Nintedanib in chronic fibrosing interstitial lung diseases. A case series.

Progressive pulmonary fibrosis (PPF) can be fatal in non-idiopathic interstitial lung diseases. We report a descriptive series of 13 patients with PPF who received treatment with nintedanib, a multitargeted tyrosine kinase inhibitor with antifibrotic effect. Although the reduced number of patients and the observational nature of a case series prevent us from providing strong evidence, our results suggest that nintedanib could be effective in PPF of various etiologies. Nintedanib could also be useful in specific populations such as patients awaiting lung transplant and elderly patients.

Radiological usual interstitial pneumonia pattern is associated with two-year mortality in patients with idiopathic pulmonary fibrosis.

Introduction: The new diagnostic guidelines for idiopathic pulmonary fibrosis (IPF) did not rule out the possibility of combining the radiological patterns of usual interstitial pneumonia (UIP) and probable UIP, given the similar management and diagnostic capacity. However, the prognostic implications of these patterns have not been fully elucidated, with different studies showing heterogeneous results. We applied the new criteria to a retrospective series of patients with IPF, assessing survival based on radiological patterns, findings, and their extension. Methods: Two thoracic radiologists reviewed high-resolution computed tomography images taken at diagnosis in 146 patients with IPF, describing the radiological findings and patterns. The association of each radiological finding and radiological patterns with two-year mortality was analysed. Results: The two-year mortality rate was 40.2% in IPF patients with an UIP radiological pattern versus 7.1% in those with probable UIP. Compared to the UIP pattern, probable UIP was protective against mortality, even after adjusting for age, sex, pulmonary function, and extent of fibrosis (hazard ratio (HR) 0.23, 95% confidence interval (CI) 0.06-0.99). Receiving antifibrotic treatment was also a protective factor (HR 0.51, 95%CI 0.27-0.98). Honeycombing (HR 3.62, 95%CI 1.27-10.32), an acute exacerbation pattern (HR 4.07, 95%CI 1.84-8.96), and the overall extent of fibrosis (HR 1.04, 95%CI 1.02-1.06) were predictors of mortality. Conclusions: In our series, two-year mortality was higher in patients with IPF who presented a radiological pattern of UIP versus probable UIP on the initial scan. Honeycombing, an acute exacerbation pattern, and a greater overall extent of fibrosis were also predictors of increased mortality. The prognostic differences between the radiological pattern of UIP and probable UIP in our series would support maintaining them as two differentiated patterns.

Strategies for calculating contrast media dose for chest CT.

BACKGROUND: Total body weight (TBW) is a frequently used contrast media (CM) strategy for dose calculation in enhanced CT, yet it is suboptimal as it lacks consideration of patient characteristics, such as body fat percentage (BFP) and muscle mass. Alternative CM dosage strategies are suggested by the literature. Our objectives were to analyze the CM dose impact when adjusting to body composition using methods of obtaining lean body mass (LBM) and body surface area (BSA) along with its correlation with demographic factors in contrast enhanced chest CT examinations. METHODS: Eighty-nine adult patients referred for CM thoracic CT were retrospectively included, categorized as either normal, muscular, or overweight. Patient body composition data was used to calculate the CM dose according to LBM or BSA. LBM was calculated with the James method, Boer method, and bioelectric impedance (BIA). BSA was calculated using the Mostellar formula. We then correlated the corresponding CM doses with demographic factors. RESULTS: BIA demonstrated the highest and lowest calculated CM dose in muscular and overweight groups respectively, compared to other strategies. For the normal group, the lowest calculated CM dose was achieved using TBW. The calculated CM dose was more closely correlated with BFP using the BIA method. CONCLUSIONS: The BIA method is more adaptive to variations in patient body habitus especially in muscular and overweight patients and is most closely correlated to patient demographics. This study could support utilizing the BIA method for calculating LBM for a body-tailored CM dose protocol for enhanced chest CT examinations. RELEVANCE STATEMENT: The BIA-based method is adaptive to variations in body habitus especially in muscular and overweight patients and is closely correlated to patient demographics for contrast-enhanced chest CT. KEY POINTS: • Calculations based on BIA showed the largest variation in CM dose. • Lean body weight using BIA demonstrated the strongest correlation to patient demographics. • Lean body weight BIA protocol may be considered for CM dosing in chest CT.

Sclerosing pneumocytoma with carcinoid tumorlets and neuroendocrine cell hyperplasia.

