Complications of lung transplantation on computed tomography: pictorial essay.

Lung transplantation is becoming increasingly more common as an alternative treatment for end-stage lung disease. Despite advances in laboratory testing, surgical technique, and donor/recipient selection, lung transplantation is still associated with significant mortality, due to postoperative complications. This paper consists of a brief review of postoperative complications in lung transplant recipients, illustrating those complications with computed tomography images.

Transplantes pulmonares são procedimentos progressivamente mais realizados em todo o mundo como opção para tratamento de doenças pulmonares em estágio terminal. Apesar dos avanços laboratoriais, da técnica cirúrgica e da seleção de doadores e receptores, a mortalidade nesses procedimentos ainda é significativa, em razão de complicações típicas dos pacientes transplantados. Este trabalho consiste em uma revisão da literatura acerca do tema, ilustrando as complicações abordadas por meio de imagens de tomografia computadorizada.

Caecal appendix lipomatosis in a pregnant patient mimicking acute appendicitis.

A 34-years-old pregnant woman admitted in the emergency unit complaining about worsening right iliac fossa pain for 2 days. Acute appendicitis was the suspected diagnosis. Laboratory exams were ordered and results were within normal limits for infectious and inflammatory aspects. Ultrasound scan revealed a pregnancy in course without alterations and a thickness of the appendix wall without inflammatory signs in the surrounding tissue. Because the suspicion of acute appendicitis remained, a magnetic resonance was done and confirmed the diagnosis of a cecal appendix lipomatosis.

LDCT lung cancer screening in populations at different risk for lung cancer.

INTRODUCTION: The improvement of low-dose CT (LDCT) lung cancer screening selection criteria could help to include more individuals who have lung cancer, or in whom lung cancer will develop, while avoiding significant cost increase. We evaluated baseline results of LDCT lung cancer screening in a population with a heterogeneous risk profile for lung cancer. METHODS: LDCT lung cancer screening was implemented alongside a preventive health programme in a private hospital in Brazil. Individuals older than 45 years, smokers and former smokers, regardless of tobacco exposure, were included. Patients were classified according to the National Lung Screening Trial (NLST) eligibility criteria and to PLCOm2012 6-year lung cancer risk. Patient characteristics, CT positivity rate, detection rate of lung cancer and false-positive rate were assessed. RESULTS: LDCT scans of 472 patients were evaluated and three lung adenocarcinomas were diagnosed. CT positivity rate (Lung-RADS 3/4) was significantly higher (p=0.019) in the NLST group (10.1% (95% CI, 5.9% to 16.9%)) than in the non-NLST group (3.6% (95% CI, 2.62% to 4.83%)) and in the PLCOm2012 high-risk group (14.3% (95% CI, 6.8% to 27.7%)) than in the PLCOm2012 low-risk group (3.7% (95% CI, 2.9% to 4.8%)) (p=0.016). Detection rate of lung cancer was also significantly higher (p=0.018) among PLCOm2012 high-risk patients (5.7% (95% CI, 2.5% to 12.6%)) than in the PLCOm2012 low-risk individuals (0.2% (95% CI, 0.1% to 1.1%)). The false-positive rate for NLST criteria (16.4% (95% CI, 13.2% to 20.1%)) was higher (p<0.001) than for PLCOm2012 criteria (7.6 (95% CI, 5.3% to 10.5%)). DISCUSSION: Our study indicates a lower performance when screening low-risk individuals in comparison to screening patients meeting NLST criteria and PLCOm2012 high-risk patients. Also, incorporating PLCOm2012 6-year lung cancer risk ≥0.0151 as an eligibility criterion seems to increase lung cancer screening effectiveness.

COVID-19 findings identified in chest computed tomography: a pictorial essay.

