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Briones Alvarado SI, Pedraza Serrano F, Caballero Segura FJ, Liendo Martínez KH, de Miguel-Diez J. Pleuroparenchymal Fibroelastosis. Is it Really Uncommon? Report of Eight Cases. OPEN RESPIRATORY ARCHIVES 2024; 6:100293. [PMID: 38293644 PMCID: PMC10827556 DOI: 10.1016/j.opresp.2023.100293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024] Open
Affiliation(s)
- Stephany Ivonne Briones Alvarado
- Department of Respiratory Medicine, General University Hospital Gregorio Marañon, Faculty of Medicine, Complutense University of Madrid, Gregorio Marañon Health Research Institute (IiSGM), Madrid, Spain
| | - Fernando Pedraza Serrano
- Department of Respiratory Medicine, General University Hospital Gregorio Marañon, Faculty of Medicine, Complutense University of Madrid, Gregorio Marañon Health Research Institute (IiSGM), Madrid, Spain
| | - Francisco Jose Caballero Segura
- Department of Respiratory Medicine, General University Hospital Gregorio Marañon, Faculty of Medicine, Complutense University of Madrid, Gregorio Marañon Health Research Institute (IiSGM), Madrid, Spain
| | | | - Javier de Miguel-Diez
- Department of Respiratory Medicine, General University Hospital Gregorio Marañon, Faculty of Medicine, Complutense University of Madrid, Gregorio Marañon Health Research Institute (IiSGM), Madrid, Spain
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Sekine A, Hagiwara E, Oda T, Muraoka T, Iwasawa T, Ikeda S, Okuda R, Kitamura H, Baba T, Takemura T, Matsumura M, Okudela K, Kumagai E, Chiba S, Motobayashi Y, Ogura T. High prevalence of upper lung field pulmonary fibrosis radiologically consistent with pleuroparenchymal fibroelastosis in patients with round atelectasis. Respir Investig 2023; 61:738-745. [PMID: 37714092 DOI: 10.1016/j.resinv.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 07/10/2023] [Accepted: 08/03/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND Upper-lung field pulmonary fibrosis (upper-PF), radiologically consistent with pleuroparenchymal fibroelastosis (PPFE), was reported to develop in patients with a history of asbestos exposure and tuberculous pleurisy, indicating that chronic pleuritis is correlated with upper-PF development. Round atelectasis reportedly emerges after chronic pleuritis. This study aimed to clarify the association between round atelectasis and upper-PF. METHODS We examined the radiological reports of all consecutive patients with round atelectasis between 2006 and 2018 and investigated the incidence of upper-PF development. RESULTS Among 85 patients with round atelectasis, 21 patients (24.7%) were confirmed to finally develop upper-PF lesions. Upper-PF was diagnosed after round atelectasis recognition in more than half of the patients (13/21, 61.9%), whereas upper-PF and round atelectasis were simultaneously detected in the remaining 8 patients. At the time of round atelectasis detection, almost all patients (19/21, 90.5%) had diffuse pleural thickening and round atelectasis was commonly observed in non-upper lobes of 19 patients (90.5%). Fourteen patients had round atelectasis in unilateral lung, and the remaining 7 patients had round atelectasis in bilateral lungs. Among all 14 patients with unilateral round atelectasis, upper-PF developed on the same (n = 11) or both sides (n = 3). Thus, upper-PF emerged on the same side where round atelectasis was present (14/14, 100%). The autopsy of one patient revealed a thickened parietal-visceral pleura suggestive of chronic pleuritis. Subpleural fibroelastosis was also observed. CONCLUSIONS Upper-PF occasionally develops on the same side of round atelectasis. Upper-PF may develop as a sequela of chronic pleuritis.