Sclerosing pneumocytoma is an uncommon pulmonary tumor which generally behaves benignly and occurs predominately in women. Rarely, it is associated with neuroendocrine proliferations such as hyperplasia, tumorlets and carcinoid tumors, which may be observed in relation to the tumor or in the distant lung parenchyma; the mechanism underlying this neuroendocrine differentiation is not clear. We present a case of a 33 year-old male with sclerosing pnemocytoma with coexistent neuroendocrine hyperplasia and combined carcinoid tumorlets. Taking into account the pluripotentiality of the round cells present in the sclerosing pneumocytoma, with positive staining for stem cells markers, it is possible that the different components of this neoplasia share a common origin, in accordance with previously reported findings.

Pathological Findings Associated With SARS-CoV-2 on Postmortem Core Biopsies: Correlation With Clinical Presentation and Disease Course.

Background: Autopsies can shed light on the pathogenesis of new and emerging diseases. Aim: To describe needle core necropsy findings of the lung, heart, and liver in decedents with COVID-19. Material: Cross-sectional study of needle core necropsies in patients who died with virologically confirmed COVID-19. Histopathological analyses were performed, and clinical data and patient course evaluated. Results: Chest core necropsies were performed in 71 decedents with a median age of 81 years (range 52-97); 47 (65.3%) were men. The median interval from symptoms onset to death was 17.5 days (range 1-84). Samples of lung (n = 62, 87.3%), heart (n = 48, 67.6%) and liver (n = 39, 54.9%) were obtained. Fifty-one lung samples (82.3%) were abnormal: 19 (30.6%) showed proliferative diffuse alveolar damage (DAD), 12 (19.4%) presented exudative DAD, and 10 (16.1%) exhibited proliferative plus exudative DAD. Of the 46 lung samples tested for SARS-CoV-19 by RT-PCR, 39 (84.8%) were positive. DAD was associated with premortem values of lactate dehydrogenase of 400 U/L or higher [adjusted odds ratio (AOR) 21.73; 95% confidence interval (CI) 3.22-146] and treatment with tocilizumab (AOR 6.91; 95% CI 1.14-41.7). Proliferative DAD was associated with an onset-to-death interval of over 15 days (AOR 7.85, 95% CI 1.29-47.80). Twenty-three of the 48 (47.9%) heart samples were abnormal: all showed fiber hypertrophy, while 9 (18.8%) presented fibrosis. Of the liver samples, 29/39 (74.4%) were abnormal, due to steatosis (n = 12, 30.8%), cholestasis (n = 6, 15.4%) and lobular central necrosis (n = 5, 12.8%). Conclusion: Proliferative DAD was the main finding on lung core needle necropsy in people who died from COVID-19; this finding was related to a longer disease course. Changes in the liver and heart were common.

Mosaic attenuation in non-fibrotic areas as a predictor of non-usual interstitial pneumonia pathologic diagnosis.

The new radiological diagnostic criteria for diagnosing idiopathic pulmonary fibrosis (IPF) seek to optimize the indications for surgical lung biopsy (SLB). We applied the new criteria to a retrospective series of patients with interstitial lung disease (ILD) who underwent SLB in order to analyse the correlation between the radiological findings suggestive of another diagnosis (especially mosaic attenuation and its location with respect to fibrotic areas) and the usual interstitial pneumonia (UIP) pathologic diagnosis. Two thoracic radiologists reviewed the HRCT images of 83 patients with ILD and SLB, describing the radiological findings and patterns based on the new criteria. The association of each radiological finding with radiological patterns and histology was analysed. Mosaic attenuation is highly prevalent in both the UIP and non-UIP pathologic diagnosis and with similar frequency (80.0% vs. 78.6%). However, the presence of significant mosaic attenuation (≥ 3 lobes) only in non-fibrotic areas was observed in 60.7% of non-UIP pathologic diagnosis compared to 20.0% in UIP. This finding was associated with other diagnoses different from IPF, mostly connective tissue disease-associated interstitial lung disease (CTD-ILD) and hypersensitivity pneumonitis (HP). In our series of pathologically confirmed ILD, mosaic attenuation in non-fibrotic areas was a predictor of non-UIP pathologic diagnosis, and was associated with other diagnoses different from UIP, mostly CTD-ILD and HP. If confirmed in larger series, this finding could constitute a valuable tool for improving the interpretation of radiological.

The role of unenhanced phase of the liver in the scanning protocol of metastatic breast cancer: implications for sensitivity, response evaluation and size measurement.

