Neurofibromatosis type 1: evaluation by chest computed tomography.

OBJECTIVE: The aim of this study was to evaluate chest computed tomography (CT) findings in patients diagnosed with neurofibromatosis type 1 (NF1). MATERIAL AND METHODS: This was a retrospective study in which we reviewed the chest CT scans of 14 patients diagnosed with NF1 and neurofibromatosis-associated diffuse lung disease (NF-DLD). The sample comprised eight women and six men. The median age was 55 years (range, 11-75 years). The diagnosis of NF1 was made on the basis of the diagnostic criteria established by the U.S. National Institutes of Health. The images were analyzed by two chest radiologists, who reached decisions by consensus. RESULTS: The predominant CT finding of NF-DLD was multiple cysts, which were observed in 13 patients (92.9%), followed by emphysema, in eight (57.1%) and subpleural bullae, in six (42.9%). Other findings included subcutaneous neurofibromas, in 12 patients (85.7%), ground-glass opacities, in one (7.1%), and tracheobronchial neurofibromas, in one (7.1%). The pulmonary abnormalities were bilateral in 12 cases (85.7%). The abnormalities were predominantly in the upper lung fields in eight cases (57.1%), and their distribution was random in 11 (78.6%). CONCLUSION: Pulmonary cysts, emphysema, and subpleural bullae appear to be the chest CT findings that are most characteristic of NF-DLD.

OBJETIVO: O objetivo deste estudo foi avaliar os achados pulmonares na tomografia computadorizada do tórax de pacientes diagnosticados com neurofibromatose tipo 1 (NF1). MATERIAIS E MÉTODOS: Foram revisados, retrospectivamente, os achados tomográficos de 14 pacientes com doença pulmonar difusa associada à NF1 (NF-DPD). A amostra incluiu oito mulheres e seis homens, com idade entre 11 e 75 anos (mediana de idade de 55 anos). O diagnóstico foi estabelecido com base em critérios diagnósticos predeterminados pelo National Institutes of Health dos Estados Unidos. As imagens foram analisadas de forma independente por dois radiologistas, que chegaram a um consenso. RESULTADOS: Os achados tomográficos predominantes foram múltiplos cistos em 13 pacientes (92,9%), enfisema em oito (57,1%) e bolhas subpleurais em seis (42,9%). Achados associados incluíram neurofibromas cutâneos e subcutâneos em 12 pacientes (85,7%), opacidades em vidro fosco em um (7,1%) e neurofibromas traqueobrônquicos em um (7,1%). As anormalidades pulmonares foram bilaterais em 12 casos (85,7%). Houve predomínio nos terços superiores em oito (57,1%) pacientes e se distribuíram randomicamente pelos pulmões em 11 (78,6%). CONCLUSÃO: Os achados tomográficos pulmonares mais frequentes na NF-DPD foram os cistos pulmonares, o enfisema e as bolhas subpleurais.

Neurofibromatosis type 1: evaluation by chest computed tomography / Neurofibromatose tipo 1: estudo por tomografia computadorizada do tórax

Abstract Objective: The aim of this study was to evaluate chest computed tomography (CT) findings in patients diagnosed with neurofibromatosis type 1 (NF1). Material and Methods: This was a retrospective study in which we reviewed the chest CT scans of 14 patients diagnosed with NF1 and neurofibromatosis-associated diffuse lung disease (NF-DLD). The sample comprised eight women and six men. The median age was 55 years (range, 11-75 years). The diagnosis of NF1 was made on the basis of the diagnostic criteria established by the U.S. National Institutes of Health. The images were analyzed by two chest radiologists, who reached decisions by consensus. Results: The predominant CT finding of NF-DLD was multiple cysts, which were observed in 13 patients (92.9%), followed by emphysema, in eight (57.1%) and subpleural bullae, in six (42.9%). Other findings included subcutaneous neurofibromas, in 12 patients (85.7%), ground-glass opacities, in one (7.1%), and tracheobronchial neurofibromas, in one (7.1%). The pulmonary abnormalities were bilateral in 12 cases (85.7%). The abnormalities were predominantly in the upper lung fields in eight cases (57.1%), and their distribution was random in 11 (78.6%). Conclusion: Pulmonary cysts, emphysema, and subpleural bullae appear to be the chest CT findings that are most characteristic of NF-DLD.

Resumo Objetivo: O objetivo deste estudo foi avaliar os achados pulmonares na tomografia computadorizada do tórax de pacientes diagnosticados com neurofibromatose tipo 1 (NF1). Materiais e Métodos Foram revisados, retrospectivamente, os achados tomográficos de 14 pacientes com doença pulmonar difusa associada à NF1 (NF-DPD). A amostra incluiu oito mulheres e seis homens, com idade entre 11 e 75 anos (mediana de idade de 55 anos). O diagnóstico foi estabelecido com base em critérios diagnósticos predeterminados pelo National Institutes of Health dos Estados Unidos. As imagens foram analisadas de forma independente por dois radiologistas, que chegaram a um consenso. Resultados: Os achados tomográficos predominantes foram múltiplos cistos em 13 pacientes (92,9%), enfisema em oito (57,1%) e bolhas subpleurais em seis (42,9%). Achados associados incluíram neurofibromas cutâneos e subcutâneos em 12 pacientes (85,7%), opacidades em vidro fosco em um (7,1%) e neurofibromas traqueobrônquicos em um (7,1%). As anormalidades pulmonares foram bilaterais em 12 casos (85,7%). Houve predomínio nos terços superiores em oito (57,1%) pacientes e se distribuíram randomicamente pelos pulmões em 11 (78,6%). Conclusão: Os achados tomográficos pulmonares mais frequentes na NF-DPD foram os cistos pulmonares, o enfisema e as bolhas subpleurais.

