades intersticiales. Bajo el término general «neumonía intersticial idiopática» se incluyen a la neumonía intersticial usual/fibrosis pulmonar idiopática, la neumonía intersticial no específica, la neumonía intersticial descamativa, la bronquiolitis respiratoria asociada a enfermedad intersticial pulmonar, la neumonía organizada, la neumonía intersticial aguda y la neumonía intersticial linfocítica. El papel del radiólogo consiste en identificar el patrón morfológico macroscópico y trabajar conjuntamente con el clínico y patólogo para generar un diagnóstico clínico integrado. El objetivo de este trabajo es realizar una revisión de las neumonías intersticiales idiopáticas y describir sus diferentes manifestaciones en la TCAR(AU)

The idiopathic interstitial pneumonias are diffuse lung diseases characterized by interstitial inflammation and fibrosis. High resolution computed tomography (HRCT) is the best imaging technique for the study of interstitial disease. The general term "idiopathic interstitial pneumonia" includes usual interstitial pneumonia/idiopathic pulmonary fibrosis, nonspecific interstitial pneumonia, desquamative interstitial pneumonia, respiratory bronchiolitis-associated interstitial lung disease, cryptogenic organizing pneumonia, acute interstitial pneumonia, and lymphocytic interstitial pneumonia. The radiologist's role consists of identifying the macroscopic morphological pattern and working together with clinicians and pathologists to generate an integrated clinical diagnosis. The objective of this article is to review the idiopathic interstitial pneumonias and to describe their different manifestations in HRCT(AU)

[Idiopathic interstitial pneumonias]. / Neumonías intersticiales idiopáticas.

The idiopathic interstitial pneumonias are diffuse lung diseases characterized by interstitial inflammation and fibrosis. High resolution computed tomography (HRCT) is the best imaging technique for the study of interstitial disease. The general term "idiopathic interstitial pneumonia" includes usual interstitial pneumonia/idiopathic pulmonary fibrosis, nonspecific interstitial pneumonia, desquamative interstitial pneumonia, respiratory bronchiolitis-associated interstitial lung disease, cryptogenic organizing pneumonia, acute interstitial pneumonia, and lymphocytic interstitial pneumonia. The radiologist's role consists of identifying the macroscopic morphological pattern and working together with clinicians and pathologists to generate an integrated clinical diagnosis. The objective of this article is to review the idiopathic interstitial pneumonias and to describe their different manifestations in HRCT.

[Intrathoracic manifestations of breast cancer]. / Manifestaciones intratorácicas del cáncer de mama.

Breast cancer continues to be the most common malignant neoplasm in women in Spain. The radiological study of intrathoracic manifestations, often secondary to complications, is of great interest because intrathoracic manifestations have a high prevalence and diagnosing them early significantly improves the patient's prognosis. The imaging techniques in current use for this purpose include plain-film chest X-rays, computed tomography (CT), magnetic resonance imaging (MRI), thoracic ultrasonography, and hybrid techniques like positron emission tomography combined with CT (PET/CT). In this article, we review the imaging findings for the different types of intrathoracic complications of breast cancer, classified as: a) complications related to tumor dissemination, b) complications related to treatment, and c) idiopathic complications.

Manifestaciones intratorácicas del cáncer de mama / Intrathoracic manifestations of breast cancer

El cáncer de mama sigue siendo la neoplasia maligna más frecuente en la mujer en nuestro país. El estudio radiológico de las manifestaciones intratorácicas, habitualmente secundarias a complicaciones, es de gran interés debido a su prevalencia, y el diagnóstico precoz de las mismas mejora de forma significativa el pronóstico de la paciente. Actualmente, las técnicas de imagen utilizadas incluyen la radiografía simple de tórax (RXT), la tomografía computarizada (TC), la resonancia magnética (RM), la ecografía torácica, y las técnicas híbridas, como la tomografía por emisión de positrones combinada con la TC (PET/TC). En este trabajo se revisan los hallazgos radiológicos de los diferentes tipos de complicaciones intratorácicas del cáncer de mama, clasificadas como: a) complicaciones relacionadas con la diseminación tumoral, b) complicaciones relacionadas con el tratamiento, y c) complicaciones idiopáticas(AU)

Breast cancer continues to be the most common malignant neoplasm in women in Spain. The radiological study of intrathoracic manifestations, often secondary to complications, is of great interest because intrathoracic manifestations have a high prevalence and diagnosing them early significantly improves the patient's prognosis. The imaging techniques in current use for this purpose include plain-film chest X-rays, computed tomography (CT), magnetic resonance imaging (MRI), thoracic ultrasonography, and hybrid techniques like positron emission tomography combined with CT (PET/CT). In this article, we review the imaging findings for the different types of intrathoracic complications of breast cancer, classified as: a) complications related to tumor dissemination, b) complications related to treatment, and c) idiopathic complications(AU)