BACKGROUND: To analyse if performing unenhanced CT of the liver aids in the evaluation of metastatic lesions, response assessment or alter the size of the lesions, compared with portal phase alone, in patients with hepatic metastases from breast carcinoma. PATIENTS AND METHODS: One-hundred and fifty-three CT scans of 36 women were included. Scans consisted of unenhanced, arterial and portal delayed phases of the liver. Two readers sorted which phase was best for visualization of metastases, evaluated the number of lesions detected in each phase, selected the best phase for assessment of response in two consecutive scans, and measured one target lesion in all the phases. Χ2 was used to compare differences among phases and paired t test for measurement differences. RESULTS: Unenhanced, arterial and portal phases were considered better phases by readers 1/2 in 68/67%, 27/28% and 69/70%, and some lesions were missed in 2%, 11% and 7%, respectively. Sensitivity was significantly better for unenhanced and portal phases compared to arterial phase. Comparison between consecutive scans was considered better in unenhanced (80/79%), followed by portal (70/69%) and arterial phases (31/31%). Maximum diameter of target lesions was 15% greater in unenhanced phase (p < 0.001). CONCLUSIONS: Portal and unenhanced phases of the liver allow better detection and delineation of metastatic hepatic lesions from breast carcinoma. In most cases, unenhanced CT is the best phase to assess response and provides the largest diameter. Therefore, we recommend the use of unenhanced CT in the evaluation of patients with breast carcinoma and suspected or known hepatic metastatic disease.

Post-acute COVID-19 syndrome. Incidence and risk factors: A Mediterranean cohort study.

OBJECTIVES: This study aims to analyze the incidence of Post-acute COVID-19 syndrome (PCS) and its components, and to evaluate the acute infection phase associated risk factors. METHODS: A prospective cohort study of adult patients who had recovered from COVID-19 (27th February to 29th April 2020) confirmed by PCR or subsequent seroconversion, with a systematic assessment 10-14 weeks after disease onset. PCS was defined as the persistence of at least one clinically relevant symptom, or abnormalities in spirometry or chest radiology. Outcome predictors were analyzed by multiple logistic regression (OR; 95%CI). RESULTS: Two hundred seventy seven patients recovered from mild (34.3%) or severe (65.7%) forms of SARS-CoV-2 infection were evaluated 77 days (IQR 72-85) after disease onset. PCS was detected in 141 patients (50.9%; 95%CI 45.0-56.7%). Symptoms were mostly mild. Alterations in spirometry were noted in 25/269 (9.3%), while in radiographs in 51/277 (18.9%). No baseline clinical features behaved as independent predictors of PCS development. CONCLUSIONS: A Post-acute COVID-19 syndrome was detected in a half of COVID19 survivors. Radiological and spirometric changes were mild and observed in less than 25% of patients. No baseline clinical features behaved as independent predictors of Post-acute COVID-19 syndrome development.

Early and delayed phases of contrast-enhanced CT for evaluating patients with malignant pleural effusion. Results of pairwise comparison by multiple observers.

OBJECTIVE: To compare images from early and delayed phases of contrast-enhanced thoracic CT for assessing pleural thickening or nodules in a series of patients with malignant pleural effusions. METHODS: Blinded images from 36 patients with malignant pleural effusions showing pleural lesions in both early (35 s delayed) and delayed (70 s delayed) phases of thoracic and abdominal contrast-enhanced CT scan were retrospectively assessed by six observers. First, images were individually scored in a six-point scale grading the quality of visualization of pleural findings such as pleural thickening or nodules. This was followed by a paired analysis, where the readers had to choose the one showing the highest quality between two images presented together corresponding to both phases of the same patient showing the same pleural lesion. When possible, contrast attenuation of the abnormal pleura was measured. Statistical analysis was performed by using paired t-test and χ 2. RESULTS: Mean attenuation of pleural lesions was significantly higher in the delayed phase (76.0 ± 25.1 vs 57.5 ± 20.7, p < 0.001). Mean score and score of individual images was statistically significant better for the delayed phase for all observers. In the paired analysis, all the readers preferred the delayed phase over the early phase in 77.8 to 91.7% of the cases. CONCLUSION: Delayed phase of contrast-enhanced CT is preferable to early phase for evaluating pleural findings. Advances in knowledge: Pleural attenuation is greater for the delayed phase compared with the early phase of contrast-enhanced chest CT. In the pairwise comparison, all the observers prefer the delayed phase over the early phase for pleural evaluation.

Best Protocol for Combined Contrast-Enhanced Thoracic and Abdominal CT for Lung Cancer: A Single-Institution Randomized Crossover Clinical Trial.

