Mediastinal and Hilar Lymph Node Measurements. Comparison of Multidetector-Row Computed Tomography and Endobronchial Ultrasound

The link between smoking, emphysema, and fibrosis: A retrospective cohort study

INTRODUCTION

The presence of emphysema is common in patients with interstitial lung disease (ILD), which is designated as combined pulmonary fibrosis and emphysema (CPFE). This study aimed to examine the association between smoking, emphysema, and fibrosis in ILD patients.

METHODS

A total of 800 patients hospitalized for ILD at the affiliated hospital of Qingdao University, Shandong, Qingdao, China, from December 2012 to December 2020 were included in our retrospective cohort study. Participants were divided into CPFE and non-CPFE groups. The patients' clinical presentations and radiographic and laboratory findings were reviewed and compared. The two groups were then divided and compared based on smoking status. Kaplan-Meier survival analysis with log-rank testing and multivariable Cox proportional hazards regression analysis were used to compare all-cause mortality.

RESULTS

Emphysema was present in 188 (23.5%) ILD patients. Smoking was associated with increased odds of CPFE (adjusted odds ratio, AOR=2.13; 95% CI: 1.33-3.41, p=0.002). The CPFE patients had a comparable risk of death to non-CPFE patients (adjusted hazard ratio, AHR=0.89; 95% CI: 0.64-1.24, p=0.493). Smoking was not a risk prognostic factor in the whole group (AHR=1.34; 95% CI: 0.90-1.99, p=0.152) or the CPFE group (AHR=0.90; 95% CI: 0.43-1.86, p=0.771). However, a significant prognostic difference between smokers and non-smokers was found in the non-CPFE group (AHR=1.62; 95% CI: 1.02-2.58, p=0.042). In ILD patients, smoking pack-years were weakly correlated with total centrilobular emphysema (CLE) scores and total fibrosis scores (TFS), but not with total emphysema scores (TES); TFS were weakly correlated with TES.

CONCLUSIONS

CPFE did not affect the prognosis of ILD. Smoking was a risk but not a prognostic factor for CPFE. However, smoking was associated with worse survival in non-CPFE patients. There was an intricate association among smoking, emphysema, and fibrosis in ILD patients.

Effect of contrast medium on early detection and analysis of mediastinal lymph nodes in computed tomography

OBJECTIVE

This study aimed to evaluate the diagnostic efficiency of contrast-to-noise and signal-to-noise ratios created by the contrast medium in detecting lymph nodes.

METHODS

In this study, 57 short-axis subcentimeter lymph nodes in 40 cardiac computed tomography patients with noncontrast- and contrast-enhanced phases were evaluated. The contrast-to-noise ratios and signal-to-noise ratios of noncontrast- and contrast-enhanced lymph node-mediastinal fat and aortic-mediastinal fat tissues were determined. In addition, lymph nodes in noncontrast- and contrast-enhanced series were evaluated subjectively.

RESULTS

There was a significant difference in lymph node-mediastinal fat signal-to-noise values between the contrast and noncontrast phases (p=0.0002). In the contrast phase, aortic density values were found to be 322.04±18.51 HU, lymph node density values were 76.41±23.41 HU, and mediastinal adipose tissue density values were -65.73±22.96 HU. Aortic-mediastinal fat contrast-to-noise ratio value was 20.23±6.92 and the lymph node-mediastinal fat contrast-to-noise ratio value was 6.43±2.07. A significant and moderate correlation was observed between aortic-mediastinal fat and lymph node-mediastinal fat contrast-to-noise ratio values in the contrast phase (r=0.605; p<0.001). In the contrast-enhanced series, there was a significant increase in the subjective detection of lymph nodes (p=0.0001).

CONCLUSION

In the detection of paratracheal lymph nodes, the contrast agent increases the detection of short-axis subcentimeter lymph nodes quantitatively and qualitatively. Contrast enhances and facilitates the detection of paratracheal lymph nodes.

Is Performance of Fluorine-18-fluorodeoxyglucose Positron Emission Tomography/Computed tomography (CT) or Contrast-enhanced CT Efficient Enough to Guide the Hilar Lymph Node Staging for Patients with Esophageal Squamous Cell Carcinoma?

Introduction

We evaluated the diagnostic performance of fluorine-18-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET)/computed tomography (CT) and contrast-enhanced CT in the detection of hilar lymph node metastasis (LNM) in esophageal squamous cell carcinoma (ESCC) to determine their value in guiding hilar lymph node staging and delineating radiation target volume.

