Pulmonary Foreign Body Granulomatosis after Cosmetic Injection.

INTRODUCTION: We occasionally encounter irregular marginated masses discovered incidentally in young individuals. In most cases, further investigations are conducted to assess the presence of a primary malignancy, as these masses often raise suspicions of malignancy. However, rare exceptional cases leave us perplexed. Granulomas arising from common lung infections and those induced by foreign substances can often pose challenge in distinguishing them from lung cancer. Therefore, we aimed to present a case of multiple pulmonary granulomatosis following cosmetic procedure. CASE PRESENTATION: A 55-year-old woman visited the hospital after an incidental discovery of an abnormal chest radiograph during a routine health check-up. Subsequent computed tomography (CT) scans showed worrisome lung nodules, leading to biopsies and positron emission tomography CT scans. Histological examination of the biopsied specimens revealed a chronic inflammatory reaction surrounded by multinucleated foreign body giant cells. Upon sharing the biopsy results with the patient and conducting additional history-taking, she had undergone various cosmetic procedures (botox injection, dermal filler treatments, and thread lifts) around the face and neck, approximately 5-6 months ago. It was hypothesized that these cosmetic materials might have led to the observed pulmonary granulomatosis. After 3 months of conservative care, a follow-up CT showed no change in the lesions. CONCLUSION: We present this case to underscore the importance of considering pulmonary foreign body granulomatosis as a potential differential diagnosis, especially when it closely resembles lung cancer, particularly following cosmetic injections.

Arteria Praebronchialis (AP) Found on MDCT: An Updated Incidence and Branching Patterns.

Preoperative detection of the arteria praebronchialis (AP), a rare variant mediastinal branch of the left pulmonary artery, can be crucial to a successful left-lung surgery; if the AP is overlooked and ligated during surgery, the blood supply to the remaining lobe may be compromised. The purpose of this study was to update the incidence and branching patterns of the AP. From 18 April 2012 to 31 December 2022, contrast-enhanced CT was screened by one radiologist for the presence of AP. Branching patterns of the AP were analyzed by three thoracic radiologists. The incidence of AP was updated to 0.068% (18/26,310) from the previously reported 0.03%; the incidence of AP for male and female patients was 0.110% and 0.017%, respectively. AP supplied only the LLL in 10 cases and both the lingular division of LUL and LLL in nine cases. Dual segmental supply by both the AP and the normal left descending pulmonary artery existed in 15 cases; exclusive segmental supply by either artery existed in four cases. The AP supplies either the LLL alone or both LLL and the lingular division of LUL, and its incidence is not negligible in the male population, necessitating routine surveillance prior to pulmonary resection.

Generative Adversarial Network-Based Image Conversion Among Different Computed Tomography Protocols and Vendors: Effects on Accuracy and Variability in Quantifying Regional Disease Patterns of Interstitial Lung Disease.

OBJECTIVE: To assess whether computed tomography (CT) conversion across different scan parameters and manufacturers using a routable generative adversarial network (RouteGAN) can improve the accuracy and variability in quantifying interstitial lung disease (ILD) using a deep learning-based automated software. MATERIALS AND METHODS: This study included patients with ILD who underwent thin-section CT. Unmatched CT images obtained using scanners from four manufacturers (vendors A-D), standard- or low-radiation doses, and sharp or medium kernels were classified into groups 1-7 according to acquisition conditions. CT images in groups 2-7 were converted into the target CT style (Group 1: vendor A, standard dose, and sharp kernel) using a RouteGAN. ILD was quantified on original and converted CT images using a deep learning-based software (Aview, Coreline Soft). The accuracy of quantification was analyzed using the dice similarity coefficient (DSC) and pixel-wise overlap accuracy metrics against manual quantification by a radiologist. Five radiologists evaluated quantification accuracy using a 10-point visual scoring system. RESULTS: Three hundred and fifty CT slices from 150 patients (mean age: 67.6 ± 10.7 years; 56 females) were included. The overlap accuracies for quantifying total abnormalities in groups 2-7 improved after CT conversion (original vs. converted: 0.63 vs. 0.68 for DSC, 0.66 vs. 0.70 for pixel-wise recall, and 0.68 vs. 0.73 for pixel-wise precision; P < 0.002 for all). The DSCs of fibrosis score, honeycombing, and reticulation significantly increased after CT conversion (0.32 vs. 0.64, 0.19 vs. 0.47, and 0.23 vs. 0.54, P < 0.002 for all), whereas those of ground-glass opacity, consolidation, and emphysema did not change significantly or decreased slightly. The radiologists' scores were significantly higher (P < 0.001) and less variable on converted CT. CONCLUSION: CT conversion using a RouteGAN can improve the accuracy and variability of CT images obtained using different scan parameters and manufacturers in deep learning-based quantification of ILD.