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Affiliation(s)
| | | | | | | | | | | | - Ryo Okuda
- Department of Respiratory Medicine, Japan
| | | | | | - Tamiko Takemura
- Department of Pathology, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Mai Matsumura
- Department of Pathology, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Koji Okudela
- Department of Pathology, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Eita Kumagai
- Department of Pathology, Yokohama City University Medical Center, Japan
| | | | - Yuto Motobayashi
- Department of Respiratory Medicine, National Hospital Organization, Yokohama Medical Center, Japan
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Inafuku K, Sekine A, Arai H, Hagiwara E, Komatsu S, Iwasawa T, Misumi T, Kikunishi N, Tajiri M, Okudela K, Rino Y, Ogura T. Radiological unilateral pleuroparenchymal fibroelastosis as a notable late complication after lung cancer surgery: incidence and perioperative associated factors. Interact Cardiovasc Thorac Surg 2022; 35:6673152. [PMID: 35993903 PMCID: PMC9487195 DOI: 10.1093/icvts/ivac223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 08/01/2022] [Accepted: 08/20/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
OBJECTIVES
Pleuroparenchymal fibroelastosis (PPFE) is a rare idiopathic interstitial pneumonia characterized by pleural-parenchymal involvement, predominantly in the upper lobes. Unilateral upper lung field pulmonary fibrosis (upper-PF) that is radiologically consistent with PPFE reportedly develops after lung cancer surgery in the operated side and presents many clinical characteristics in common with PPFE. However, the incidence and perioperative associated factors remain unclear.
METHODS
All consecutive patients with lung cancer resected completely from 2008 to 2016 were investigated retrospectively. Pre-/postoperative characteristics were compared between patients with and without unilateral upper-PF. Cumulative incidence curves were estimated using competing risk analysis.
RESULTS
Among the 587 included patients, 25 patients (4.3%) were diagnosed as unilateral upper-PF. The 3-, 5- and 10-year cumulative incidence of unilateral upper-PF was 2.3%, 3.3% and 5.3%, respectively. In multivariable analysis, male sex, presence of a pulmonary apical cap, lobar resection and low % vital capacity (%VC < 80%) were independent perioperative associated factors. The 10-year cumulative incidence was 6.3% in patients treated with lobar resection, 8.0% in male patients, 10.3% in patients with pulmonary apical cap and 14.5% in patients with low %VC. Postoperative pleural effusion at 6 months after surgery was much more common in the patients who later developed unilateral upper-PF (96.0% vs 24.2%). This pleural effusion persisted and was accompanied thereafter by pleural thickening and subpleural pulmonary fibrosis. During the clinical courses of 25 patients with unilateral upper-PF, 18 patients presented symptoms related to upper-PF and 6 patients died.
CONCLUSIONS
Unilateral upper-PF is an occasional but under-recognized late complication after lung cancer surgery.
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Affiliation(s)
- Kenji Inafuku
- Department of Thoracic Surgery, Kanagawa Cardiovascular and Respiratory Center , Yokohama, Japan
| | - Akimasa Sekine
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center , Yokohama, Japan
| | - Hiromasa Arai
- Department of Thoracic Surgery, Kanagawa Cardiovascular and Respiratory Center , Yokohama, Japan
| | - Eri Hagiwara
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center , Yokohama, Japan
| | - Shigeru Komatsu
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center , Yokohama, Japan
| | - Tae Iwasawa
- Department of Radiology, Kanagawa Cardiovascular and Respiratory Center , Yokohama, Japan
| | - Toshihiro Misumi
- Department of Biostatistics, Yokohama City University School of Medicine , Yokohama, Japan
| | - Noritake Kikunishi
- Department of Thoracic Surgery, Kanagawa Cardiovascular and Respiratory Center , Yokohama, Japan
| | - Michihiko Tajiri
- Department of Thoracic Surgery, Kanagawa Cardiovascular and Respiratory Center , Yokohama, Japan
| | - Koji Okudela
- Department of pathology, Yokohama City University School of Medicine , Yokohama, Japan
| | - Yasushi Rino
- Department of Surgery, Yokohama City University School of Medicine , Yokohama, Japan
| | - Takashi Ogura
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center , Yokohama, Japan