Methods

Consecutive patients with ESCC who underwent both PET/CT and contrast-enhanced CT before radical lymphadenectomy and esophagectomy at our institution from September 2009 to November 2018 were enrolled. The sensitivity (SE), specificity (SP), positive predictive value (PPV), and negative predictive value (NPV) of FDG-PET/CT and contrast-enhanced CT for diagnosing hilar LNM were calculated.

Results

Of the 174 patients included, contrast-enhanced CT predicted nine positive cases, while PET/CT predicted one, and eight (4.6%) were identified as pathologically positive for their resected hilar lymph nodes. The SE, SP, PPV, and NPV of PET/CT and contrast-enhanced CT were 0.000, 0.994, 0.000, and 0.954; and 0.125, 0.952, 0.111, and 0.958, respectively. The specificity showed a significant difference (P=0.037). PET/CT is slightly more specific than contrast-enhanced CT.

Conclusions

PET/CT and contrast-enhanced CT may be useful tools for predicting the negativity of hilar LN status, but they are not recommended for guiding the hilar lymph node staging and the delineating of hilar LNM in radiotherapy planning of ESCC patients based on their low PPV.

Prognostic value of mediastinal lymph node enlargement in chronic interstitial lung disease

PURPOSE

Mediastinal lymph node (MLN) enlargement detected on chest computed tomography (CT) is frequent in patients with interstitial lung disease (ILD) and is shown in approximately 70% of cases of idiopathic pulmonary fibrosis (IPF). We hypothesized that enlarged MLNs might be a predictor of poor prognosis, associated with lower survival and stronger disease severity.

METHODS

This study included patients with idiopathic pulmonary fibrosis (IPF) or nonspecific interstitial pneumonia (NSIP) from January 2009 to December 2018. Baseline chest CT scan and one-year follow-up scan of the patients were reviewed for the extent of lung fibrosis and MLNs. Two radiologists independently assessed MLN diameter and location. Patients with drug toxicity-related ILD, sarcoidosis, chronic hypersensitivity pneumonitis and other rare idiopathic interstitial pneumonias were excluded. The primary endpoint was survival. Secondary endpoints included number of hospitalizations for respiratory causes, lung function evaluated by forced vital capacity (FVC) and diffusing capacity for carbon monoxide (DLCO), and lung fibrosis score determined by CT scan.

RESULTS

We retrospectively reviewed the medical registries of 110 patients with chronic pulmonary fibrosis (mean age 71 years, 60.4% male). Nine participants were excluded because the CT scans were of poor diagnostic quality for the evaluation of the mediastinum or unavailable for review. The analysis of 101 patients showed that enlarged MLNs (short axis diameter ≥10 mm) were present in 50.5% (n=51) and strongly predicted survival (HR= 2.11, 95% CI 1.12-3.96, p = 0.020). Patients with MLN enlargement experienced greater number of hospitalizations for respiratory causes (mean 2.5 vs. 1.8, p = 0.010) and had significantly worse lung function parameters (FVC, 71% vs. 81%, p = 0.018 and DLCO, 40% vs. 50%, p = 0.001) and a higher lung fibrosis score (50% vs. 39%, p = 0.001).

CONCLUSION

In patients with IPF and NSIP, enlarged MLNs predict survival, are associated with increased number of hospitalizations, and show signs of poorer lung function and more severe fibrosis.

Usefulness of Staging Chest CT in Breast Cancer: Evaluating Diagnostic Yield of Chest CT According to the Molecular Subtype and Clinical Stage

The aim of this study is to investigate the clinical utility of staging chest CT in breast cancer by evaluating diagnostic yield (DY) of chest CT in detection of metastasis, according to the molecular subtype and clinical stage. This retrospective study included 840 patients with 855 breast cancers from January 2017 to December 2018. The number of patients in clinical stage 0/I, II, III and IV were 457 (53.5%), 298 (34.9%), 92 (10.8%) and 8 (0.9%), respectively. Molecular subtype was identified in 841 cancers and there were 709 (84.3%) luminal type, 55 (6.5%) human epidermal growth factor receptor 2 (HER2)-enriched type and 77 (9.2%) triple-negative (TN) type. The DYs in clinical stage 0/I, cII, cIII and cIV were 0.2% (1/457), 1.7% (5/298), 4.3% (4/92) and 100.0% (8/8), respectively. The DYs in luminal type, HER2-enriched type and TN type were 1.7% (12/709), 3.6% (2/55) and 2.6% (2/77), respectively. Clinical stage was associated with the DY (p = 0.000). However, molecular subtype was not related to the DY (p = 0.343). Molecular subtype could not provide useful information to determine whether staging chest CT should be performed in early-stage breast cancer. However, chest CT should be considered in advanced breast cancer.