Importance of chest HRCT in the diagnostic evaluation of fibrosing interstitial lung diseases.

Many conditions result in chronic interstitial lung disease (ILD), being classified as fibrosing ILDs, including idiopathic pulmonary fibrosis, connective tissue diseases, sarcoidosis, and fibrotic hypersensitivity pneumonitis. HRCT plays an important role in the clinical evaluation of fibrosing ILDs. Current treatment perspectives are encouraging and reinforce the need for HRCT scans of adequate technical quality for early detection of fibrosing ILD. Despite efforts in this regard, the significance and management of imaging findings of early interstitial lung abnormalities have yet to be clarified. After identification of CT findings consistent with fibrosing ILD, radiologists must be able to identify characteristic morphological patterns and, in some cases, features of specific clinical entities. In cases in which HRCT features are not sufficiently specific for a definitive diagnosis, HRCT can aid in selecting the best site for surgical lung biopsy. CT follow-up is useful for identifying progressive fibrosing ILDs and detecting complications unrelated to the underlying disease, including infections, acute exacerbations, and neoplasms. Automated quantification tools have clinical applicability and are likely to be available for use in imaging analysis in the near future. In addition, incorporation of CT evaluation into scoring systems based on clinical and functional parameters for staging fibrosing disease is likely to become valuable in determining prognosis. Knowledge of the clinical applications of CT evaluation is essential for specialists managing patients with fibrosing ILD and can have a positive impact on the clinical course of the disease.

Carbohydrate antigen 15-3 as a marker of disease severity in patients with chronic hypersensitivity pneumonitis.

OBJECTIVE: Biomarkers associated with mucin 1, such as Krebs von den Lungen-6 and carbohydrate antigen (CA) 15-3, are increased in various interstitial lung diseases. Our aim was to determine whether CA 15-3 could be considered a biomarker of disease severity in patients with chronic hypersensitivity pneumonitis (cHP). METHODS: This was a prospective observational study involving adult patients with cHP. Serum levels of CA 15-3 were measured and were correlated with variables related to disease severity and extension. HRCT scans were quantitatively analyzed using a computational platform and an image analysis tool (Computer Aided Lung Informatics for Pathology Evaluation and Rating). CA 15-3 levels were normalized by logarithmic transformation. RESULTS: The sample comprised 41 patients. The mean age of the patients was 60.1 ± 11.6 years. The mean FVC in % of predicted was 70.3% ± 17.3%, and the median of the serum level of CA 15-3 was 48.1 U/mL. CA 15-3 levels inversely correlated with FVC in % of predicted (r = -0,30; p = 0,05), DLCO in % of predicted (r = -0,54; p < 0,01), and SpO2 at the end of a 4-min step test (r = -0,59; p < 0,01), but they directly correlated with total quantitative HRCT scores (r = 0,47; p = 0,004), especially regarding ground-glass opacities (r = 0.58; p < 0,001). CONCLUSIONS: CA 15-3 is likely to be a biomarker of disease severity of patients with cHP, particularly regarding gas exchange abnormalities.

Carbohydrate antigen 15-3 as a marker of disease severity in patients with chronic hypersensitivity pneumonitis* / Antígeno carboidrato 15-3 como marcador de gravidade da doença em pacientes com pneumonite de hipersensibilidade crônica

ABSTRACT Objective: Biomarkers associated with mucin 1, such as Krebs von den Lungen-6 and carbohydrate antigen (CA) 15-3, are increased in various interstitial lung diseases. Our aim was to determine whether CA 15-3 could be considered a biomarker of disease severity in patients with chronic hypersensitivity pneumonitis (cHP). Methods: This was a prospective observational study involving adult patients with cHP. Serum levels of CA 15-3 were measured and were correlated with variables related to disease severity and extension. HRCT scans were quantitatively analyzed using a computational platform and an image analysis tool (Computer Aided Lung Informatics for Pathology Evaluation and Rating). CA 15-3 levels were normalized by logarithmic transformation. Results: The sample comprised 41 patients. The mean age of the patients was 60.1 ± 11.6 years. The mean FVC in % of predicted was 70.3% ± 17.3%, and the median of the serum level of CA 15-3 was 48.1 U/mL. CA 15-3 levels inversely correlated with FVC in % of predicted (r = −0,30; p = 0,05), DLCO in % of predicted (r = −0,54; p < 0,01), and SpO2 at the end of a 4-min step test (r = −0,59; p < 0,01), but they directly correlated with total quantitative HRCT scores (r = 0,47; p = 0,004), especially regarding ground-glass opacities (r = 0.58; p < 0,001). Conclusions: CA 15-3 is likely to be a biomarker of disease severity of patients with cHP, particularly regarding gas exchange abnormalities.

RESUMO Objetivo: Biomarcadores associados à mucina-1, tais como Krebs von den Lungen-6 e carbohydrate antigen (CA, antígeno carboidrato) 15-3, encontram-se aumentados em diversas doenças pulmonares intersticiais. Nosso objetivo foi determinar se CA 15-3 poderia ser considerado um biomarcador de gravidade de doença em pacientes com pneumonite de hipersensibilidade crônica (PHc). Métodos: Estudo prospectivo observacional envolvendo pacientes adultos com PHc. Os níveis séricos de CA 15-3 foram medidos e correlacionados com variáveis relacionadas à gravidade e extensão da doença. As imagens de TCAR foram analisadas quantitativamente utilizando uma plataforma computacional e uma ferramenta de análise de imagem (Computer-Aided Lung Informatics for Pathology Evaluation and Rating). Os níveis de CA 15-3 foram normalizados por transformação logarítmica. Resultados: A amostra foi composta por 41 pacientes. A média de idade dos pacientes foi de 60,1 ± 11,6 anos. A média da CVF em % do previsto foi de 70,3% ± 17,3%, e a mediana do nível sérico de CA 15-3 foi de 48,1 U/mL. Os níveis de CA 15-3 se correlacionaram inversamente com CVF em % do previsto (r = −0,30; p = 0,05), DLCO em % do previsto (r = −0,54; p < 0,01) e SpO2 ao final de um teste de degrau de 4 minutos (r = −0,59; p < 0,01), mas se correlacionaram diretamente com a pontuação quantitativa total da TCAR (r = 0,47; p = 0,004), especialmente quanto a opacidades em vidro fosco (r = 0,58; p < 0,001). Conclusões: É provável que o CA 15-3 seja um biomarcador de gravidade de doença em pacientes com PHc, particularmente quanto a anormalidades nas trocas gasosas.

