2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension

Guidelines summarize and evaluate all available evidence on a particular issue at the time of the writing process, with the aim of assisting health professionals in selecting the best management strategies for an individual patient with a given condition, taking into account the impact on outcome, as well as the risk–benefit ratio of particular diagnostic or therapeutic means. Guidelines and recommendations should help health professionals to make decisions in their daily practice. However, the final decisions concerning an individual patient must be made by the responsible health professional(s) in consultation with the patient and caregiver as appropriate.

Structured multidisciplinary discussion of HRCT scans for IPF/UIP diagnosis may result in indefinite outcomes

Recent ATS/ERS/JRS/ALAT guidelines for the diagnosis and management of Idiopathic Pulmonary Fibrosis (IPF) have defined key features and specific high-resolution computerized tomography (HRCT) patterns for the diagnosis of UIP. The aim is the sorting of patients with suspected IPF into three subgroups, confident, possible or inconsistent with UIP patterns, after a multidisciplinary discussion (MDD). Specialists in respiratory diseases, radiologists and pathologists should reach IPF diagnosis based on either patients' clinical, radiological and laboratory data, either submitting patients to surgical biopsy. After ATS/ERS/JRS/ALAT recommendations have been applied, it has been identified a subgroup of patients showing uniform apical-basal distribution of honeycombing and reticular abnormalities that could not be categorized as confident, or possible nor inconsistent with UIP. These patients were subsequently diagnosed with IPF after MDD and lung biopsy. Inclusion of this pattern in the recommendation for IPF diagnosis would be worth considering.

The Senile Lung as a Possible Source of Pitfalls on Chest Ultrasonography and Computed Tomography

BACKGROUND

Age-associated changes in the pulmonary system could be detected with imaging techniques. Widespread use of lung ultrasonography (US) requires characterization of a normal pattern.

OBJECTIVES

To compare US and computed tomography (CT) findings in healthy subjects undergoing both techniques (with CT as the gold standard).

METHODS

We prospectively selected 59 subjects undergoing chest CT and US on the same day, without a history of smoking, respiratory symptoms, or known pulmonary pathologies. There were 44 patients in group 1 (age ≥60 years - elderly) and 15 patients in group 2 (age ≤50 years - young). Lung US was performed with a convex and a linear probe, and 10 chest areas per patient were analyzed. Convex and linear probe agreement was evaluated by means of the Cohen κ statistic; Fisher's exact test was used to compare categorical variables between groups.

RESULTS

Isolated B-lines were frequent in both group 1 (54.5%) and group 2 (40.0%); the number of chest areas positive for B-lines increased with age (16.1% in group 1 vs. 5.3% in group 2, p = 0.0028). In group 2, we found that 37.5% of subjects with B-lines had at least 1 chest area with multiple B-lines, but only 2 subjects had 2 or more. Moreover, in group 1 the chest CT documented a reticular pattern (2.3%), areas of increased density (9.1%), ground glass (6.8%), cysts (2.3%), bronchiectasis (22.7%), and bronchial thickening (6.8%); in group 2, only cysts (6.7%) and bronchiectasis (6.7%) were found.

CONCLUSIONS

The senile lung is characterized by mild changes on CT and US. Chest areas positive for B-lines increase with age, and focal multiple B-lines can be found. However, diffuse patterns, especially in symptomatic subjects, suggest a different diagnosis.

Sonography of the normal lung: Comparison between young and elderly subjects

BACKGROUND

The senile lung undergoes physiologic changes that are well known but have not been investigated with ultrasound (US). Thus, the aim of our study was to compare the US appearances of the lungs in a group of healthy, nonsmoker elderly subjects with those in a group of young subjects.

METHODS

One hundred elderly subjects older than 65 years of age (mean age ± SD, 79 ± 7 years) and 50 younger subjects less than 56 years of age (mean age ± SD, 33 ± 12) underwent US examination of the lungs. We analyzed the anterior, midlateral, and posterobasal surface of each lung to evaluate the presence or absence of A-lines and B-lines. Fisher's exact test and Pearson's χ² test were used to compare the findings in the two groups.