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Sekine A, Hagiwara E, Iwasawa T, Otoshi R, Erina T, Shintani R, Okabayashi H, Ikeda S, Oda T, Okuda R, Kitamura H, Baba T, Komatsu S, Ogura T. Asbestos exposure and tuberculous pleurisy as developmental causes of progressive unilateral upper-lung field pulmonary fibrosis radiologically consistent with pleuroparenchymal fibroelastosis. Respir Investig 2021; 59:837-844. [PMID: 34172419 DOI: 10.1016/j.resinv.2021.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 05/18/2021] [Accepted: 05/20/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Unilateral upper-lung field pulmonary fibrosis (upper-PF), which is radiologically consistent with pleuroparenchymal fibroelastosis, develops after thoracic surgery. In most patients with unilateral upper-PF, aberrant intra-/extra thoracic air commonly emerges and an autopsy shows chronic pleuritis, which indicates that pleural involvement is associated with upper-PF development. If so, there may be patients with unilateral upper-PF who have a history of pleural involvement, including tuberculous pleurisy (TP) or asbestos exposure (AE). This study aimed to examine this supposition. METHODS We examined the radiological reports of all consecutive patients from 2012 to 2018 to investigate whether there were patients having unilateral upper-PF and a history of TP or AE. RESULTS Eight patients were included in the study. Five patients had a history of TP, and the remaining three had that of AE. All patients were men and had respiratory symptoms, and seven patients presented with restrictive ventilatory impairment. The interval between TP or last AE and upper-PF development was long, with a median of over 20 years. The upper-PF lesion was commonly located in the right lung, and aberrant intrathoracic air was observed in five patients during their clinical course. Additionally, the upper-PF lesion transformed into a cystic lesion in six patients, which resulted in Aspergillus infection in two patients. The prognosis was poor, with a median overall survival of 38 months. CONCLUSIONS Unilateral upper-PF developed even in patients with a history of pleural involvement. Our results indicate that pleural involvement plays an important role in the development of unilateral upper-PF.
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Affiliation(s)
- Akimasa Sekine
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan.
| | - Eri Hagiwara
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Tae Iwasawa
- Department of Radiology, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Ryota Otoshi
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Tabata Erina
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Ryota Shintani
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Hiroko Okabayashi
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Satoshi Ikeda
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Tsuneyuki Oda
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Ryo Okuda
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Hideya Kitamura
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Tomohisa Baba
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Shigeru Komatsu
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Takashi Ogura
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
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Ricoy J, Suárez-Antelo J, Antúnez J, Martínez de Alegría A, Ferreiro L, Toubes ME, Casal A, Valdés L. Pleuroparenchymal fibroelastosis: Clinical, radiological and histopathological features. Respir Med 2021; 191:106437. [PMID: 33992495 DOI: 10.1016/j.rmed.2021.106437] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 04/10/2021] [Accepted: 04/21/2021] [Indexed: 01/24/2023]
Abstract
Pleuroparenchymal fibroelastosis (PPFE) is a rare, generally idiopathic form of interstitial pneumonia with unique clinical, radiological and histopathological features. It is named after the presence of upper lobe pleural and subjacent parenchymal fibrosis, with accompanying elastic fibers. Although it is usually an idiopathic disease, it has been linked to other co-existent diseases. Diagnostic suspicion of PPFE is based on the identification of typical abnormalities on chest CT scan, which are prevailingly located in the upper lobes, adjacent to the apex of the lungs. Diagnosis can be confirmed by histological analysis, although biopsy is not always feasible. The disease is generally progressive, but not uniformly. The course of the disease is frequently slow and involves a progressive loss of upper lobe volume, which results in platythorax, associated with a significant reduction of body mass. PPFE concomitant to other interstitial lung diseases is associated with a poorer prognosis. The disease occasionally progresses rapidly causing irreversible respiratory insufficiency, which leads to death. Currently, there is no effective pharmacological therapy available, and lung transplantation is the best therapeutic option. The purpose of this review is to draw the attention to PPFE, describe its clinical, radiological and histopathological features, analyze its diagnostic criteria, and provide an update on the management of the disease.