Importance of chest HRCT in the diagnostic evaluation of fibrosing interstitial lung diseases / Importância da TCAR de tórax na avaliação de pneumopatias intersticiais fibrosantes

ABSTRACT Many conditions result in chronic interstitial lung disease (ILD), being classified as fibrosing ILDs, including idiopathic pulmonary fibrosis, connective tissue diseases, sarcoidosis, and fibrotic hypersensitivity pneumonitis. HRCT plays an important role in the clinical evaluation of fibrosing ILDs. Current treatment perspectives are encouraging and reinforce the need for HRCT scans of adequate technical quality for early detection of fibrosing ILD. Despite efforts in this regard, the significance and management of imaging findings of early interstitial lung abnormalities have yet to be clarified. After identification of CT findings consistent with fibrosing ILD, radiologists must be able to identify characteristic morphological patterns and, in some cases, features of specific clinical entities. In cases in which HRCT features are not sufficiently specific for a definitive diagnosis, HRCT can aid in selecting the best site for surgical lung biopsy. CT follow-up is useful for identifying progressive fibrosing ILDs and detecting complications unrelated to the underlying disease, including infections, acute exacerbations, and neoplasms. Automated quantification tools have clinical applicability and are likely to be available for use in imaging analysis in the near future. In addition, incorporation of CT evaluation into scoring systems based on clinical and functional parameters for staging fibrosing disease is likely to become valuable in determining prognosis. Knowledge of the clinical applications of CT evaluation is essential for specialists managing patients with fibrosing ILD and can have a positive impact on the clinical course of the disease.

RESUMO Inúmeras doenças determinam dano intersticial crônico no parênquima pulmonar e são agrupadas com a denominação de pneumopatias intersticiais fibrosantes, incluindo fibrose pulmonar idiopática, doenças do colágeno, sarcoidose, pneumonite por hipersensibilidade fibrótica etc. Entre os métodos complementares à avaliação clínica, a TCAR tem um papel relevante. Perspectivas atuais de tratamento são encorajadoras e reforçam a necessidade de realização de estudos com técnica adequada, visando a detecção confiável de acometimento intersticial fibrosante o mais precocemente possível. Embora esforços tenham sido direcionados nesse sentido, o significado e manejo de anormalidades pulmonares intersticiais incipientes, detectadas nos estudos de imagem, ainda não são claros. Uma vez detectado o acometimento fibrosante, é importante que o radiologista conheça aspectos característicos de determinados padrões morfológicos e reconheça elementos que possam apontar para entidades clínicas específicas. Em casos nos quais a especificidade dos achados não é suficiente para a suspeição diagnóstica, as imagens de TC servem de guia para a escolha de sítios para biópsia cirúrgica. O seguimento evolutivo é útil para a determinação de pneumopatias fibrosantes progressivas e para a detecção de complicações não relacionadas à doença de base, como infecções, exacerbação aguda e neoplasias. Ferramentas automatizadas de quantificação têm aplicabilidade clínica e devem estar acessíveis para a análise imagética no futuro próximo. Além disso, a incorporação da avaliação tomográfica a escores com parâmetros clínicos e funcionais de estadiamento do acometimento fibrosante poderá se tornar valiosa na determinação prognóstica. O conhecimento das diversas aplicabilidades clínicas do método tomográfico é fundamental aos especialistas que acompanham esses pacientes, podendo impactar positivamente sua trajetória clínica.

COVID-19: a brief update for radiologists.

Coronavirus disease 2019 (COVID-19), which is caused by a new coronavirus-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-is a pandemic with major impacts on the health care sector, and a broad view of the disease is of fundamental importance for any radiologist. The purpose of this review is to address the main clinical and imaging aspects of COVID-19, as well as guidelines for requesting and using imaging methods; measures to protect patients and health care professionals; systems for quantifying pulmonary findings and preparing integrated reports; and the main innovations that have emerged during this pandemic.

A COVID-19, doença causada por um novo coronavírus (SARS-CoV-2), é uma pandemia que tem causado grandes impactos no setor de saúde, sendo fundamental para o médico radiologista uma visão ampla da doença. O objetivo desta revisão é abordar os principais aspectos clínicos e imaginológicos da COVID-19, assim como as diretrizes para solicitação e utilização dos métodos de imagem, medidas de proteção a pacientes e profissionais de saúde, sistemas de quantificação dos achados pulmonares e de elaboração de relatórios integrados e as principais inovações que têm surgido neste momento de pandemia.

COVID-19: a brief update for radiologists / COVID-19: uma breve atualização para radiologistas

Abstract Coronavirus disease 2019 (COVID-19), which is caused by a new coronavirus-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-is a pandemic with major impacts on the health care sector, and a broad view of the disease is of fundamental importance for any radiologist. The purpose of this review is to address the main clinical and imaging aspects of COVID-19, as well as guidelines for requesting and using imaging methods; measures to protect patients and health care professionals; systems for quantifying pulmonary findings and preparing integrated reports; and the main innovations that have emerged during this pandemic.