OBJECTIVE: The purpose of this study was to evaluate the superiority of either of two protocols for combined contrast-enhanced thoracic and abdominal CT of patients with lung cancer by comparing contrast enhancement, contrast-related artifacts, image quality, and radiation dose. SUBJECTS AND METHODS: In this randomized controlled crossover clinical trial, 77 patients who underwent 203 CT examinations were enrolled. All patients underwent at least two examinations performed with both protocols. Protocol A consisted of two acquisitions: one 35-second delayed CT acquisition for the chest followed by a 70-second delayed abdominal acquisition. Protocol B was a single 60-second delayed acquisition covering the chest and the abdomen. Attenuation and noise of the aorta, pulmonary artery, and liver were measured. Contrast-related artifacts, mediastinal lymph node visualization, liver enhancement, and noise were visually scored. Dose-length product was recorded. Statistical analysis was performed by t and chi-square tests and kappa statistics. RESULTS: Contrast-related artifacts were more severe at all evaluated levels, and visualization of lymph node regions was statistically significantly worse with protocol A. There were no differences in enhancement or noise score of the liver. Tumor delineation and pleural findings were better evaluated with delayed phase images. Dose-length product was significantly higher with protocol A (645.0 vs 521.5 mGy · cm; p < 0.0001). CONCLUSION: A single 60-second delayed acquisition for thoracic and abdominal contrast-enhanced CT is associated with less contrast artifact and affords better visualization of lymph nodes at a lower radiation dose while acceptable vascular and hepatic contrast enhancement is maintained.

Transsphenoidal Approach in Endoscopic Endonasal Surgery for Skull Base Lesions: What Radiologists and Surgeons Need to Know.

In the last 2 decades, endoscopic endonasal transsphenoidal surgery has become the most popular choice of neurosurgeons and otolaryngologists to treat lesions of the skull base, with minimal invasiveness, lower incidence of complications, and lower morbidity and mortality rates compared with traditional approaches. The transsphenoidal route is the surgical approach of choice for most sellar tumors because of the relationship of the sphenoid bone to the nasal cavity below and the pituitary gland above. More recently, extended approaches have expanded the indications for transsphenoidal surgery by using different corridors leading to specific target areas, from the crista galli to the spinomedullary junction. Computer-assisted surgery is an evolving technology that allows real-time anatomic navigation during endoscopic surgery by linking preoperative triplanar radiologic images and intraoperative endoscopic views, thus helping the surgeon avoid damage to vital structures. Preoperative computed tomography is the preferred modality to show bone landmarks and vascular structures. Radiologists play an important role in surgical planning by reporting extension of sphenoid pneumatization, recesses and septations of the sinus, and other relevant anatomic variants. Radiologists should understand the relationships of the sphenoid bone and skull base structures, anatomic variants, and image-guided neuronavigation techniques to prevent surgical complications and allow effective treatment of skull base lesions with the endoscopic endonasal transsphenoidal approach.

Has "respiratory coaching" before deep inspiration an impact on the incidence of transient contrast interruption during pulmonary CT angiography?

PURPOSE: To evaluate if respiratory coaching performed prior to CT pulmonary angiography (CTPA) image acquisition has an impact on the occurrence of transient interruption of contrast (TIC) phenomenon. MATERIALS AND METHODS: Two hundred and thirty-one consecutive patients with suspected pulmonary embolism (PE) were referred for CTPA. They were randomised into two groups, with or without respiratory coaching (groups A and B, respectively). Those patients who were deemed not able to be coached were not randomised and were assigned to a third group (C). Two radiologists evaluated the degree of enhancement of the pulmonary arteries and the presence and grade of TIC. The χ(2) test was used to compare differences among groups in occurrence and grade of this phenomenon. RESULTS: There were no significant differences in the presence of any grade of TIC among the three groups, with 30 positive cases (32%) in group A, 33 (35%) in group B, and 12 (27%) in group C (P = 0.61). When TIC was graded and divided into significant or not, the different groups also did not differ significantly. CONCLUSION: Performing respiratory coaching before CTPA had no statistically significant effect on the incidence and severity of TIC in this prospective randomised study. MAIN MESSAGES: • Significant transient interruption of contrast appears in 12% of pulmonary CT angiograms. • Severe transient interruption of contrast leading to nondiagnostic tests appears in 2% of studies. • In our study respiratory coaching has no impact on the incidence of transient interruption of contrast.