The disease caused by the new coronavirus, or COVID-19, has been recently described and became a health issue worldwide. Its diagnosis of certainty is given by polymerase chain reaction. High-resolution computed tomography, however, is useful in the current context of pandemic, especially for the most severe cases, in assessing disease extent, possible differential diagnoses and searching complications. In patients with suspected clinical symptoms and typical imaging findings, in which there is still no laboratory test result, or polymerase chain reaction is not available, the role of this test is still discussed. In addition, it is important to note that part of the patients present false-negative laboratory tests, especially in initial cases, which can delay isolation, favoring the spread of the disease. Thus, knowledge about the COVID-19 and its imaging manifestations is extremely relevant for all physicians involved in the patient care, clinicians or radiologists.

The role of magnetic resonance imaging in Ménière disease: the current state of endolymphatic hydrops evaluation.

Technical advances in magnetic resonance imaging have allowed to accurately detect and grade endolymphatic space distension in Ménière disease; this was only possible in post-mortem histological studies until a few years ago. Magnetic resonance imaging rules out other causes of vertigo and hearing loss, and is able to evaluate the cochlear and vestibular compartments of the endolymphatic space using a dedicated protocol.

67Ga Scintigraphy for Assessment of Disease Severity and Treatment Response in Patients With Paracoccidioidomycosis.

OBJECTIVE: The evaluation of therapy response of patients with deep mycosis is a major challenge. The aim of this study was to assess the severity of disease at admission and evaluate treatment response of patients with paracoccidioidomycosis using Ga scintigraphy. SUBJECTS AND METHODS: Seventy-three patients with fully active disease were enrolled. A scoring system based on clinicoradiological and serological evaluation and Ga scan was devised. Pretherapy Ga score of 73 patients was compared with clinicoradiological and serological scores. A subgroup of 23 patients was followed up during treatment, and the rates of improvement of their clinicoradiological, serological, and Ga scores during treatment were compared at 3 time points (fully active phase, after clinical improvement, and clinically inactive disease). RESULTS: The correlations between scores before therapy were statistically significant. Ga score correlated with clinical score (r = 0.47, P < 0.001). Serological score correlated with both Ga and clinical scores (r = 0.32, P = 0.006, and r = 0.25, P = 0.034, respectively). Concerning evaluation of therapy response, clinicoradiological, serological, and Ga scores decreased significantly after therapy (P < 0.001). Notably, Ga score was the single one to become negative in most patients at the end of treatment (20 of 23 patients compared with 7 on clinicoradiological evaluation and 10 on serology, P = 0.003). CONCLUSIONS: In patients with paracoccidioidomycosis, pretherapy Ga scintigraphy correlates with disease severity. Serial Ga scans seem to be helpful in evaluating the response to therapy.

Ultrasound evaluation of inguinoscrotal pain: an imaging-based review for the ultrasonographer.

Emergencies involving the inguinal region and scrotum are common and can be caused by a plethora of different causes. In most cases, such conditions have nonspecific symptoms and are quite painful. Some inguinoscrotal conditions have high complication rates. Early and accurate diagnosis is therefore imperative. Ultrasound is the method of choice for the initial evaluation of this vast range of conditions, because it is a rapid, ionizing radiation-free, low-cost method. Despite the practicality and accuracy of the method, which make it ideal for use in emergency care, the examiner should be experienced and should be familiarized with the ultrasound findings of the most common inguinoscrotal diseases. On the basis of that knowledge, the examiner should also be able to make an accurate, direct, precise report, helping the emergency room physician make decisions regarding the proper (clinical or surgical) management of each case. Here, we review most of the inguinoscrotal conditions, focusing on the imaging findings and discussing the critical points for the appropriate characterization of each condition.

Complicações dos transplantes pulmonares na tomografia computadorizada: ensaio iconográfico / Complications of lung transplantation on computed tomography: pictorial essay

Resumo Transplantes pulmonares são procedimentos progressivamente mais realizados em todo o mundo como opção para tratamento de doenças pulmonares em estágio terminal. Apesar dos avanços laboratoriais, da técnica cirúrgica e da seleção de doadores e receptores, a mortalidade nesses procedimentos ainda é significativa, em razão de complicações típicas dos pacientes transplantados. Este trabalho consiste em uma revisão da literatura acerca do tema, ilustrando as complicações abordadas por meio de imagens de tomografia computadorizada.