Lymphatic Pathways of the Thorax: Predictable Patterns of Spread

OBJECTIVE. This article reviews thoracic lymphatic pathways and tributaries, discusses lymphatic anatomic variants and their clinical implications, and emphasizes common patterns of thoracic lymphadenopathy from extrapulmonary malignancies. CONCLUSION. Recognition of common patterns and pathways of thoracic lymphatic drainage can help identify the site of tumor origin and allow a more focused examination of disease extent, both of which are important for disease prognosis and management.

Prognosticating Outcomes in Interstitial Lung Disease by Mediastinal Lymph Node Assessment. An Observational Cohort Study with Independent Validation

RATIONALE

Mediastinal lymph node (MLN) enlargement on chest computed tomography (CT) is prevalent in patients with interstitial lung disease (ILD) and may reflect immunologic activation and subsequent cytokine-mediated immune cell trafficking.

OBJECTIVES

We aimed to determine whether MLN enlargement on chest CT predicts clinical outcomes and circulating cytokine levels in ILD.

METHODS

MLN measurements were obtained from chest CT scans of patients with ILD at baseline evaluation over a 10-year period. Patients with sarcoidosis and drug toxicity-related ILD were excluded. MLN diameter and location were assessed. Plasma cytokine levels were analyzed in a subset of patients. The primary outcome was transplant-free survival (TFS). Secondary outcomes included all-cause and respiratory hospitalizations, lung function, and plasma cytokine concentrations. Cox regression was used to assess mortality risk. Outcomes were assessed in three independent ILD cohorts.

MEASUREMENTS AND MAIN RESULTS

Chest CT scans were assessed in 1,094 patients (mean age, 64 yr; 52% male). MLN enlargement (≥10 mm) was present in 66% (n = 726) and strongly predicted TFS (hazard ratio [HR], 1.53; 95% confidence interval [CI], 1.12-2.10; P = 0.008) and risk of all-cause and respiratory hospitalizations (internal rate of return [IRR], 1.52; 95% CI, 1.17-1.98; P = 0.002; and IRR, 1.71; 95% CI, 1.15-2.53; P = 0.008, respectively) when compared with subjects with MLN <10 mm. Patients with MLN enlargement had lower lung function and decreased plasma concentrations of soluble CD40L (376 pg/ml vs. 505 pg/ml, P = 0.001) compared with those without MLN enlargement. Plasma IL-10 concentration >45 pg/ml predicted mortality (HR, 4.21; 95% CI, 1.21-14.68; P = 0.024). Independent analysis of external datasets confirmed these findings.

CONCLUSIONS

MLN enlargement predicts TFS and hospitalization risk in ILD and is associated with decreased levels of a key circulating cytokine, soluble CD40L. Incorporating MLN and cytokine findings into current prediction models might improve ILD prognostication.

Abdominal lymph node size in children at computed tomography

BACKGROUND

Lymph node enlargement is commonly used to indicate abnormality.

OBJECTIVE

To evaluate the normal size and prevalence of abdominal lymph nodes in children at CT.

MATERIALS AND METHODS

In this retrospective study, we included a total of 152 children ages 1-17 years who underwent abdominal CT examination after high-energy trauma. We measured abdominal lymph nodes in five lymph node stations (inguinal, iliac, para-aortic, hepatic and mesenteric). For the largest lymph node in each level, we measured long- and short-axis diameters in both the axial and coronal planes. We then calculated distribution parameters, correlation coefficients between lymph node size and age, and reference intervals.

RESULTS

The prevalence of detectable lymph nodes was high for the inguinal (100%), iliac (98%), para-aortic (97%) and mesenteric (99%) stations and lower for the hepatic station (32%). Lymph node size showed small to medium significant correlations (ranging from 0.21 to 0.50) with age. When applying the Lugano criteria and RECIST (Response Criteria in Solid Tumors), 29 children (19%) would have had one or more enlarged abdominal lymph nodes.

CONCLUSION

The results of this study provide normative data of abdominal lymph node size in children. The current adult guidelines for enlarged lymph nodes seem adequate for most children with the exception of young adolescents, in which larger lymph nodes were relatively common, particularly in the inguinal region.

The diagnostic accuracy of endobronchial ultrasound and spiral chest computed tomography scan in the prediction of infiltrating and non-infiltrating lymph nodes in patients undergoing endobronchial ultrasound

Purpose

Endobronchial ultrasound (EBUS) and spiral chest computed tomography (CT) scan are important methods in the prediction of infiltrating and non-infiltrating lymph nodes, and the determination of their diagnostic accuracy would result in a reduction of the burden of problems and an improvement in prognosis. The purpose in this study was to determine the diagnostic accuracy of endobronchial ultrasound and spiral chest CT scan in the prediction of infiltrating and non-infiltrating lymph nodes in patients undergoing endobronchial ultrasound.

