Evaluation of the clinical benefit of an electromagnetic navigation system for CT-guided interventional radiology procedures in the thoraco-abdominal region compared with conventional CT guidance (CTNAV II): study protocol for a randomised controlled trial.

BACKGROUND: Interventional radiology includes a range of minimally invasive image-guided diagnostic and therapeutic procedures that have become routine clinical practice. Each procedure involves a percutaneous needle insertion, often guided using computed tomography (CT) because of its availability and usability. However, procedures remain complicated, in particular when an obstacle must be avoided, meaning that an oblique trajectory is required. Navigation systems track the operator's instruments, meaning the position and progression of the instruments are visualised in real time on the patient's images. A novel electromagnetic navigation system for CT-guided interventional procedures (IMACTIS-CT®) has been developed, and a previous clinical trial demonstrated improved needle placement accuracy in navigation-assisted procedures. In the present trial, we are evaluating the clinical benefit of the navigation system during the needle insertion step of CT-guided procedures in the thoraco-abdominal region. METHODS/DESIGN: This study is designed as an open, multicentre, prospective, randomised, controlled interventional clinical trial and is structured as a standard two-arm, parallel-design, individually randomised trial. A maximum of 500 patients will be enrolled. In the experimental arm (navigation system), the procedures are carried out using navigation assistance, and in the active comparator arm (CT), the procedures are carried out with conventional CT guidance. The randomisation is stratified by centre and by the expected difficulty of the procedure. The primary outcome of the trial is a combined criterion to assess the safety (number of serious adverse events), efficacy (number of targets reached) and performance (number of control scans acquired) of navigation-assisted, CT-guided procedures as evaluated by a blinded radiologist and confirmed by an expert committee in case of discordance. The secondary outcomes are (1) the duration of the procedure, (2) the satisfaction of the operator and (3) the irradiation dose delivered, with (4) subgroup analysis according to the expected difficulty of the procedure, as well as an evaluation of (5) the usability of the device. DISCUSSION: This trial addresses the lack of published high-level evidence studies in which navigation-assisted CT-guided interventional procedures are evaluated. This trial is important because it addresses the problems associated with conventional CT guidance and is particularly relevant because the number of interventional radiology procedures carried out in routine clinical practice is increasing. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01896219 . Registered on 5 July 2013.

DIPNECH: when to suggest this diagnosis on CT.

Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) is an under-recognized disease characterized by proliferation of neuroendocrine cells in the bronchial wall. It is considered a pre-invasive lesion for lung carcinoid tumours and is found in 5.4% of patients undergoing surgical resection for lung carcinoid tumours. Other manifestations of DIPNECH include bronchial obstruction and formation of tumorlets. DIPNECH preferentially affects middle-aged women. Patients are either asymptomatic or present with long-standing dyspnoea due to obstructive syndrome that can be mistaken for asthma. At CT, mosaic attenuation with multiple small nodules is very suggestive of DIPNECH. The aim of this review is to describe DIPNECH-related CT features and correlate them with histology, in order to help radiologists suggest this diagnosis and distinguish DIPNECH from other causes of mosaic perfusion.

Initial characteristics and outcome of hospitalized patients with amiodarone pulmonary toxicity.

UNLABELLED: Amiodarone-induced pulmonary toxicity (APT) is a serious adverse event that can lead to death. The aims of our study are to determine factors associated with mortality and to describe outcome and sequelae of patients with APT. METHODS: Forty-six patients with APT were divided into two groups according to survival at day 90 for a clinical, functional, biological and radiological comparaison. We then evaluated the evolution of 15 survivors at a median of three months [1-6 months] and/or 12 months [8-36 months]. RESULTS: Mortality of APT at day 90 was 37% (17 patients) and was linked to the speed of onset of symptoms and a high HRCT alveolar score. Angiotensin system antagonist treatment was prescribed significantly more in the survival group (p = 0.042, HR 0.34 (95% CI 0.12-0.96)). In surviving patients, dyspnea, vital capacity and HRCT alveolar score improved significantly while HRCT fibrosis score deteriorated gradually during the first six months. At the end of the study, all the surviving patients presented functional and/or radiological sequelae. CONCLUSIONS: Severity of APT is linked to the extent and speed of onset of pulmonary damage. After the initial episode, the patients who survived improved slowly but with persistent sequelae.

Chronic bronchiolitis in ankylosing spondylitis.

The pleuro-pulmonary signs of ankylosing spondylitis are generally asymptomatic, typically represented by biapical lung fibrosis. To our knowledge, the severe bronchiolitis which is sometimes observed in other spondyloarthropathies has not been described in ankylosing spondylitis. We report two cases of severe chronic bronchiolitis in ankylosing spondylitis patients. Their clinical and radiological presentation were similar, characterized by progressive deterioration of stage III-IV dyspnea, non-reversible obstructive ventilatory defect, and CT scan showing air trapping with mosaic attenuation and ground-glass opacity in expiration. Lung biopsies confirmed the diagnosis of severe follicular bronchiolitis in one patient and constrictive bronchiolitis is suspected in the other. Only the patient with follicular bronchiolitis responded positively to treatment with low doses of macrolides.