Resumo A COVID-19, doença causada por um novo coronavírus (SARS-CoV-2), é uma pandemia que tem causado grandes impactos no setor de saúde, sendo fundamental para o médico radiologista uma visão ampla da doença. O objetivo desta revisão é abordar os principais aspectos clínicos e imaginológicos da COVID-19, assim como as diretrizes para solicitação e utilização dos métodos de imagem, medidas de proteção a pacientes e profissionais de saúde, sistemas de quantificação dos achados pulmonares e de elaboração de relatórios integrados e as principais inovações que têm surgido neste momento de pandemia.

Thoracic calcifications on magnetic resonance imaging: correlations with computed tomography.

OBJECTIVE: To identify the characteristics of thoracic calcifications on magnetic resonance (MR) imaging, as well as correlations between MR imaging and CT findings. METHODS: This was a retrospective study including data on 62 patients undergoing CT scans and MR imaging of the chest at any of seven hospitals in the Brazilian states of Rio Grande do Sul, São Paulo, and Rio de Janeiro between March of 2014 and June of 2016 and presenting with calcifications on CT scans. T1- and T2-weighted MR images (T1- and T2-WIs) were semiquantitatively analyzed, and the lesion-to-muscle signal intensity ratio (LMSIR) was estimated. Differences between neoplastic and non-neoplastic lesions were analyzed. RESULTS: Eighty-four calcified lesions were analyzed. Mean lesion density on CT was 367 ± 435 HU. Median LMSIRs on T1- and T2-WIs were 0.4 (interquartile range [IQR], 0.1-0.7) and 0.2 (IQR, 0.0-0.7), respectively. Most of the lesions were hypointense on T1- and T2-WIs (n = 52 [61.9%] and n = 39 [46.4%], respectively). In addition, 19 (22.6%) were undetectable on T1-WIs (LMSIR = 0) and 36 (42.9%) were undetectable on T2-WIs (LMSIR = 0). Finally, 15.5% were hyperintense on T1-WIs and 9.5% were hyperintense on T2-WIs. Median LMSIR was significantly higher for neoplastic lesions than for non-neoplastic lesions. There was a very weak and statistically insignificant negative correlation between lesion density on CT and the following variables: signal intensity on T1-WIs, LMSIR on T1-WIs, and signal intensity on T2-WIs (r = -0.13, p = 0.24; r = -0.18, p = 0.10; and r = -0.16, p = 0.16, respectively). Lesion density on CT was weakly but significantly correlated with LMSIR on T2-WIs (r = -0.29, p < 0.05). CONCLUSIONS: Thoracic calcifications have variable signal intensity on T1- and T2-weighted MR images, sometimes appearing hyperintense. Lesion density on CT appears to correlate negatively with lesion signal intensity on MR images.

Thoracic calcifications on magnetic resonance imaging: correlations with computed tomography / Calcificações torácicas na ressonância magnética: correlações com a tomografia computadorizada

ABSTRACT Objective: To identify the characteristics of thoracic calcifications on magnetic resonance (MR) imaging, as well as correlations between MR imaging and CT findings. Methods: This was a retrospective study including data on 62 patients undergoing CT scans and MR imaging of the chest at any of seven hospitals in the Brazilian states of Rio Grande do Sul, São Paulo, and Rio de Janeiro between March of 2014 and June of 2016 and presenting with calcifications on CT scans. T1- and T2-weighted MR images (T1- and T2-WIs) were semiquantitatively analyzed, and the lesion-to-muscle signal intensity ratio (LMSIR) was estimated. Differences between neoplastic and non-neoplastic lesions were analyzed. Results: Eighty-four calcified lesions were analyzed. Mean lesion density on CT was 367 ± 435 HU. Median LMSIRs on T1- and T2-WIs were 0.4 (interquartile range [IQR], 0.1-0.7) and 0.2 (IQR, 0.0-0.7), respectively. Most of the lesions were hypointense on T1- and T2-WIs (n = 52 [61.9%] and n = 39 [46.4%], respectively). In addition, 19 (22.6%) were undetectable on T1-WIs (LMSIR = 0) and 36 (42.9%) were undetectable on T2-WIs (LMSIR = 0). Finally, 15.5% were hyperintense on T1-WIs and 9.5% were hyperintense on T2-WIs. Median LMSIR was significantly higher for neoplastic lesions than for non-neoplastic lesions. There was a very weak and statistically insignificant negative correlation between lesion density on CT and the following variables: signal intensity on T1-WIs, LMSIR on T1-WIs, and signal intensity on T2-WIs (r = −0.13, p = 0.24; r = −0.18, p = 0.10; and r = −0.16, p = 0.16, respectively). Lesion density on CT was weakly but significantly correlated with LMSIR on T2-WIs (r = −0.29, p < 0.05). Conclusions: Thoracic calcifications have variable signal intensity on T1- and T2-weighted MR images, sometimes appearing hyperintense. Lesion density on CT appears to correlate negatively with lesion signal intensity on MR images.