Material and methods

In this observational prospective study, 40 consecutive patients with infiltrating and non-infiltrating lymph nodes in Masih-Daneshvari Hospital in 2017 and 2018 were enrolled, and the sensitivity, specificity, and accuracy of EBUS and CT-scan versus fine needle aspiration pathology results were determined in them.

Results

The results in this study demonstrated that the congruence between EBUS and CT scan was 80.5% (p = 0.0001). The sensitivity, specificity, and accuracy for CT scan were 100%, 22.6%, and 40%, respectively, and the sensitivity, specificity, and accuracy for EBUS were 100%, 16.1%, and 35%, respectively.

Conclusion

According to the obtained results, it may be concluded that CT scan and EBUS results have good congruence and high sensitivity to differentiate infiltrating and non-infiltrating lymph nodes. Hence, these methods are useful for screening methods, but due to their low specificity and accuracy the use of them for a confirmative approach is not beneficial. However, regarding the accessibility and less invasive nature, use of chest CT scan is more rational and is recommended in these patients.

Ultrasound techniques in the evaluation of the mediastinum, part I: endoscopic ultrasound (EUS), endobronchial ultrasound (EBUS) and transcutaneous mediastinal ultrasound (TMUS), introduction into ultrasound techniques

Ultrasound imaging has gained importance in pulmonary medicine over the last decades including conventional transcutaneous ultrasound (TUS), endoscopic ultrasound (EUS), and endobronchial ultrasound (EBUS). Mediastinal lymph node staging affects the management of patients with both operable and inoperable lung cancer (e.g., surgery vs. combined chemoradiation therapy). Tissue sampling is often indicated for accurate nodal staging. Recent international lung cancer staging guidelines clearly state that endosonography (EUS and EBUS) should be the initial tissue sampling test over surgical staging. Mediastinal nodes can be sampled from the airways [EBUS combined with transbronchial needle aspiration (EBUS-TBNA)] or the esophagus [EUS fine needle aspiration (EUS-FNA)]. EBUS and EUS have a complementary diagnostic yield and in combination virtually all mediastinal lymph nodes can be biopsied. Additionally endosonography has an excellent yield in assessing granulomas in patients suspected of sarcoidosis. The aim of this review, in two integrative parts, is to discuss the current role and future perspectives of all ultrasound techniques available for the evaluation of mediastinal lymphadenopathy and mediastinal staging of lung cancer. A specific emphasis will be on learning mediastinal endosonography. Part I is dealing with an introduction into ultrasound techniques, mediastinal lymph node anatomy and diagnostic reach of ultrasound techniques and part II with the clinical work up of neoplastic and inflammatory mediastinal lymphadenopathy using ultrasound techniques and how to learn mediastinal endosonography.

Agreement of Mediastinal Lymph Node Size Between Computed Tomography and Endobronchial Ultrasonography: A Study of 617 Patients

BACKGROUND

Endobronchial ultrasound (EBUS) is the preferred minimally invasive technique for the evaluation of intrathoracic lymphadenopathy. Enlarged lymph nodes on computed tomography (CT) are defined as those 1 cm or larger in short-axis diameter. Whether there is agreement between the measurements of lymph node size on CT and EBUS remains unknown.

METHODS

This was a retrospective analysis of prospectively collected data from patients who underwent EBUS-guided transbronchial needle aspiration (TBNA) for intrathoracic lymphadenopathy. The diameters of lymph nodes were measured in an axis perpendicular to the airway on both CT and EBUS. The correlation and agreement between the two measurements were analyzed.

RESULTS

During the study period, 617 patients (mean age, 46.0 years [standard deviation, 15.2]), of whom 239 (38.7%) were women, underwent EBUS. A total of 1,153 lymph nodes were measured by CT and EBUS. Although there was a moderate correlation between the two modalities for lymph node size (Pearson correlation coefficient = 0.49, p < 0.001), the limits of agreement between CT and EBUS were wide (mean bias, 0.1; limits of agreement, -15.6 to 15.9 mm). The limits of agreement were wide for all categories of lymph nodes (benign vs malignant, distinct vs indistinct margin, and ≤2-cm vs >2-cm nodes).

CONCLUSIONS

Despite a significant correlation between CT of the chest and EBUS for measuring the size of intrathoracic lymph nodes, the limits of agreement were fairly wide enough to be clinically acceptable for allowing the use of the two modalities interchangeably for this purpose.