Evaluación del programa de diagnóstico y tratamiento rápido del cáncer de pulmón / Evaluation of the quick diagnosis and treatment program for lung cancer

Objetivo: Analizar la eficacia y el cumplimiento del programa de diagnóstico y tratamiento rápido (PDTR) del cáncer de pulmón. Adicionalmente se revisan datos epidemiológicos en los pacientes diagnosticados de cáncer de pulmón en el Hospital de la Santa Creu i Sant Pau. Material y métodos: Se incluyeron 58 pacientes diagnosticados de cáncer de pulmón. Veintinueve de ellos fueron incluidos en el programa PDTR desde octubre de 2005 hasta mayo de 2006, y el resto fueron seleccionados aleatoriamente de entre los pacientes diagnosticados de cáncer de pulmón durante el año anterior al inicio del programa (grupo control). Se compararon los intervalos de tiempo desde la primera visita al diagnóstico y al tratamiento, así como diferentes variables (edad, sexo, tipo histológico, estadificación TNM). Resultados: Se encontró una reducción de tiempo en el grupo PDTR (p<0,001) que mostró una media entre la primera visita y el inicio del tratamiento de 26,72 días (desviación típica [DT]=13,6), mientras que en el grupo control fue de 84 días (DT=53). La estadificación TNM fue inferior en el grupo PDTR, aunque sólo con significación estadística para la N (grado de afectación ganglionar) (p=0,007). Conclusión: Con el programa PDTR se ha conseguido reducir el tiempo desde la llegada del paciente al inicio del tratamiento a menos de 30 días en la mayoría de los pacientes, lo que representa una reducción significativa de éste. Su efecto sobre el pronóstico es controvertido y requerirá estudios a largo plazo (AU)

Objective: To analyze the efficiency of the program of quick diagnosis and treatment (PDTR, programa de diagnóstico y tratamiento rápido) of lung cancer established in the Hospital de la Santa Creu i Sant Pau of Barcelona to review the epidemiology of lung cancer. Methods and materials: Fifty-eight patients with lung cancer were studied. Twenty-nine of them were included in the program between October 2005 and May 2006, and the remaining were randomly selected among those diagnosed the year before (control group). Time between first visit, diagnosis and treatment and other variables (age, sex, histological type and TNM stage) were compared between groups. Results: Significant differences were found between the two groups. PDTR patients had a mean time between first visit and treatment of 26.7 days (Standard Deviation [SD]=13.6), whereas this was 84 days (SD=53) in the control group. The PDTR group had a lower TNM stage, but statistical significance was only found in N (lymph node involvement) (p=0.007). Conclusion: Most patients included in the PDTR program spend less than 30 days between first visit and treatment, which represents a significant reduction in time (p<0.001). The effect on prognosis is controversial and will need long term studies (AU)

[Evaluation of the quick diagnosis and treatment program for lung cancer]. / Evaluación del programa de diagnóstico y tratamiento rápido del cáncer de pulmón.

OBJECTIVE: To analyze the efficiency of the program of quick diagnosis and treatment (PDTR, programa de diagnóstico y tratamiento rápido) of lung cancer established in the Hospital de la Santa Creu i Sant Pau of Barcelona to review the epidemiology of lung cancer. METHODS AND MATERIALS: Fifty-eight patients with lung cancer were studied. Twenty-nine of them were included in the program between October 2005 and May 2006, and the remaining were randomly selected among those diagnosed the year before (control group). Time between first visit, diagnosis and treatment and other variables (age, sex, histological type and TNM stage) were compared between groups. RESULTS: Significant differences were found between the two groups. PDTR patients had a mean time between first visit and treatment of 26.7 days (Standard Deviation [SD]=13.6), whereas this was 84 days (SD=53) in the control group. The PDTR group had a lower TNM stage, but statistical significance was only found in N (lymph node involvement) (p=0.007). CONCLUSION: Most patients included in the PDTR program spend less than 30 days between first visit and treatment, which represents a significant reduction in time (p<0.001). The effect on prognosis is controversial and will need long term studies.

Correlation between high-resolution computed tomography and galactomannan antigenemia in adult hematologic patients at risk for invasive aspergillosis.