RESULTS

A-lines were absent in 94/100 (94%) elderly subjects versus 2/50 (4%) young subjects (p < 0.0001). B-lines were found in 37/100 (37%) elderly subjects: ≤3 lines per field of view in 27/37 (73%); >3 lines in 2/37 (5%); both ≤3 lines and >3 lines (depending on the region scanned) in 8/37 (22%). In contrast, only in 5/50 (10%) young subjects were B-lines visible (≤3 lines per field of view in all cases [p < 0.001]).

CONCLUSIONS

The majority of the elderly subjects did not have A-lines, and B-lines were observed in a high percentage. The reduction of impedance between lung parenchyma and soft tissues of the chest wall and the increased thickness of interlobular septa might explain these results. © 2014 Wiley Periodicals, Inc. J Clin Ultrasound 43:230-234, 2015.

Endovascular treatment of an aortic traumatic double rupture

Traumatic thoracic aortic rupture is a life-threatening condition; aortic isthmus is the most common site of rupture, but in rare cases traumatic injury can localize elsewhere, such as at aortic arch or at the level of the diaphragm. In the past few years, endovascular treatment of traumatic aortic injury became a safe procedure, with lower mortality and complication, if compared with open surgery. We report a case of a 40-year-old-man admitted to emergency department after a violent car crash in which an aortic traumatic double rupture was successfully treated with two endovascular stent-grafts coverage.

HFE gene variants and iron-induced oxygen radical generation in idiopathic pulmonary fibrosis

In idiopathic pulmonary fibrosis (IPF), lung accumulation of excessive extracellular iron and macrophage haemosiderin may suggest disordered iron homeostasis leading to recurring microscopic injury and fibrosing damage. The current study population comprised 89 consistent IPF patients and 107 controls. 54 patients and 11 controls underwent bronchoalveolar lavage (BAL). Haemosiderin was assessed by Perls' stain, BAL fluid malondialdehyde (MDA) by high-performance liquid chromatography, BAL cell iron-dependent oxygen radical generation by fluorimetry and the frequency of hereditary haemochromatosis HFE gene variants by reverse dot blot hybridisation. Macrophage haemosiderin, BAL fluid MDA and BAL cell unstimulated iron-dependent oxygen radical generation were all significantly increased above controls (p<0.05). The frequency of C282Y, S65C and H63D HFE allelic variants was markedly higher in IPF compared with controls (40.4% versus 22.4%, OR 2.35, p=0.008) and was associated with higher iron-dependent oxygen radical generation (HFE variant 107.4±56.0, HFE wild type (wt) 59.4±36.4 and controls 16.7±11.8 fluorescence units per 10(5) BAL cells; p=0.028 HFE variant versus HFE wt, p=0.006 HFE wt versus controls). The data suggest iron dysregulation associated with HFE allelic variants may play an important role in increasing susceptibility to environmental exposures, leading to recurring injury and fibrosis in IPF.

Overview of current lung imaging in acute respiratory distress syndrome

Imaging plays a key role in the diagnosis and follow-up of acute respiratory distress syndrome (ARDS). Chest radiography, bedside lung ultrasonography and computed tomography scans can provide useful information for the management of patients and detection of prognostic factors. However, imaging findings are not specific and several possible differential diagnoses should be taken into account. Herein we will review the role of radiological techniques in ARDS, highlight the plain radiological and computed tomography findings according to the pathological stage of the disease (exudative, inflammatory and fibroproliferative), and summarise the main points for the differential diagnosis with cardiogenic oedema, which is still challenging in the acute stage.

Non-small cell lung cancer after surgery and chemoradiotherapy: follow-up and response assessment

The imaging techniques in patients treated for lung cancer may be challenging to interpret. Radiologists are often asked to evaluate computed tomography (CT) scans after surgery, and this interpretation requires an understanding of both the timing and type of the surgical procedure. However, follow-up strategies are still not well defined. The assessment of tumor response to chemoradiotherapy relies on a tight integration of CT and clinical findings. Positron emission tomography-computed tomography (PET-CT) with fluorodeoxyglucose may help to exclude tumor recurrence when the sole CT scan is equivocal. More efforts are needed to validate the tools for volumetric tumor measurement in routine practice and to demonstrate their superiority compared to the Response Evaluation Criteria in Solid Tumors (RECIST). Familiarity with the assessment of lung cancer perfusion is also important because of the increasing use of cytostatic therapy. In this review, we outlined the imaging assessment of tumor recurrence after surgery and the role of CT, magnetic resonance imaging, and PET-CT in the follow-up after chemotherapy, radiotherapy, and radiofrequency ablation.