Value of shear wave elastography during second-look breast ultrasonography for suspicious lesions on magnetic resonance imaging.

PURPOSE: This study aimed to determine whether the addition of shear wave elastography (SWE) helps to improve diagnostic performance of second-look ultrasonography (SLUS) for suspicious lesions on magnetic resonance imaging (MRI). METHODS: We retrospectively reviewed 76 breast lesions in 62 patients who underwent SLUS and SWE for suspicious lesions on MRI from August 2017 to November 2019. The six-point color scale (Ecol) and four-type color pattern (Epattern) were used for qualitative evaluation, and the mean (Emean) and maximum elasticity (Emax) and standard deviation of elasticity (ESD) were recorded as quantitative parameters. Clinical and imaging findings between benign and malignant lesions were compared, and the diagnostic performance was assessed using receiver-operating characteristic (ROC) analysis. RESULTS: The biopsies revealed 52 benign and 24 malignant lesions. Of all SWE parameters, only ESD was significantly higher in malignant lesions than in benign lesions (p = 0.012). The sensitivity of B-mode US was 100%, but the specificity was low (19.2%). Using SWE parameters to classify lesions improved specificity at the expense of sensitivity. When lesions assigned to Breast Imaging Reporting and Data System (BI-RADS) category 3 or 4a were reclassified considering each SWE parameter, the area under the ROC curve (AUC) and sensitivity increased. The AUC of the US BI-RADS category adjusted by ESD was higher than that of B-mode US BI-RADS (0.770 vs. 0.746). CONCLUSION: SWE parameters, and especially ESD, may play a complimentary role in improving the specificity of SLUS. However, the decision to omit biopsies for suspicious lesions with soft features should be made with caution.

Multidetector CT findings of primary pleural angiosarcoma : a systematic review, an additional cases report.

BACKGROUND: To demonstrate and analyze the relatively common imaging findings in this rare primary pleural angiosarcoma (PPA). CASE PRESENTATION: Three cases of PPA, proven by video-assisted thoracic surgery biopsies are retrospectively reviewed. Patients were all male. Age ranges from 65 to 75 years old age (mean; 69). Major chief complaints were dyspnea and chest pain. One has a history of colon cancer, the other has a tuberculosis history and the other has no known history. Multidetector chest CT and PET CT were all done. Immunohistochemical studies were performed including CD31, CD34, or factor VIII-related antigen, vimentin, and cytokeratin. We also review the literatures on recently published PPA. All masses were from 1 to 10 cm. All three patients had multiple pleural based masses, which were ovoid in shape with relatively sharp margin in unilateral hemithorax. Multiple small circumscribed pleural masses are limited in the pleural space in two patients, whereas two, huge lobulated masses about up to 10 cm were present with pleural and extrapleural involvement in one patient. In two patients with pleural mass only, multiple pleural masses were only seen in parietal pleura in one patient and were in both visceral and parietal pleura in one patient. Pleural effusion were found in one side in one patient and in both sides in one patient. One angiosarcoma was arised from chronic tuberculotic pleurisy sequelae. All pleural masses are heterogenous with irregular internal low densities in all patients. Hematogenous metastases were found in liver, vertebra, rib in one patient, and were in lungs with mediastinal lymph node metastases in the other patient. Three patients survived for longer than 3months after diagnosis, but continued to deteriorate rapidly. Two patients underwent chemotherapy after surgical excision, and the other one with multiple metastases treated chemotherapy after CT-guided biopsy, but eventually all died. As a result of comparative analysis of a total of 13 patients' images including 10 cases previously published, there was pleural effusion in all except 2 cases. CONCLUSIONS: PPA were all necrotic without any vascularized enhancing nature, and manifested as unilateral circumscribed or localized pleural-based masses.