RESUMO Objetivo: Identificar as características das calcificações torácicas na ressonância magnética (RM) e as correlações entre os achados de RM e TC. Métodos: Estudo retrospectivo no qual foram analisados dados referentes a 62 pacientes que foram submetidos a TC e RM de tórax em sete hospitais nos estados do Rio Grande do Sul, São Paulo e Rio de Janeiro entre março de 2014 e junho de 2016 e que apresentaram calcificações na TC. As imagens de RM ponderadas em T1 e T2 (doravante denominadas T1 e T2) foram analisadas semiquantitativamente, e a razão entre a intensidade do sinal da lesão e do músculo (LMSIR, do inglês lesion-to-muscle signal intensity ratio) foi estimada. Diferenças entre lesões neoplásicas e não neoplásicas foram analisadas. Resultados: Foram analisadas 84 lesões calcificadas. A média de densidade das lesões na TC foi de 367 ± 435 UH. A mediana da LMSIR foi de 0,4 [intervalo interquartil (II): 0,1-0,7] em T1 e 0,2 (II: 0,0-0,7) em T2. A maioria das lesões mostrou-se hipointensa em T1 e T2 [n = 52 (61,9%) e n = 39 (46,4%), respectivamente]. Além disso, 19 (22,6%) foram indetectáveis em T1 (LMSIR = 0) e 36 (42,9%) foram indetectáveis em T2 (LMSIR = 0). Finalmente, 15,5% mostraram-se hiperintensas em T1 e 9,5% mostraram-se hiperintensas em T2. A mediana da LMSIR foi significativamente maior nas lesões neoplásicas do que nas não neoplásicas. Houve uma correlação negativa muito fraca e estatisticamente insignificante entre a densidade das lesões na TC e as seguintes variáveis: intensidade do sinal em T1, LMSIR em T1 e intensidade do sinal em T2 (r = −0,13, p = 0,24; r = −0,18, p = 0,10 e r = −0,16, p = 0,16, respectivamente). A densidade das lesões na TC apresentou correlação fraca, porém significativa com a LMSIR em T2 (r = −0,29, p < 0,05). Conclusões: As calcificações torácicas apresentam intensidade de sinal variável em T1 e T2; em alguns casos, mostram-se hiperintensas. A densidade da lesão na TC aparentemente correlaciona-se negativamente com a intensidade do sinal da lesão na RM.

Management of lung nodules in Brazil-assessment of realities, beliefs and attitudes: a study by the Brazilian Society of Thoracic Surgery (SBCT), the Brazilian Thoracic Society (SBPT) and the Brazilian College of Radiology (CBR).

BACKGROUND: Pulmonary nodules are common; some are inconsequential while others are malignant. Management of solitary pulmonary nodule (SPN) in Brazil appears to be highly variable, potentially leading to suboptimal outcomes. Assessment of the variability and the association with the degree of availability of resources can provide a foundation for development of clinical guidelines for management of SPN specific for the Brazilian setting. METHODS: A web-based survey was developed by thoracic surgeons, pulmonologists and radiologists to evaluate SPN perception and management. This survey was sent to their respective national societies members and answers collected between August and December 2016. That included multiple choice questions regarding age, specialty, SPN management, accessibility to exams and interventional procedures characterizing public (SUS) and supplementary private working settings. RESULTS: A total of 461 questionnaires were answered. More than half of participants live in cities with over one million people. Specialties were reasonable equilibrated with 43.5% radiologists, 33.5% thoracic surgeons, 20.3% pulmonologists and 2.6% others. Most of the respondents work in both public and private sector (72.7%). Private has a similar reality compared to well-developed nations regarding exams accessibility and interventions. SUS setting has a significant variability access according to the participants. CT is only easily available in 31.9% of cases, PET-CT is easily available in 24.4%, bronchoscopy is easily available for 42.8%, transthoracic needle biopsy is only easily available in 13.9% and video-assisted thoracoscopic surgery (VATS) biopsy is not available in 19.5%. When there is a probability of malignancy of 50% or higher, 46.5% of participants would be comfortable recommending surgical biopsy. When the probability is higher than 10%, only 36.9% would be comfortable following up radiologically. CONCLUSIONS: Brazil has a very different setting for public and private patients regarding exams accessibility and management options. That might explain why participants have a higher tendency to choose interventional diagnosis and explains why current guidelines may not be applicable to developing countries reality.

Usual interstitial pneumonia: typical, possible, and "inconsistent" patterns.

Idiopathic pulmonary fibrosis is a severe and progressive chronic fibrosing interstitial lung disease, a definitive diagnosis being established by specific combinations of clinical, radiological, and pathological findings. According to current international guidelines, HRCT plays a key role in establishing a diagnosis of usual interstitial pneumonia (UIP). Current guidelines describe three UIP patterns based on HRCT findings: a typical UIP pattern; a pattern designated "possible UIP"; and a pattern designated "inconsistent with UIP", each pattern having important diagnostic implications. A typical UIP pattern on HRCT is highly accurate for the presence of histopathological UIP, being currently considered to be diagnostic of UIP. The remaining patterns require further diagnostic investigation. Other known causes of a UIP pattern include drug-induced interstitial lung disease, chronic hypersensitivity pneumonitis, occupational diseases (e.g., asbestosis), and connective tissue diseases, all of which should be included in the clinical differential diagnosis. Given the importance of CT studies in establishing a diagnosis and the possibility of interobserver variability, the objective of this pictorial essay was to illustrate all three UIP patterns on HRCT.

Usual interstitial pneumonia: typical, possible, and "inconsistent" patterns / Pneumonia intersticial usual: padrões típico, possível e inconsistente

ABSTRACT Idiopathic pulmonary fibrosis is a severe and progressive chronic fibrosing interstitial lung disease, a definitive diagnosis being established by specific combinations of clinical, radiological, and pathological findings. According to current international guidelines, HRCT plays a key role in establishing a diagnosis of usual interstitial pneumonia (UIP). Current guidelines describe three UIP patterns based on HRCT findings: a typical UIP pattern; a pattern designated "possible UIP"; and a pattern designated "inconsistent with UIP", each pattern having important diagnostic implications. A typical UIP pattern on HRCT is highly accurate for the presence of histopathological UIP, being currently considered to be diagnostic of UIP. The remaining patterns require further diagnostic investigation. Other known causes of a UIP pattern include drug-induced interstitial lung disease, chronic hypersensitivity pneumonitis, occupational diseases (e.g., asbestosis), and connective tissue diseases, all of which should be included in the clinical differential diagnosis. Given the importance of CT studies in establishing a diagnosis and the possibility of interobserver variability, the objective of this pictorial essay was to illustrate all three UIP patterns on HRCT.