Abstract Lung transplantation is becoming increasingly more common as an alternative treatment for end-stage lung disease. Despite advances in laboratory testing, surgical technique, and donor/recipient selection, lung transplantation is still associated with significant mortality, due to postoperative complications. This paper consists of a brief review of postoperative complications in lung transplant recipients, illustrating those complications with computed tomography images.

68Ga-DOTATATE PET/CT in Nonneuroendocrine Tumors: A Pictorial Essay.

PET-CT with somatostatin analogs labeled with Ga is increasingly recognized as the best imaging modality for the evaluation of well-differentiated neuroendocrine tumors (NETs). However, somatostatin receptor (SSR) is not an exclusive marker for NET. A variety of tumors other than NETs express SSR, leading to a significant risk of false-positive PET/CT results. We illustrate false-positive Ga-DOTATATE PET/CT findings due to high uptake by non-Hodgkin lymphoma, metastatic meningioma, breast cancer, thyroid adenoma, and papillary carcinoma. Although Ga-DOTATATE is a noteworthy tracer for oncological application, pathological conditions with overexpression of SSR should be recognized to prevent misinterpretation of PET/CT images.

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.

Advances in lung ultrasound.

Ultrasound examination of the chest has advanced in recent decades. This imaging modality is currently used to diagnose several pathological conditions and provides qualitative and quantitative information. Acoustic barriers represented by the aerated lungs and the bony framework of the chest generate well-described sonographic artifacts that can be used as diagnostic aids. The normal pleural line and A, B, C, E and Z lines (also known as false B lines) are artifacts with specific characteristics. Lung consolidation and pneumothorax sonographic patterns are also well established. Some scanning protocols have been used in patient management. The Blue, FALLS and C.A.U.S.E. protocols are examples of algorithms using artifact combinations to achieve accurate diagnoses. Combined chest ultrasonography and radiography are often sufficient to diagnose and manage lung and chest wall conditions. Chest ultrasonography is a highly valuable diagnostic tool for radiologists, emergency and intensive care physicians. RESUMO O exame ultrassonográfico do tórax avançou nas últimas décadas, sendo utilizado para o diagnóstico de inúmeras condições patológicas, e fornecendo informações qualitativas e quantitativas. Os pulmões aerados e o arcabouço ósseo do tórax representam barreira sonora para o estudo ultrassonográfico, gerando artefatos que, bem conhecidos, são utilizados como ferramentas diagnósticas. Eco pleural normal, linhas A, linhas B, linhas C, linhas E e Z (conhecidas como falsas linhas B) são artefatos com características peculiares. Os padrões de consolidação e de pneumotórax também são bem estabelecidos. Alguns protocolos têm sido utilizados no manuseio dos pacientes: Blue Protocol, Protocolo FALLS e Protocolo C.A.U.S.E são exemplos de três propostas que, por meio da associação entre os artefatos, permitem sugerir diagnósticos precisos. A ultrassonografia de tórax, aliada à radiografia de tórax, muitas vezes é suficiente para o diagnóstico e a conduta das afecções pulmonares e da parede torácica. Trata-se de ferramenta diagnóstica de grande valia para médicos radiologistas, emergencistas e intensivistas.

Correlation of Thyroid Imaging Reporting and Data System [TI-RADS] and fine needle aspiration: experience in 1,000 nodules.