Rare causes of pulmonary hypertension: spectrum of radiological findings and review of the literature

Following a brief introduction covering the clinical signs and symptoms of pulmonary hypertension (PH), its most recent classification into six groups, and the computed tomography (CT) features common to all forms of PH, this paper illustrates the typical patterns that can be found on chest radiography and CT in rare causes of PH. We present and compare with the existing literature our personal series of cases of rare forms of PH, found in the following diseases: veno-occlusive disease, pulmonary capillary haemangiomatosis, non-thrombotic pulmonary embolism (tumour embolism and carcinomatous lymphangitis, talcosis, hydatid disease), pulmonary artery sarcoma, neurofibromatosis, sarcoidosis, and Langerhans cell histiocytosis. Rare forms of PH show low incidence and prevalence, and are, therefore, poorly recognised. Their diagnosis is a challenge for clinicians, pathologists, and radiologists, and any additional knowledge about the CT findings may help the diagnosis in the case of patients affected by PH of unknown origin.

Predictive factors of diagnostic accuracy of CT-guided transthoracic fine-needle aspiration for solid noncalcified, subsolid and mixed pulmonary nodules

PURPOSE

The aim of this study was to analyse factors predicting the diagnostic accuracy of computed tomography (CT)-guided transthoracic fine-needle aspiration (TTFNA) for solid noncalcified, subsolid and mixed pulmonary nodules, with particular attention to those responsible for false negative results with a view to suggesting a method for their correction.

MATERIALS AND METHODS

From January 2007 to March 2010, we retrospectively reviewed the CT images of 198 patients of both sexes (124 males and 74 females; mean age, 70 years; range age, 44-90) used for the guidance of TTFNA of pulmonary nodules. Aspects considered were: lesion size and density, distance from the pleura, and lesion site. Multiplanar reformatted images (MPR) were retrospectively obtained in the sagittal and axial oblique planes relative to needle orientation.

RESULTS

The overall diagnostic accuracy of TTFNA CT-guided biopsy was 86% for nodules between 0.7 and 3 cm, 83.3% for those between 0.7 and 1.5 cm, and 92% for those between 2 and 3 cm. Accuracy was 95.1% for solid pulmonary nodules, 84.6% for mixed nodules, and 66.6% for subsolid nodules. The diagnostic accuracy of CT-guided TTFNA in relation to the distance between the nodule and the pleural plane was 95.6% for lesions adhering to the pleura and 83.5% for central ones. The diagnostic accuracy was 84.2% for the pulmonary upper lobe nodules, 85.3% for the lower lobe and 90.9% for those in the lingula and middle lobe. In 75% of false negative and inadequate/insufficient cases the needle was found to lie outside the lesion, after reconstruction of the needle path by MPR.

CONCLUSIONS

The positive predictive factors of CT-guided TTFNA are related to the nodule size, density and distance from the pleural plane. The most common negative predictive factor of CT-guided TTFNA is the wrong position of the needle tip, as observed in the sagittal and axial oblique sections of the MPR reconstructions. The diagnostic accuracy of CT-guided TTFNA can therefore be improved by using the MPR technique to plan the needle path during the FNA procedure.

Pulmonary artery intimal sarcoma. Problems in the differential diagnosis

PURPOSE

Pulmonary artery sarcomas (PAS) are rare malignant tumours that originate from the intimal layer of the pulmonary artery, occur in middle age and have a poor prognosis. In planning appropriate treatment, malignant disease should be suspected whenever there are specific clinical and radiological manifestations, in order to establish the differential diagnosis with acute pulmonary embolism or chronic thromboembolic pulmonary hypertension, with which this malignancy is most commonly confused.

MATERIALS AND METHODS

Between 2008 and 2012, we managed four adult patients with a nonspecific clinical presentation who, at the conclusion of the diagnostic process, were found to be affected by PAS. Because of the initial suspicion of pulmonary embolism, all patients underwent chest radiograph, lung perfusion scintigraphy, trans-oesophageal echocardiography, and computed tomography (CT) angiography of the chest. Then, because of the peculiar CT findings and lack of response to anticoagulation therapy, a clinical suspicion of PAS was considered and all patients underwent positron-emission tomography (PET)-CT, and one patient also magnetic resonance imaging (MRI) of the chest. Subsequently, all patients underwent thromboendoarterectomy with histological investigation of the surgical specimen, which confirmed the clinical and radiological suspicion of PAS.