Effects of low-dose pirfenidone on survival and lung function decline in patients with idiopathic pulmonary fibrosis (IPF): Results from a real-world study.

BACKGROUND: Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive fibrosing interstitial pneumonia of unknown etiology. In several randomized clinical trials, and in the clinical practice, pirfenidone is used to effectively and safely treat IPF. However, sometimes it is difficult to use the dose of pirfenidone used in clinical trials. This study evaluated the effects of low-dose pirfenidone on IPF disease progression and patient survival in the real-world. METHODS: This retrospective, observational study enrolled IPF patients seen at the time of diagnosis at a single center from 2008 to 2018. Longitudinal clinical and laboratory data were prospectively collected. We compared the clinical characteristics, survival, and pulmonary function decline between patients treated and untreated with various dose of pirfenidone. RESULTS: Of 295 IPF patients, 100 (33.9%) received pirfenidone and 195 (66.1%) received no antifibrotic agent. Of the 100 patients who received pirfenidone, 24 (24%), 50 (50%), and 26 (26%), respectively, were given 600, 1200, and 1800 mg pirfenidone daily. The mean survival time was 57.03 ± 3.90 months in the no-antifibrotic drug group and 73.26 ± 7.87 months in the pirfenidone-treated group (p = 0.027). In the unadjusted analysis, the survival of the patients given pirfenidone was significantly better (hazard ratio [HR] = 0.69, 95% confidence interval [CI]: 0.48-0.99, p = 0.04). After adjusting for age, gender, body mass index, and the GAP score [based on gender (G), age (A), and two physiological lung parameters (P)], survival remained better in the patients given pirfenidone (HR = 0.56, 95% CI: 0.37-0.85, p = 0.006). In terms of pulmonary function, the decreases in forced vital capacity (%), forced expiratory volume in 1 s (%) and the diffusing capacity of lung for carbon monoxide (%) were significantly smaller (p = 0.000, p = 0.001, and p = 0.007, respectively) in patients given pirfenidone. CONCLUSIONS: Low-dose pirfenidone provided beneficial effects on survival and pulmonary function decline in the real-world practice.

The implications of clinical risk factors, CAR index, and compositional changes of immune cells on hyperprogressive disease in non-small cell lung cancer patients receiving immunotherapy.

BACKGROUND: Immune checkpoint blockades (ICBs) are characterized by a durable clinical response and better tolerability in patients with a variety of advanced solid tumors. However, we not infrequently encounter patients with hyperprogressive disease (HPD) exhibiting paradoxically accelerated tumor growth with poor clinical outcomes. This study aimed to investigate implications of clinical factors and immune cell composition on different tumor responses to immunotherapy in patients with non-small cell lung cancer (NSCLC). METHODS: This study evaluated 231 NSCLC patients receiving ICBs between January 2014 and May 2018. HPD was defined as a > 2-fold tumor growth kinetics ratio during ICB therapy and time-to-treatment failure of ≤2 months. We analyzed clinical data, imaging studies, periodic serologic indexes, and immune cell compositions in tumors and stromata using multiplex immunohistochemistry. RESULTS: Of 231 NSCLC patients, PR/CR and SD were observed in 50 (21.6%) and 79 (34.2%) patients, respectively and 26 (11.3%) patients met the criteria for HPD. Median overall survival in poor response groups (HPD and non-HPD PD) was extremely shorter than disease-controlled group (SD and PR/CR) (5.5 and 6.1 months vs. 16.2 and 18.3 months, respectively, P = 0.000). In multivariate analysis, HPD were significantly associated with heavy smoker (p = 0.0072), PD-L1 expression ≤1% (p = 0.0355), and number of metastatic site ≥3 (p = 0.0297). Among the serologic indexes including NLR, PLR, CAR, and LDH, only CAR had constantly significant correlations with HPD at the beginning of prior treatment and immunotherapy, and at the 1st tumor assessment. The number of CD4+ effector T cells and CD8+ cytotoxic T cells, and CD8+/PD-1+ tumor-infiltrating lymphocytes (TIL) tended to be smaller, especially in stromata of HPD group. More M2-type macrophages expressing CD14, CD68 and CD163 in the stromal area and markedly fewer CD56+ NK cells in the intratumoral area were observed in HPD group. CONCLUSIONS: Our study suggests that not only clinical factors including heavy smoker, very low PD-L1 expression, multiple metastasis, and CAR index, but also fewer CD8+/PD-1+ TIL and more M2 macrophages in the tumor microenvironment are significantly associated with the occurrence of HPD in the patients with advanced/metastatic NSCLC receiving immunotherapy.