Anatomía radiológica de las arterias etmoidales: estudio por TC en cadáver / Radiological anatomy of the ethmoidal arteries: CT cadaver study

Introducción y objetivos: El objetivo del trabajo es realizar un estudio de la anatomía radiológica de las arterias etmoidales. Métodos: Se realizó un estudio descriptivo con imágenes de tomografía computarizada correspondientes a 20 cabezas de cadáver perfundidas con material radiopaco. Se analizaron diferentes parámetros anatómicos. Resultados: La arteria etmoidal anterior se localizó en el 95% (38/40) de los casos. En el 87,55% (35/40) de las fosas se originó de la arteria oftálmica, encontrando en seis casos variantes de la normalidad. La longitud media del canal etmoidal anterior fue de 8,43±0,74mm con un ángulo de entrada en la base de cráneo de 37,3±5,48º. En el 90% de los casos (36/40), se localizó entre la segunda y la tercera lamela. La arteria etmoidal posterior sólo pudo localizarse en (14/40) fosas nasales. El 28,5% (4/14) presentaron variantes en su origen. La longitud media del canal etmoidal posterior fue de 7,1±1,02mm realizando un ángulo anterior a su salida de la órbita de 7,11±4,07º La distancia desde la espina nasal hasta la arteria etmoidal anterior fue de 55,51±5,52mm. El ángulo realizado entre la espina nasal y el canal etmoidal anterior fue de 57,67±1,68º. La distancia entre el nasión y el canal etmoidal anterior fue de 29,31±2,53mm, de la arteria etmoidal anterior a la arteria etmoidal posterior fue de 11,24±2,14mm y de la arteria etmoidal posterior al nervio óptico de 7,26±1,33mm. Se apreciaron celdas supraorbitarias en el 15% (6/40) de las fosas. Conclusiones: La técnica utilizada permitió realizar un análisis vascular completo del trayecto de las arterias etmoidales (AU)

Introduction and objectives: Our aim was to study the radiological anatomy of the ethmoidalarteries. Methods: A descriptive study was performed including CT images of 20 cadaver heads. The specimens were perfused with a radiopaque material and various anatomical parameters were analysed. Results: The anterior ethmoidal artery was found in 95% (38/40) of cases. It originated from the ophthalmic artery in 87.5% (34/40) of nasal cavities. In six cases, normal variants were found. The mean length of the anterior ethmoidal canal was 8.43±0.74mm. The angle performed into the skull base was 37.3±5.48º. In 90% of cases (36/40), it was located between the second and third lamella. The posterior ethmoidal artery was localised only in 14/40 cases, with 28.5% (4/14) of them showing normal variants. The mean length of the posterior ethmoidal canal was 7.1±1.02mm. The angle performed into the skull base was 7.11±4.07º. The distance from sill to the anterior ethmoid artery was 55.51±5.52mm. The angle between the nasalspine and the anterior ethmoidal canal was 57.67±1.68º. The distance between the nasion and the anterior ethmoidal canal was 29.31±2.53mm, the distance was 11.24±2.14mm from the anterior ethmoid artery to the posterior ethmoid artery and from the posterior ethmoid artery to the optic nerve, 7.26±1.33mm. Supraorbital cells were observed in 15% (6/40) of the cases. Conclusions: A complete vascular study of the ethmoidal arteries was possible by using this technique (AU)

[Radiological anatomy of the ethmoidal arteries: CT cadaver study]. / Anatomía radiológica de las arterias etmoidales: estudio por TC en cadáver.

INTRODUCTION AND OBJECTIVES: Our aim was to study the radiological anatomy of the ethmoidal arteries. METHODS: A descriptive study was performed including CT images of 20 cadaver heads. The specimens were perfused with a radiopaque material and various anatomical parameters were analysed. RESULTS: The anterior ethmoidal artery was found in 95% (38/40) of cases. It originated from the ophthalmic artery in 87.5% (34/40) of nasal cavities. In six cases, normal variants were found. The mean length of the anterior ethmoidal canal was 8.43 ± 0.74 mm. The angle performed into the skull base was 37.3 ± 5.48°. In 90% of cases (36/40), it was located between the second and third lamella. The posterior ethmoidal artery was localised only in 14/40 cases, with 28.5% (4/14) of them showing normal variants. The mean length of the posterior ethmoidal canal was 7.1 ± 1.02 mm. The angle performed into the skull base was 7.11 ± 4.07°. The distance from sill to the anterior ethmoid artery was 55.51 ± 5.52 mm. The angle between the nasal spine and the anterior ethmoidal canal was 57.67 ± 1.68°. The distance between the nasion and the anterior ethmoidal canal was 29.31 ± 2.53 mm, the distance was 11.24 ± 2.14 mm from the anterior ethmoid artery to the posterior ethmoid artery and from the posterior ethmoid artery to the optic nerve, 7.26 ± 1.33 mm. Supraorbital cells were observed in 15% (6/40) of the cases. CONCLUSIONS: A complete vascular study of the ethmoidal arteries was possible by using this technique.