OBJECTIVE: To correlate the Thyroid Imaging Reporting and Data System (TI-RADS) and the Bethesda system in reporting cytopathology in 1,000 thyroid nodules. METHODS: A retrospective study conducted from November 2011 to February 2014 that evaluated 1,000 thyroid nodules of 906 patients who underwent ultrasound exam and fine needle aspiration. RESULTS: A significant association was found between the TI-RADS outcome and Bethesda classification (p<0.001). Most individuals with TI-RADS 2 or 3 had Bethesda 2 result (95.5% and 92.5%, respectively). Among those classified as TI-RADS 4C and 5, most presented Bethesda 6 (68.2% and 91.3%, respectively; p<0.001). The proportion of malignancies among TI-RADS 2 was 0.8%, and TI-RADS 3 was 1.7%. Among those classified as TI-RADS 4A, proportion of malignancies was 16.0%, 43.2% in 4B, 72.7% in 4C and 91.3% among TI-RADS 5 (p<0.001), showing clear association between TI-RADS and biopsy results. CONCLUSION: The TI-RADS is appropriate to assess thyroid nodules and avoid unnecessary fine needle aspiration, as well as to assist in making decision about when this procedure should be performed. OBJETIVO: Apresentar a correlação entre o Thyroid Imaging Reporting and Data System (TI-RADS) e o sistema Bethesda, para relatar citopatologia em 1.000 nódulos tireoidianos. MÉTODOS: Estudo retrospectivo realizado no período de novembro de 2011 a fevereiro de 2014, que avaliou 1.000 nódulos tireoidianos de 906 pacientes submetidos a exame de ultrassonografia e à punção aspirativa por agulha fina. RESULTADOS: Observou-se associação significativa entre o TI-RADS e o resultado da classificação de Bethesda (p<0,001). A maioria dos indivíduos com TI-RADS 2 ou 3 teve resultado citológico Bethesda 2 (95,5% e 92,5%, respectivamente). Entre aqueles classificados TI-RADS 4C e 5, a maioria teve resultado Bethesda 6 (68,2% e 91,3%, respectivamente; p<0,001). A proporção de malignidades em TI-RADS 2 foi 0,8% e em TI-RADS 3 foi 1,7%. Entre TI-RADS 4A, foi de 16,0%, 43,2% em 4B, 72,7% em 4C e em 5 foi de 91,3% (p<0,001), mostrando clara associação entre o TI-RADS e os resultados da biópsia. CONCLUSÃO: O TI-RADS é apropriado para avaliar nódulos da tireoide e evitar punção aspirativa por agulha fina desnecessária, além de auxiliar na decisão sobre quando este procedimento deve ser realizado.

Caecal appendix lipomatosis in a pregnant patient mimicking acute appendicitis / Lipomatose do apêndice cecal em paciente grávida mimetizando apendicite aguda

ABSTRACT A 34-years-old pregnant woman admitted in the emergency unit complaining about worsening right iliac fossa pain for 2 days. Acute appendicitis was the suspected diagnosis. Laboratory exams were ordered and results were within normal limits for infectious and inflammatory aspects. Ultrasound scan revealed a pregnancy in course without alterations and a thickness of the appendix wall without inflammatory signs in the surrounding tissue. Because the suspicion of acute appendicitis remained, a magnetic resonance was done and confirmed the diagnosis of a cecal appendix lipomatosis.

RESUMO Paciente de 34 anos, do sexo feminino, grávida, chega ao pronto-socorro com queixa de dor na fossa ilíaca direita piorando nos últimos 2 dias com suspeita de apendicite aguda. Foram solicitados exames laboratoriais, que estavam dentro dos limites de normalidade para aspectos infecciosos e inflamatórios. Exame de imagem também foi solicitado, sendo a ultrassonografia o método de escolha, que revelou gravidez em curso sem alterações e espessura da parede do apêndice sem sinais inflamatórios. Ainda com suspeita de apendicite aguda, foi realizada ressonância magnética, confirmando a hipótese de lipomatose do apêndice cecal.