Comparing attenuations of malignant and benign solitary pulmonary nodule using semi-automated region of interest selection on contrast-enhanced CT.

BACKGROUND: The purpose of this study was to determine whether semi-automated region of interest (ROI) measurement of CT attenuations of solitary pulmonary nodule (SPN) is an accurate approach in differentiating malignant from benign SPN. METHODS: Ninety cases of pathologically proven SPN were retrospectively reviewed. CT attenuations of SPN before and after contrast injection were measured using semi-automated ROI selection method. Attenuations within a range of -100 to 200 Hounsfield units (HU) as soft tissue density range were set. The ROI included the entire SPN regardless of its internal soft tissue contents after automatic elimination of airs, calcific, or bony densities. RESULTS: There were 42 (46.7%) malignant SPN and 48 (53.3%) benign SPN, which were grouped into A (18 tuberculoma, 13 fungus), B (5 focal organizing pneumonia, 5 abscess), and C (7 other benign tumors). The malignant SPN showed significantly higher mean attenuations of enhancement and net-enhancement than all benign SPN (P<0.001). Using the area under the receiver operating characteristic curve (AUC), the cut-off net-enhancement of 15 HU gave 83% sensitivity, 65% specificity and 73% accuracy for predicting malignancy. Malignant SPN (mean 67.9 HU) had significantly higher enhancement than group A (mean 52.6 HU, P<0.001, 95% CI: 8.73, 21.81) and group B (mean 57.0 HU, P=0.025, 95% CI: -1.43, 20.34) while group C showed no significant difference (mean 68.1 HU, P=0.97). Net enhancements were higher in group B (mean 18.8 HU) than in group A (mean 8.8 HU) (P<0.001, 95% CI: 11.8, 23.18). CONCLUSIONS: The semi-automated ROI measurement of SPN's attenuations on CT is an accurate approach in distinguishing indeterminate SPN.

Interstitial pneumonia with autoimmune features show better survival and less exacerbations compared to idiopathic pulmonary fibrosis.

BACKGROUND: Patients with interstitial lung disease (ILD) who show features related to autoimmunity without meeting criteria for a defined connective tissue disease are categorized as interstitial pneumonia with autoimmune features (IPAF). The present study compared clinical characteristics and clinical outcomes of patients with IPAF to patients with connective tissue disease related-interstitial lung disease (CTD-ILD) and patients with idiopathic pulmonary fibrosis (IPF). METHODS: ILD patients who were consecutively enrolled in a single institution ILD cohort between 2008 and 2015 were evaluated for the study. Clinical data had been prospectively collected, while radiologic imaging and pathologic findings were re-reviewed for the present study. RESULTS: Out of 305 patients with ILD, 54 (17.7%) patients met the classification of IPAF, 175 (57.4%) patients had IPF, and 76 (24.9%) patients were diagnosed with CTD-ILD. Compared to IPF, incidences of acute exacerbations in 1,3 and 5 years were significantly less in the IPAF group (p = 0.022, p = 0.026 and p = 0.007, respectively). From multivariate analysis for mortality, age (p = 0.034, HR 1.022, 95% CI: 1.002-1.044), FVC (p < 0.001, HR 0.970, 95% CI: 0.955-0.984), ILD exacerbation (p = 0.001, HR 2.074, 95% CI: 1.366-3.148), and ILD type (p = 0.047, HR 0.436, 95% CI: 0.192-0.984 (IPAF vs IPF), respectively) showed significant association. CONCLUSIONS: Compared to the other ILD groups, IPAF showed distinct clinical characteristics. The IPAF group showed better survival and less episodes of exacerbation when compared to the IPF group.