Can exhaled nitric oxide differentiate causes of pulmonary fibrosis?

BACKGROUND: Interstitial lung diseases (ILD) comprise a heterogeneous group of disorders, and when diagnosed at the stage of pulmonary fibrosis, the underlying lung disease can sometimes be difficult to identify. The aim of the present study was to determine whether there are differences in FENO (fraction of exhaled nitric oxide) between different subtypes of fibrotic ILD. METHODS: Sixty-one patients, with honeycombing on computed tomography (CT) scan, and whose FENO levels had been measured during chronic dyspnoea evaluation, were divided into four groups based on pulmonary fibrosis aetiology: idiopathic pulmonary fibrosis (IPF), chronic hypersensitivity pneumonitis (HP), connective tissue disease-associated ILD disorders (CTD-ILD), drug-induced pneumonia. The FENO values of each group were compared and CT scan features were analysed to identify the mechanisms involved in FENO change. RESULTS: The median FENO value of patients with chronic HP was 51 ppb (IQR 36-74), higher than that of the other groups (22 ppb (IQR 17-30) in IPF, 19 ppb (IQR 17-21) in drug-induced pneumonia, and 25 ppb (IQR 17-37) for CTD-ILD; p = 0.008). At the cut-off value of 41 ppb, the optimal sensitivity and specificity to diagnose HP with FENO were respectively 76.9% and 85.4%. On CT scans, only extensive lobular areas with decreased attenuation, a recognized marker of bronchiolar disease, were associated with high FENO values (p = 0.0002). CONCLUSION: FENO could be a tool for differentiating chronic HP from other types of pulmonary fibrosis. The mechanism involved seems to be bronchiolar disease.

Airway obstruction by an aortic false aneurysm.

Aortic false aneurysms are rare complications of aortic valve replacement and cardiac surgical procedures in general. Aortic false aneurysms can also presents as a mediastinal mass. A false aneurysm etiology should always be considered in mediastinal mass exploration of patients with a cardiac surgery history. Although, a computed tomography (CT) scan can detect a mediastinal mass, it can equally misdiagnose an aneurysm in the absence of tumour contrast enhancement. We present the case of a 60-year-old woman who was hospitalized for a laryngeal dyspnea. She had undergone aortic valve replacement 3 years earlier and had no other relevant medical history. In the last 3 months, she presented a progressively worsening dyspnea and cough. A chest radiograph showed a large mass in the superior mediastinum. A contrast-enhanced CT-scan showed an anterior mediastinal mass (9 cm × 8 cm × 9 cm) not enhanced by contrast product, suggestive of a tissue density tumour. The mass was in fact an aortic false aneurysm where the communication with the aorta was too narrow to be filled by the contrast product in arterial phase imaging. The aneurysm was excised and successfully replaced with a prosthetic graft during deep hypothermic and circulatory arrest. In this case report, we discuss the unusual clinical presentation of this pseudoaneurysm and the absence of contrast enhancement during CT-scan, which could have lead to a catastrophic error.

Organising pneumonia can be the inaugural manifestation in connective tissue diseases, including Sjogren's syndrome.

Connective tissue diseases are known to be one of the causes of organising pneumonia (OP). However, this association is rare and signs of OP usually occur in the context of an already diagnosed disease. We report three cases of OP preceding the articular symptoms of the underlying connective tissue disease by 3-6 months in two cases of rheumatoid arthritis and by 36 months in one patient with primary Sjögren's syndrome. The diagnosis of post-infectious OP had initially been suspected in the three cases and the patients had not been followed up further. The occurrence of OP preceding articular or any other extrapulmonary involvement of connective tissue disease had been reported in only four cases in the literature and, to our knowledge, no case preceding Sjögren's syndrome had ever been reported. These observations suggest that exhaustive investigations should be considered when OP is diagnosed, including antinuclear auto-antibodies and investigations for Sjögren's syndrome, even when there are no clinical signs suggesting an underlying connective tissue disease. These investigations should also be repeated during the course of the disease, especially in the case of OP continuing to progress under treatment and, of course, if signs of connective tissue disease appear.

[Tropical pneumonia: pulmonary melioidosis]. / Une pneumonie exotique à ne pas méconnaitre : la mélioïdose pulmonaire.

Melioidosis is a disease that is endemic in North Australia and Southeast Asia, caused by Burkholderia pseudomallei. This Gram-negative organism can affect all organs, but presents most commonly as severe pneumonia. We report a 58-year-old man who presented with a B. pseudomallei pneumonia on his return from Thailand. Radiography revealed a complete disappearance of symptoms after a 3-week therapy with ceftazidime and doxycycline followed by 4 months of combined amoxicillin-clavulanic acid and doxycycline therapy. No relapse had occurred 18 months later.