RESUMO A fibrose pulmonar idiopática é uma pneumopatia intersticial fibrosante crônica de curso grave e progressivo, e seu diagnóstico se dá em combinações específicas de correlações clínicas e radiológicas, ou ainda patológicas. A TCAR tem papel chave no diagnóstico morfológico do padrão de pneumonia intersticial usual (PIU), segundo as recomendações internacionais vigentes. Os níveis de certeza para a leitura do padrão tomográfico foram inseridos em diretrizes atuais, descritos como padrão PIU típico, padrão PIU possível e padrão inconsistente com PIU, cada qual com importantes implicações na cadeia diagnóstica. A presença do padrão PIU típico tem alta concordância com o padrão PIU histopatológico, e, nessa situação, a TCAR é tida como suficiente para a determinação do padrão morfológico. Nos demais padrões, investigações diagnósticas complementares são indicadas. O diagnóstico diferencial com outras entidades, incluindo pneumopatias intersticiais por exposição medicamentosa, exposições extrínsecas (pneumonite de hipersensibilidade crônica), doenças ocupacionais (asbestose) e doenças do tecido conjuntivo, deve ser considerado clinicamente. Dada a importância da abordagem tomográfica, a qual pode apresentar relevantes discordâncias na avaliação interobservador, nosso objetivo foi ilustrar os padrões tomográficos de PIU neste ensaio pictórico.

High-resolution computed tomography findings in eight patients with hantavirus pulmonary syndrome.

OBJECTIVE: The purpose of this study was to describe the high-resolution computed tomography (HRCT) findings in patients with hantavirus pulmonary syndrome (HPS). MATERIALS AND METHODS: We retrospectively reviewed HRCT findings from eight cases of HPS. All patients were men, aged 19-70 (mean, 41.7) years. Diagnoses were established by serological test (enzyme-linked immunosorbent assay) in all patients. Two chest radiologists analyzed the images and reached decisions by consensus. RESULTS: The predominant HRCT findings were ground-glass opacities (GGOs) and smooth inter- and intralobular septal thickening, found in all eight cases; however, the crazy-paving pattern was found in only three cases. Pleural effusion and peribronchovascular thickening were observed in five patients. The abnormalities were bilateral in all patients. CONCLUSION: The predominant HRCT findings in patients with HPS were GGOs and smooth inter- and intralobular septal thickening, which probably correlate with the histopathologic findings of pulmonary edema.

OBJETIVO: Descrever os achados na tomografia computadorizada de alta resolução (TCAR) de pacientes com síndrome pulmonar do hantavírus. MATERIAIS E MÉTODOS: Revisamos, retrospectivamente, os achados tomográficos de oito pacientes portadores da síndrome pulmonar do hantavírus, todos do sexo masculino e com idade de 19 a 70 anos (média de 41,7 anos). O diagnóstico foi estabelecido por teste sorológico de ensaio de imunoabsorção enzimática em todos os pacientes. Dois radiologistas de tórax analisaram as imagens e decidiram em consenso. RESULTADOS: Os achados predominantes na TCAR foram opacidades em vidro fosco e espessamento septal inter e intralobular, observados nos oito pacientes; porém, padrão de pavimentação em mosaico foi encontrado em apenas três deles. Derrame pleural e espessamento peribroncovascular foram observados em cinco pacientes. As anormalidades foram bilaterais em todos os pacientes. CONCLUSÃO: Opacidades em vidro fosco e espessamento septal inter e intralobular foram os achados predominantes na TCAR nos pacientes com síndrome pulmonar do hantavírus, o que, provavelmente, se correlaciona com achados histopatológicos de edema pulmonar.

High-resolution computed tomography findings in eight patients with hantavirus pulmonary syndrome / Síndrome pulmonar do hantavírus: achados na tomografia computadorizada de alta resolução

Abstract Objective: The purpose of this study was to describe the high-resolution computed tomography (HRCT) findings in patients with hantavirus pulmonary syndrome (HPS). Materials and Methods: We retrospectively reviewed HRCT findings from eight cases of HPS. All patients were men, aged 19-70 (mean, 41.7) years. Diagnoses were established by serological test (enzyme-linked immunosorbent assay) in all patients. Two chest radiologists analyzed the images and reached decisions by consensus. Results: The predominant HRCT findings were ground-glass opacities (GGOs) and smooth inter- and intralobular septal thickening, found in all eight cases; however, the crazy-paving pattern was found in only three cases. Pleural effusion and peribronchovascular thickening were observed in five patients. The abnormalities were bilateral in all patients. Conclusion: The predominant HRCT findings in patients with HPS were GGOs and smooth inter- and intralobular septal thickening, which probably correlate with the histopathologic findings of pulmonary edema.

Resumo Objetivo: Descrever os achados na tomografia computadorizada de alta resolução (TCAR) de pacientes com síndrome pulmonar do hantavírus. Materiais e Métodos: Revisamos, retrospectivamente, os achados tomográficos de oito pacientes portadores da síndrome pulmonar do hantavírus, todos do sexo masculino e com idade de 19 a 70 anos (média de 41,7 anos). O diagnóstico foi estabelecido por teste sorológico de ensaio de imunoabsorção enzimática em todos os pacientes. Dois radiologistas de tórax analisaram as imagens e decidiram em consenso. Resultados: Os achados predominantes na TCAR foram opacidades em vidro fosco e espessamento septal inter e intralobular, observados nos oito pacientes; porém, padrão de pavimentação em mosaico foi encontrado em apenas três deles. Derrame pleural e espessamento peribroncovascular foram observados em cinco pacientes. As anormalidades foram bilaterais em todos os pacientes. Conclusão: Opacidades em vidro fosco e espessamento septal inter e intralobular foram os achados predominantes na TCAR nos pacientes com síndrome pulmonar do hantavírus, o que, provavelmente, se correlaciona com achados histopatológicos de edema pulmonar.