Aggressive mycobacterium abscessus on repeated exogenous lipoid pneumonia in the right middle lobe.

A 65-year-old woman with no underlying disease had been repeated the development and improvement of lipoid pneumonia in the Rt. lower lobe. On a continuous follow up scan, this lesion showed a very aggressive tendency so that the CT-guided lung biopsy was performed to exclude lung cancer. However, as there was no consistent clinical course with the result, she performed the video-assisted thoracic surgery (VATS), wedge resection of Rt. lower lobe. Finally, nontuberculous mycobacterium (NTM) infection was confirmed, not lung cancer, and improved by proper treatment. We report this case for the following reasons: unlike previously reported cases, NTM infection occurred in an unusual situation and uncommon imaging findings similar to lung cancer confused the early diagnosis.

Computed tomographic thoracic morphologic indices in normal subjects and patients with chronic obstructive pulmonary disease: Comparison with spiral CT densitometry and pulmonary function tests.

OBJECTIVES: To determine what computed tomographic (CT) dimensions can predict obstructive lung disease on routine chest CT scans by comparing morphological and densitometric CT findings with pulmonary function test (PFT) in normal subjects and patients with chronic obstructive pulmonary disease (COPD). MATERIALS AND METHODS: Consecutive patients (n = 646; 260 females and 386 males; mean age 54.9 years, ranged 20-90 years) who received chest CT scans with densitometry during a 3-month period were retrospectively analyzed in single center. PFT was undertaken in 235 patients (152 males, 83 females) at same times of CT scanning. The patients were grouped by age (<30 years, 31-45 years, 46-60 years, and >61 years). CT parameters including tracheal, azygoesophageal, thoracic vertical, anterior-posterior (AP), transverse diameters, transverse cardiac diameter, diameters of main, right, and left pulmonary arteries, and CT densitometric values including lung volume and density (-900 to -1000 Hounsfield Units, HU), low attenuation value cluster (default threshold: -950 HU) were compared with PFT values. Spearman correlation coefficients was used to evaluate the relationship between the CT indices and PFT. RESULTS: Ninety of 235 patients with PFT were smokers (76 males, 14 females). Obstructive PFT was detected in 65 patients (27.7%: 46 males, 19 females). Male smokers with obstructive PFT displayed significantly larger thoracic anterior-posterior (mean: normal, 172.3 cm versus COPD, 185.9 cm, p = 0.0001) and smaller transverse diameters (mean: normal, 247.0 cm vs. COPD, 235.8 cm, p = 0.01), and increased right pulmonary artery diameter (mean: normal, 20.3 cm v s. COPD, 22.1 cm, p < 0.001), and increased left pulmonary artery diameter (mean: normal, 19.7 cm vs. COPD, 20.6 cm, p < 0.025). The lung parenchyma density (-1000 to -900 HU) and greater concentration of largest cluster on densitometry were significantly different between normal and obstructive PFT pattern in male smoker. Residual volume and total lung capacity are positively correlated with lung volume and lung density (-1000 to -800) of densitometry. CONCLUSIONS: CT findings of the overexpansion of the lungs, such as increases in the vertical diameter of the lung and decreases in the transverse diameter of the heart, can be significant as indirect findings of early chronic obstructive diseases. However, despite the significant CT findings in male smokers, particularly those in their 40s, most lung function parameters were not decidedly abnormal.