RESULTS

CT is the technique that enabled the first step in the differential diagnosis between PAS and pulmonary embolism. The CT characteristics suggestive of PAS included the particular filling defect occupying the entire lumen of the pulmonary trunk with increase in diameter of the involved vessel and patchy and delayed contrast enhancement at CT angiography, more evident in the venous phase. PET-CT was used to differentiate between PAS and pulmonary embolism on the basis of the intensity of increased radiopharmaceutical uptake. MRI was used in one case of equivocal results on PET-CT, to improve tissue characterisation of the lesions and differentiation between the thrombotic and neoplastic components.

CONCLUSIONS

The radiologist is usually the first to raise a suspicion of PAS in patients with severe dyspnoea and filling defect in the pulmonary artery, unresponsive to anticoagulation therapy. Combining CT and PET-CT proved to be extremely useful in assessing patients with suspected PAS. Early diagnosis with the help of integrated imaging remains today the main direction to pursue in order to obtain improvements in prognosis.

Increased mean lung density: another independent predictor of lung cancer?

OBJECTIVES

To investigate the relationship between emphysema phenotype, mean lung density (MLD), lung function and lung cancer by using an automated multiple feature analysis tool on thin-section computed tomography (CT) data.

METHODS

Both emphysema phenotype and MLD evaluated by automated quantitative CT analysis were compared between outpatients and screening participants with lung cancer (n=119) and controls (n=989). Emphysema phenotype was defined by assessing features such as extent, distribution on core/peel of the lung and hole size. Adjusted multiple logistic regression models were used to evaluate independent associations of CT densitometric measurements and pulmonary function test (PFT) with lung cancer risk.

RESULTS

No emphysema feature was associated with lung cancer. Lung cancer risk increased with decreasing values of forced expiratory volume in 1s (FEV1) independently of MLD (OR 5.37, 95% CI: 2.63-10.97 for FEV1<60% vs. FEV1≥90%), and with increasing MLD independently of FEV1 (OR 3.00, 95% CI: 1.60-5.63 for MLD>-823 vs. MLD<-857 Hounsfield units).

CONCLUSION

Emphysema per se was not associated with lung cancer whereas decreased FEV1 was confirmed as being a strong and independent risk factor. The cross-sectional association between increased MLD and lung cancer requires future validations.

Long-term surveillance of ground-glass nodules: evidence from the MILD trial

INTRODUCTION

The purpose of this study was to evaluate the natural evolution of ground-glass nodules (GGNs) in the Multicentric Italian Lung Detection (MILD) trial, which adopted a nonsurgical approach to this subset of lesions.

METHODS

From September 2005 to August 2007, 56 consecutive MILD participants with 76 GGNs were identified from 1866 individuals who underwent baseline low-dose computed tomography. The features of GGNs were assessed and compared with the corresponding repeat low-dose computed tomographies after a mean time of 50.26 ± 7.3 months. The GGNs were classified as pure (pGGN) or part-solid (psGGN) GGNs. The average of the maximum and the minimum diameters for both pGGNs and psGGNs and the maximum diameter of the solid portion of psGGNs were manually measured. At follow-up, GGNs were classified as follows: resolved, decreased, stable, or progressed (according to three defined growth patterns).

RESULTS

A total of 15 of 48 pGGNs (31.3%) resolved, 4 of 48 (8.3%) decreased in size, 21 of 48 (43.8%) remained stable, and 8 of 48 (16.7%) progressed. Among the psGGNs with a solid component smaller than 5 mm, 3 of 26 (11.5%) resolved, 11 of 26 (42.3%) remained stable, and 12 of 26 (46.2%) progressed. One of the two psGGNs with a solid component larger than 5 mm remained stable, and the other decreased in size. Four lung cancers were detected among the GGN subjects, but only one arose from a psGGN, and was resected in stage Ia.

CONCLUSIONS

The progression rate of the GGNs toward clinically relevant disease was extremely low in the MILD trial and supports an active surveillance attitude.