Radiologist agreement on the quantification of bronchiectasis by high-resolution computed tomography.

OBJECTIVE: To evaluate radiologist agreement on the quantification of bronchiectasis by high-resolution computed tomography (HRCT). MATERIALS AND METHODS: The HRCT scans of 43 patients with bronchiectasis were analyzed by two radiologists, who used a scoring system to grade the findings. Kappa (κ) values and overall agreement were calculated. RESULTS: For the measurement and appearance of bronchiectasis, the interobserver agreement was moderate (κ = 0.45 and κ = 0.43, respectively), as was the intraobserver agreement (κ = 0.54 and κ = 0.47, respectively). Agreement on the presence of mucous plugging was fair, for central distribution (overall interobserver agreement of 68.3% and κ = 0.39 for intraobserver agreement) and for peripheral distribution (κ = 0.34 and κ = 0.35 for interobserver and intraobserver agreement, respectively). The agreement was also fair for peribronchial thickening (κ = 0.21 and κ = 0.30 for interobserver and intraobserver agreement, respectively). There was fair interobserver and intraobserver agreement on the detection of opacities (κ = 0.39 and 71.9%, respectively), ground-glass attenuation (64.3% and κ = 0.24, respectively), and cysts/bullae (κ = 0.47 and κ = 0.44, respectively). Qualitative analysis of the HRCT findings of bronchiectasis and the resulting individual patient scores showed that there was an excellent correlation between the observers (intraclass correlation coefficient of 0.85 and 0.81 for interobserver and intraobserver agreement, respectively). CONCLUSION: In the interpretation of HRCT findings of bronchiectasis, radiologist agreement appears to be fair. In our final analysis of the findings using the proposed score, we observed excellent interobserver and intraobserver agreement.

OBJETIVO: Avaliar a concordância entre radiologistas na quantificação de bronquiectasias pela tomografia computadorizada de alta resolução (TCAR). MATERIAIS E MÉTODOS: Foram avaliadas TCARs de 43 pacientes com bronquiectasias. Os achados foram graduados segundo um escore, e os valores de kappa (κ) e concordância geral foram calculados. RESULTADOS: Para o tamanho e a aparência das bronquiectasias, houve concordância moderada interobservador (κ = 0,45 e κ = 0,43, respectivamente) e intraobservador (κ = 0,54 e κ = 0,47, respectivamente). Para a presença de impactação mucoide, a concordância foi mediana (central: concordância geral de 68,3% interobservador e κ = 0,39 intraobservador; periférica: κ = 0,34 interobservador e κ = 0,35 intraobservador). Para espessamento brônquico, a concordância foi mediana (κ = 0,21 interobservador e κ = 0,30 intraobservador). Na análise de opacidades, vidro fosco e cistos/bolhas, a concordância foi mediana (κ = 0,39, concordância geral de 64,3% e κ = 0,47 interobservador e concordância geral de 71,9%, κ = 0,24 e κ = 0,44 intraobservador, respectivamente). Após análise qualitativa dos achados de bronquiectasias na TCAR, realizou-se um escore final para cada paciente, com excelente correlação entre os observadores (coeficiente de correlação intraclasse de 0,85 interobservador e 0,81 intraobservador). CONCLUSÃO: Os achados tomográficos de bronquiectasias apresentaram concordância regular entre os observadores. Na análise final dos achados, foi encontrada excelente correlação entre os observadores e na avaliação do mesmo observador.

Pitfalls and artifacts in the interpretation of oncologic PET/CT of the chest.

PET/CT is widely used for the evaluation of patients with thoracic malignancies. Although the levels of 18F-fluorodeoxyglucose (FDG) uptake are usually high in neoplastic diseases, they can also be physiological, due to artifacts. In addition, FDG uptake can occur in benign conditions such as infectious, inflammatory, and iatrogenic lesions. Furthermore, some malignant tumors, such as adenocarcinoma in situ (formerly known as bronchoalveolar carcinoma) and carcinoid tumors, may not show FDG uptake. Here, we illustrate the main pitfalls and artifacts in the interpretation of the results of oncologic PET/CT of the chest, outlining strategies for avoiding misinterpretation.

PET/CT é amplamente utilizada para avaliação de pacientes com neoplasias torácicas. Altos níveis de captação de 18F-fluordesoxiglicose (FDG) são geralmente vistos em neoplasias, mas também podem ser fisiológicos, decorrentes de artefatos ou ocorrerem em condições benignas, como lesões infecciosas, inflamatórias e iatrogênicas. Por outro lado, alguns tumores malignos podem não captar FDG, como o adenocarcinoma in situ (anteriormente denominado de carcinoma bronquioloalveolar) e tumores carcinoides. Os autores ilustram as principais armadilhas e artefatos na interpretação dos exames torácicos de PET/CT oncológicos, com estratégias para evitar erros de interpretação.

Pitfalls and artifacts in the interpretation of oncologic PET/CT of the chest / Armadilhas e artefatos na interpretação de PET/CT na oncologia torácica

Abstract PET/CT is widely used for the evaluation of patients with thoracic malignancies. Although the levels of 18F-fluorodeoxyglucose (FDG) uptake are usually high in neoplastic diseases, they can also be physiological, due to artifacts. In addition, FDG uptake can occur in benign conditions such as infectious, inflammatory, and iatrogenic lesions. Furthermore, some malignant tumors, such as adenocarcinoma in situ (formerly known as bronchoalveolar carcinoma) and carcinoid tumors, may not show FDG uptake. Here, we illustrate the main pitfalls and artifacts in the interpretation of the results of oncologic PET/CT of the chest, outlining strategies for avoiding misinterpretation.

