Metastatic pulmonary calcification: Experience from a single center in Singapore.

Metastatic pulmonary calcification (MPC) was seen in 79% of patients with end-stage renal disease (ESRD) during autopsy. However, it is not commonly diagnosed in vivo. Its pathogenesis is not fully understood. We report a retrospective series of 5 cases of MPC from a single center in Singapore. MPC were diagnosed using radiological or histological features. Mean onset of MPC from diagnosis of ESRD was 22.6 ± 3.1 years. One patient remains asymptomatic. Four patients died, one was related to MPC. All patients had calcifications at the lung apices on radiological studies. Three patients with MPC were diagnosed based on radiological features while 2 had histological features. Four patients underwent parathyroidectomy without radiological changes before parathyroidectomy. Median intact parathyroid hormone of this series was 5.6 pmol/L (IQR 1.3-139.4), alkaline phosphatase 74 U/L (IQR 62-461), calcium 2.10 mmol/L (IQR 1.85-2.40), and phosphate 1.30 mmol/L (IQR 0.87-1.63). The observed low iPTH suggests that MPC might occur in low iPTH. Our case series showed MPC might occur in low iPTH after parathyroidectomy, in contrast to existing literature that suggests MPC is diagnosed in patients with elevated iPTH. Parathyroidectomy does not prevent MPC.

Pictorial essay: Uncommon causes of coronary artery encasement.

This pictorial essay presents cases of non-atherosclerotic coronary artery encasement which were encountered in our institution, including malignant lymphoma, Erdheim-Chester disease, immunoglobulin G4 (IgG4)-related disease and Polyarteritis Nodosa. These conditions usually have multisystemic involvement which aid in the diagnosis. Awareness of these uncommon disorders and their ancillary findings can facilitate early, accurate diagnosis and appropriate management.

Fibred confocal fluorescence microscopy in the diagnosis of interstitial lung diseases.

BACKGROUND: Accurate diagnosis is critical to both therapeutic decisions and prognostication in interstitial lung diseases (ILD). However, surgical lung biopsies carry high complication rates. Fibred confocal fluorescence microscopy (FCFM) offers an alternative as it can visualize lung tissue in vivo at the cellular level with minimal adverse events. We wanted to investigate the diagnostic utility, and safety of using FCFM for patients with ILD. METHODS: In patients with suspected ILD, FCFM images were obtained from multiple bronchopulmonary segments using a miniprobe inserted through the working channel of a flexible bronchoscope. The procedure was performed under moderate sedation in an outpatient setting. Morphometric measurements and fibre pattern analyses were co-related with computed tomography (CT) findings and patients' final diagnoses based on multi-disciplinary consensus. RESULTS: One hundred and eighty four segments were imaged in 27 patients (18 males) with a median age of 67 years (range, 24-79 years). They were grouped into chronic fibrosing interstitial pneumonia (16 patients) and other ILDs. Six distinct FCFM patterns were observed: normal, increased fibres, densely packed fibres, hypercellular, thickened fibres and others/non-specific. The pattern resembling densely packed fibres was seen in at least one segment in 68.8% patients with chronic fibrosing interstitial pneumonia, but only 36.4% in other ILD (P=0.097). An association between inflammatory patterns on CT and a hypercellular pattern on FCFM was also found (P<0.001). CONCLUSIONS: Our study shows the potential of FCFM in classifying ILD, but its role in further diagnosis remains limited.

A breath from Houdini - A case of giant bullous emphysema.

We describe a case of a young man presenting with exertional dyspnea. His chest radiograph showed hyperlucency in his left lung, and he was subsequently diagnosed to have giant bullous emphysema. An approach to lesions of decreased attenuation on computed tomography of the chest, with a focus on cystic lung diseases is discussed. This is followed by a literature review of the clinical presentation, natural history, radiology and management of giant bullous emphysema. Although this is an uncommon condition, a clinician has to be cognizant of the fact that it may mimic other common respiratory diseases. This review highlights the importance of these caveats as misguided treatment options may lead to devastating consequences.

Imaging of lung transplantation: review.

OBJECTIVE Lung transplantation is an established treatment for end-stage pulmonary disease. Complications of lung transplantation include airway stenosis and dehiscence, reimplantation response, acute rejection, infection, posttransplantation lymphoproliferative disorder, and bronchiolitis obliterans syndrome. The incidence of graft rejection and airway anastomosis experienced in the early years of lung transplantation have been significantly reduced by advances in immunosuppression and surgical techniques. Infection is currently the most common cause of mortality during the first 6 months after transplantation, whereas chronic rejection or obliterative bronchiolitis is the most common cause of mortality thereafter. This article reviews the radiologic findings of different surgical techniques as well as the common early and late complications of lung transplantation. CONCLUSION Radiology plays a pivotal role in the diagnosis and management of complications of lung transplantation. Advancements in surgical technique and medical therapy influence the spectrum of expected radiologic findings. Familiarity with the radiologic appearances of common surgical techniques and complications of lung transplantation is important.

The use of computer-aided detection for the assessment of pulmonary arterial filling defects at computed tomographic angiography.

PURPOSE: To validate a computer-aided detection (CAD) tool for the detection of pulmonary arterial filling defects at computed tomographic pulmonary angiography (CTPA) and to assess its benefit for readers of different levels of experience. METHODS: One hundred consecutive CTPA studies were retrospectively evaluated by a chest radiologist for presence of emboli, serving as the reference standard. Subsequently, examinations were analyzed using commercially available second-generation CAD software (ImageChecker CT, version 2.1; R2 Technology, Inc., Sunnyvale, Calif). The staff radiologist assessed all CAD marks and classified them as true positive or false positive (FP), and any unmarked emboli were classified as false negative. Computer-aided detection software was also evaluated on a case basis compared with the reference standard.For the second part of the study, the 100 CTPAs were reviewed by 3 additional readers of different levels of experience, both without and with CAD, and findings correlated with the reference standard. RESULTS: Twenty-one studies (21%) were positive for pulmonary embolism. Of these, 18 were true positive on a case basis, and 3 were false negative. Of the 79 negative studies, 16 were true negative with no CAD marks, and the remaining 63 were FP. On a case basis, CAD sensitivity was 86%, specificity was 20%, negative predictive value was 84%, and positive predictive value (PPV) was 22%.Overall, the CAD software yielded 318 marks, identifying 64 of 93 emboli with an additional 254 FP marks. On a mark basis, sensitivity was 69%, and PPV was 20%.Computer-aided detection did not influence the most experienced reader (a chest fellow). Although CAD improved the subjective confidence of the second-year resident in some cases, it had no influence on overall interpretation or accuracy. Computer-aided detection improved accuracy only for the most inexperienced reader, helping this reader to identify 9 emboli not initially appreciated. CONCLUSIONS: Computer-aided detection specificity and PPV are poor due to expected FP marks, although, often, these can be easily dismissed. However, CAD software may play an important role as a second reader for residents or inexperienced readers.