OBJECTIVES: To analyse the predominant radiological pattern of pulmonary lesions in adult hematologic patients at risk for invasive aspergillosis (IA) together with the results of serial serum Aspergillus galactomannan antigen testing (GM). MATERIAL AND METHODS: In a prospective study for patients at high risk of aspergillus pulmonary infection, serum GM were performed 2-3 times per week during the periods of high risk for IA and high-resolution CT (HRCT) was performed in case of abnormal chest X-ray (CXR) and/or persistent fever after 5 days of antibiotic treatment. Changes on HRCT scan were classified as airway IA and angioinvasive IA. IA was classified as proven or probable in accordance with the definitions stated by the European Organization for Research and Treatment of Cancer/Mycosis Study Group (EORTC-MS). Positive GM testing was not considered as microbiological criterion. RESULTS: 38 hematological patients were diagnosed of probable (n=28) or proven (n=10) IA. 55% patients had a neutrophil count less than 500 mm(-3) (n=21), and 37% patients > or =2 risk factors for IA. All probable IA were diagnosed by bronchoalveolar lavage (BAL). Proven IA was reached by positive histopathologic and culture results of samples obtained by autopsy (n=4), percutaneous (n=3) or transbronchial biopsy (n=3). 18 patients had airway IA, and 60% had a GM level > or =1.5. 20 patients were diagnosed of angioinvasive IA from which 80% had a GM level > or =1.5. CONCLUSION: Serum GM levels may be lower in patients with airway IA than in those with an angioinvasive form. HRCT and serum GM are complementary tests in the diagnosis of IA.

Serial high resolution CT in non-specific interstitial pneumonia: prognostic value of the initial pattern.

AIM: To assess the relationship between initial CT pattern and serial changes in CT findings and pulmonary function tests (PFTs) in patients with non-specific interstitial pneumonia (NSIP). MATERIALS AND METHODS: Serial high resolution (HR) CTs and PFTs were retrospectively analyzed in 38 cases of histologically proven NSIP, including 4 with cellular NSIP, 13 with mixed cellular and fibrotic NSIP, and 21 with fibrotic NSIP. The presence and extent of various CT findings were assessed. A fibrosis index (defined as the ratio of the extent of a reticular/honeycomb pattern to the overall extent of abnormal parenchyma) was derived. RESULTS: The predominant CT pattern was reticular/honeycomb in 27 (84%) cases and ground-glass/consolidation in 6 (16%) cases. Between scans, mean disease extent reduced by 5.2%. Disease extent reduced by >10% in 13 (34%) and increased by >10% in 6 (16%) patients. Histopathological subtype of NSIP did not correlate with individual CT pattern, predominant pattern, fibrosis index or serial change in disease extent on CT or PFTs. Response on follow-up CT was associated with fibrosis index, predominant pattern and extent of consolidation on initial CT. CONCLUSION: In NSIP disease, progression on CT correlates with the predominant CT pattern, fibrosis index, and extent of consolidation but not with histopathological subtype. An inflammatory (ground-glass/consolidation) predominant pattern is associated with better outcome in terms of disease extent on HRCT.

Esofagoparesia en un paciente diabético diagnosticada durante un ingreso por insuficiencia respiratoria / Esophagoparesis diagnosed during hospitalization for respiratory failure

Los síntomas considerados más típicos de la neuropatía digestiva son la plenitud posprandial, la dispepsia y la diarrea. Sin embargo, no es frecuente la presencia de síntomas esofágicos que motiven un estudio digestivo. A continuación se describe el caso de un paciente con diabetes y alteración importante de la motilidad esofágica diagnosticada durante un ingreso por insuficiencia respiratoria (AU)

High-resolution CT of lung disease related to collagen vascular disease.

Although connective tissue diseases may have similar radiographic appearances, a variety of pathologic processes can be seen in the lung of these patients. In such circumstances, early recognition of lung involvement is now easily demonstrated by imaging methods. The development of thin-section and dynamic CT techniques has significantly improved diagnostic accuracy. Moreover, expiratory HRCT is a helpful technique in demonstrating air trapping in these patients. The radiologist plays a significant role in the evaluation of pulmonary manifestations of connective tissue diseases.

Imaging of pneumonia: trends and algorithms.

Pneumonia is one of the major infectious diseases responsible for significant morbidity and mortality throughout the world. Imaging plays a crucial role in the detection and management of patients with pneumonia. This review article discusses the different imaging methods used in the diagnosis and management of suspected pulmonary infections. The imaging examination should always begin with conventional radiography. When the results of routine radiography are inconclusive, computed tomography is mandatory. A combination of pattern recognition with knowledge of the clinical setting is the best approach to the pulmonary infectious processes. A specific pattern of involvement can suggest a likely diagnosis in many instances. In acquired immune deficiency syndrome patients, diffuse ground-glass and interstitial infiltrates are most commonly present in Pneumocystis carinii pneumonia whereas in the nonimmunosuppressed patients, a segmental lobar infiltrate is suggestive of a bacterial pneumonia. Round pneumonia is most often encountered in children than adults and is most often caused by Streptococcus pneumoniae. Different combinations of parenchymal and pleural abnormalities may be suggestive for additional diagnoses. When an infectious pulmonary process is suspected, knowledge of the varied radiographic manifestations will narrow the differential diagnosis, helping to direct additional diagnostic measures, and serving as an ideal tool for follow-up examinations.