Resumo PET/CT é amplamente utilizada para avaliação de pacientes com neoplasias torácicas. Altos níveis de captação de 18F-fluordesoxiglicose (FDG) são geralmente vistos em neoplasias, mas também podem ser fisiológicos, decorrentes de artefatos ou ocorrerem em condições benignas, como lesões infecciosas, inflamatórias e iatrogênicas. Por outro lado, alguns tumores malignos podem não captar FDG, como o adenocarcinoma in situ (anteriormente denominado de carcinoma bronquioloalveolar) e tumores carcinoides. Os autores ilustram as principais armadilhas e artefatos na interpretação dos exames torácicos de PET/CT oncológicos, com estratégias para evitar erros de interpretação.

Radiologist agreement on the quantification of bronchiectasis by high-resolution computed tomography / Concordância entre radiologistas na quantificação de bronquiectasias pela tomografia computadorizada de alta resolução

Abstract Objective: To evaluate radiologist agreement on the quantification of bronchiectasis by high-resolution computed tomography (HRCT). Materials and Methods: The HRCT scans of 43 patients with bronchiectasis were analyzed by two radiologists, who used a scoring system to grade the findings. Kappa (κ) values and overall agreement were calculated. Results: For the measurement and appearance of bronchiectasis, the interobserver agreement was moderate (κ = 0.45 and κ = 0.43, respectively), as was the intraobserver agreement (κ = 0.54 and κ = 0.47, respectively). Agreement on the presence of mucous plugging was fair, for central distribution (overall interobserver agreement of 68.3% and κ = 0.39 for intraobserver agreement) and for peripheral distribution (κ = 0.34 and κ = 0.35 for interobserver and intraobserver agreement, respectively). The agreement was also fair for peribronchial thickening (κ = 0.21 and κ = 0.30 for interobserver and intraobserver agreement, respectively). There was fair interobserver and intraobserver agreement on the detection of opacities (κ = 0.39 and 71.9%, respectively), ground-glass attenuation (64.3% and κ = 0.24, respectively), and cysts/bullae (κ = 0.47 and κ = 0.44, respectively). Qualitative analysis of the HRCT findings of bronchiectasis and the resulting individual patient scores showed that there was an excellent correlation between the observers (intraclass correlation coefficient of 0.85 and 0.81 for interobserver and intraobserver agreement, respectively). Conclusion: In the interpretation of HRCT findings of bronchiectasis, radiologist agreement appears to be fair. In our final analysis of the findings using the proposed score, we observed excellent interobserver and intraobserver agreement.

Resumo Objetivo: Avaliar a concordância entre radiologistas na quantificação de bronquiectasias pela tomografia computadorizada de alta resolução (TCAR). Materiais e Métodos: Foram avaliadas TCARs de 43 pacientes com bronquiectasias. Os achados foram graduados segundo um escore, e os valores de kappa (κ) e concordância geral foram calculados. Resultados: Para o tamanho e a aparência das bronquiectasias, houve concordância moderada interobservador (κ = 0,45 e κ = 0,43, respectivamente) e intraobservador (κ = 0,54 e κ = 0,47, respectivamente). Para a presença de impactação mucoide, a concordância foi mediana (central: concordância geral de 68,3% interobservador e κ = 0,39 intraobservador; periférica: κ = 0,34 interobservador e κ = 0,35 intraobservador). Para espessamento brônquico, a concordância foi mediana (κ = 0,21 interobservador e κ = 0,30 intraobservador). Na análise de opacidades, vidro fosco e cistos/bolhas, a concordância foi mediana (κ = 0,39, concordância geral de 64,3% e κ = 0,47 interobservador e concordância geral de 71,9%, κ = 0,24 e κ = 0,44 intraobservador, respectivamente). Após análise qualitativa dos achados de bronquiectasias na TCAR, realizou-se um escore final para cada paciente, com excelente correlação entre os observadores (coeficiente de correlação intraclasse de 0,85 interobservador e 0,81 intraobservador). Conclusão: Os achados tomográficos de bronquiectasias apresentaram concordância regular entre os observadores. Na análise final dos achados, foi encontrada excelente correlação entre os observadores e na avaliação do mesmo observador.

Thoracic lymphadenopathy in benign diseases: A state of the art review.

Lymphadenopathy is a common radiological finding in many thoracic diseases and may be caused by a variety of infectious, inflammatory, and neoplastic conditions. This review aims to describe the patterns of mediastinal and hilar lymphadenopathy found in benign diseases in immunocompetent patients. Computed tomography is the method of choice for the evaluation of lymphadenopathy, as it is able to demonstrate increased size of individual nodes, abnormalities of the interface between the mediastinum and lung, invasion of surrounding fat, coalescence of adjacent nodes, obliteration of the mediastinal fat, and hypo- and hyperdensity in lymph nodes. Intravenous contrast enhancement may be needed to help distinguish nodes from vessels. The most frequent infections resulting in this finding are tuberculosis and fungal disease (particularly histoplasmosis and coccidioidomycosis). Sarcoidosis is a relatively frequent cause of lymphadenopathy in young adults, and can be distinguished from other diseases - especially when enlarged lymph nodes are found to be multiple and symmetrical. Other conditions discussed in this review are silicosis, drug reactions, amyloidosis, heart failure, Castleman's disease, viral infections, and chronic obstructive pulmonary disease.