COVID-19 findings identified in chest computed tomography: a pictorial essay / Achados da COVID-19 identificados na tomografia computadorizada de tórax: ensaio pictórico

ABSTRACT The disease caused by the new coronavirus, or COVID-19, has been recently described and became a health issue worldwide. Its diagnosis of certainty is given by polymerase chain reaction. High-resolution computed tomography, however, is useful in the current context of pandemic, especially for the most severe cases, in assessing disease extent, possible differential diagnoses and searching complications. In patients with suspected clinical symptoms and typical imaging findings, in which there is still no laboratory test result, or polymerase chain reaction is not available, the role of this test is still discussed. In addition, it is important to note that part of the patients present false-negative laboratory tests, especially in initial cases, which can delay isolation, favoring the spread of the disease. Thus, knowledge about the COVID-19 and its imaging manifestations is extremely relevant for all physicians involved in the patient care, clinicians or radiologists.

RESUMO A doença causada pelo novo coronavírus, ou COVID-19, foi descrita recentemente e tornou-se uma questão de saúde mundial. Seu diagnóstico de certeza é dado pela reação em cadeia da polimerase. A tomografia computadorizada de alta resolução, entretanto, mostra-se útil no contexto atual de pandemia, especialmente nos casos mais graves, na avaliação da extensão da doença, em possíveis diagnósticos diferenciais e na pesquisa de complicações. Em pacientes com quadro clínico suspeito e achados de imagem típicos, nos quais ainda não há resultado laboratorial ou a reação em cadeia da polimerase não se encontra disponível, ainda se discute o papel desse exame. Importante ressaltar que parte dos pacientes apresenta exames laboratoriais falsos-negativos, notadamente em casos iniciais, o que pode retardar medidas de isolamento, favorecendo a propagação da doença. Dessa forma, o conhecimento da COVID-19 e de suas manifestações nos exames de imagem é de extrema importância para os médicos envolvidos no atendimento, sejam clínicos ou radiologistas.

Reduction of poor contrast enhancement of the pulmonary artery in computed tomography angiography using an alternative respiratory maneuver.

PURPOSE: The aim of the study was to compare the effects of different respiratory maneuvers in computed tomography pulmonary angiography for the diagnosis of pulmonary embolism (PE) on the contrast enhancement of pulmonary circulation and on the quality of lung window images. MATERIALS AND METHODS: A retrospective analysis of 520 examinations, half obtained after deep inspiration followed by breath-holding and half solely during breath-holding. Subjective quality analyses and objective measurements of pulmonary arterial enhancement and lung parenchyma attenuation were performed. RESULTS: Elimination of deep inspiration reduced suboptimal opacification of the pulmonary artery (PA), from 7.3% to 2.7%, with 2.7% of the deep inspiration scans having attenuation values <150 Hounsfield units (HU). The prevalence of PE was similar between the groups (19% vs. 23%, respectively), with excellent interobserver diagnostic agreement (κ=0.89 to 0.91). Lung windows were compromised in 6.9% of the studies with respiratory pause, and these examinations had a higher attenuation of the lung parenchyma (median: -709.8 HU) compared with deep inspiration (-794.8 HU). A positive correlation between attenuation of the PA and the ascending aorta was observed (r=0.40 to 0.56). CONCLUSIONS: Eliminating deep inspiration before image acquisition had opposite effects with the same magnitude: it caused a reduction in inadequate PA enhancement at the cost of an increased number of nondiagnostic lung images and did not compromise diagnostic consistency for PE.

Bullet embolism of pulmonary artery: a case report.

The authors report the case of a patient victim of gunshots, with a very rare complication: venous bullet embolism from the left external iliac vein to the lingular segment of the left pulmonary artery. Diagnosis is made with whole-body radiography or computed tomography. Digital angiography is reserved for supplementary diagnosis or to be used as a therapeutic procedure.

Relatamos o caso de um paciente vítima de tiros por arma de fogo e com uma rara complicação: embolia venosa de um projétil desde a veia ilíaca externa esquerda até o ramo lingular da artéria pulmonar esquerda. Radiografias de corpo inteiro ou tomografia computadorizada do corpo inteiro devem ser utilizadas. Angiografia digital fica reservada para complementação diagnóstica ou como procedimento terapêutico.