Spectrum of pulmonary aspergillosis: histologic, clinical, and radiologic findings.

Aspergillosis is a serious pathologic condition caused by Aspergillus organisms and is frequently seen in immunocompromised patients. At computed tomography (CT), saprophytic aspergillosis (aspergilloma) is characterized by a mass with soft-tissue attenuation within a lung cavity. The mass is typically separated from the cavity wall by an airspace ("air crescent" sign) and is often associated with thickening of the wall and adjacent pleura. CT findings in allergic bronchopulmonary aspergillosis consist primarily of mucoid impaction and bronchiectasis involving predominantly the segmental and subsegmental bronchi of the upper lobes. Aspergillus necrotizing bronchitis may manifest as an endobronchial mass, obstructive pneumonitis or collapse, or a hilar mass. Bronchiolitis is characterized by centrilobular nodules and branching linear or nodular areas of increased attenuation ("tree-in-bud" pattern). Obstructing bronchopulmonary aspergillosis mimics allergic bronchopulmonary aspergillosis at CT and manifests as bilateral bronchial and bronchiolar dilatation, large mucoid impactions, and diffuse lower lobe consolidation caused by postobstructive atelectasis. Characteristic CT findings in angioinvasive aspergillosis consist of nodules surrounded by a halo of ground-glass attenuation ("halo sign") or pleura-based, wedge-shaped areas of consolidation. Although imaging findings in pulmonary aspergillosis may be nonspecific, in the appropriate clinical setting, familiarity with the CT findings may suggest or even help establish the diagnosis.

Mycobacterium genavense infection in AIDS: imaging findings in eight patients.

This retrospective study included eight HIV-positive patients with a M. genavense infection. Seven of these patients had a CT scan of the abdomen and a US examination, whereas one patient with pulmonary symptoms had conventional chest radiographs and thin-section CT scan of the thorax. Multiple large retroperitoneal and mesenteric lymph nodes were demonstrated in seven patients; low-attenuation centers within enlarged nodes were identified in two patients. On CT scans two cases showed circumferential wall thickening of the proximal small bowel with a deep ulceration in one of these patients. Additional findings included focal lesions in the liver (n = 1), spleen (n = 2), splenomegaly (n = 6), and hepatomegaly (n = 4). The CT scans from the thoracic examination demonstrated multiple diffuse nodular infiltrates in both lungs. M. genavense infection should be considered in the differential diagnosis of AIDS patients with CD4 counts below 100 cells/mm3 presenting with abdominal lymphadenopathy, multinodular or homogeneous hepatosplenic enlargement and circumferential thickening of the small bowel wall.

Bronchoscopy guided by high-resolution computed tomography for the diagnosis of pulmonary infections in patients with hematologic malignancies and normal plain chest X-ray.

BACKGROUND AND OBJECTIVES: High-resolution computed tomography (HRCT) of the chest is able to demonstrate the presence of pulmonary infiltrates in febrile neutropenic patients with normal chest X-rays. Fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) is a safe procedure for the etiological diagnosis of pulmonary infiltrates in oncohematologic patients. The objective of this study was to determine the diagnostic yield and subsequent therapeutic changes of a protected BAL (p-BAL) guided by HRCT in febrile oncohematologic patients unresponsive to broad-spectrum antibiotics with a normal chest X-ray. DESIGN AND METHODS: Twenty-two episodes from 20 oncohematologic patients were included: group A, 9 episodes (8 patients) with no respiratory symptoms and group B, 13 episodes (12 patients) with signs or symptoms of pulmonary infection. HRCT and p-BAL were performed in all episodes within the first 24 hours. RESULTS: HRCT showed abnormalities in all 22 episodes (bilateral abnormalities in 14 of the 22 episodes [64%]) and the most frequent pattern was ground-glass infiltrate (7 out of 22 episodes). An infectious agent was isolated in 12 of the 22 episodes, 5 in group A and 7 in group B with a diagnostic yield of 54%. Antimicrobial therapy was modified in 12 of the 22 episodes (54%): 5 in group A and 7 in group B. In 6 episodes, treatment was changed according to HRCT results and in the remaining 6 due to positive microbiologic results. Modifications in empirical therapy were associated with a favorable response in 44% episodes of group A and in 31% of group B. INTERPRETATION AND CONCLUSIONS: Oncohematologic patients with fever of unknown origin unresponsive to empirical antibiotics and with a normal chest X-ray can be candidates to undergo a HRCT. This subgroup of high-risk patients can benefit from a combined strategy consisting of BAL guided by a previous HRCT.