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Affiliation(s)
- Jorge Ricoy
- Department of Pulmonology, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, Spain.
| | - Juan Suárez-Antelo
- Department of Pulmonology, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, Spain.
| | - José Antúnez
- Department of Pathology, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, Spain.
| | - Anxo Martínez de Alegría
- Department of of Radiology, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, Spain.
| | - Lucía Ferreiro
- Department of Pulmonology, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, Spain; Multidisciplinary Research Group on Pulmonology, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.
| | - María Elena Toubes
- Department of Pulmonology, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, Spain.
| | - Ana Casal
- Department of Pulmonology, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, Spain.
| | - Luis Valdés
- Department of Pulmonology, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, Spain; Multidisciplinary Research Group on Pulmonology, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.
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Sekine A, Satoh H, Takemura T, Matsumura M, Okudela K, Iwasawa T, Okabayashi H, Ikeda S, Yamakawa H, Oda T, Okuda R, Kitamura H, Baba T, Komatsu S, Hagiwara E, Ogura T. Unilateral upper lung-field pulmonary fibrosis radiologically consistent with pleuroparenchymal fibroelastosis after thoracic surgery: Clinical and radiological courses with autopsy findings. Respir Investig 2020; 58:448-456. [PMID: 32660899 DOI: 10.1016/j.resinv.2020.05.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 04/17/2020] [Accepted: 05/04/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pleuroparenchymal fibroelastosis (PPFE) is a rare idiopathic interstitial pneumonia characterized by pleural and parenchymal involvements predominantly in the upper lobes. Unilateral upper-lung field pulmonary fibrosis (upper-PF) radiologically consistent with PPFE was recently reported in patients with a history of open thoracotomy and presented with impaired thoracic movements in the operated side with unknown mechanisms. This retrospective study aimed to elucidate the clinical and radiological courses and pathological findings of unilateral upper-PF. METHODS All the consecutive patients diagnosed as having unilateral upper-PF between March 2012 and April 2018 were included. Radiological images and clinical courses before and after the diagnosis were thoroughly reviewed. RESULTS Fourteen patients were included. Unilateral upper-PF was diagnosed after a median of 4.8 years from the open thoracotomy or video-assisted thoracic surgery for treating lung or esophageal cancer, or bronchiectasis. Before or at diagnosis, 12 (85.7%) of 14 patients developed aberrant intrathoracic/extrathoracic air suggestive of pleural fistula, although the degree was slight. Of note, the upper-PF lesion apparently deteriorated once aberrant air emerged in all the patients. After diagnosis, the upper-PF lesion transformed into cystic lesion in 9 patients, 4 of whom eventually developed pulmonary aspergillosis. The prognosis was poor, with a median overall survival of 49.3 months. The autopsy in one patient demonstrated findings consistent with PPFE and chronic pleuritis. CONCLUSIONS Unilateral upper-PF developed after thoracic surgeries and had many clinical, radiological, and pathological characteristics in common with idiopathic PPFE. Our results indicate that the commonly observed aberrant air may be correlated with disease development and progression.
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Affiliation(s)
- Akimasa Sekine
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan.
| | - Hiroaki Satoh
- Department of Internal Medicine, Mito Medical Center, University of Tsukuba, Mito, Japan
| | - Tamiko Takemura
- Department of Pathology, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Mai Matsumura
- Department of Pathology, Graduate School of Medicine, Yokohama-City University, Yokohama, Japan
| | - Koji Okudela
- Department of Pathology, Graduate School of Medicine, Yokohama-City University, Yokohama, Japan
| | - Tae Iwasawa
- Department of Radiology, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Hiroko Okabayashi
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Satoshi Ikeda
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Hideaki Yamakawa
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Tsuneyuki Oda
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Ryo Okuda
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Hideya Kitamura
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Tomohisa Baba
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Shigeru Komatsu
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Eri Hagiwara
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Takashi Ogura
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
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Jacob J, Odink A, Brun AL, Macaluso C, de Lauretis A, Kokosi M, Devaraj A, Desai S, Renzoni E, Wells AU. Functional associations of pleuroparenchymal fibroelastosis and emphysema with hypersensitivity pneumonitis. Respir Med 2018; 138:95-101. [PMID: 29724400 PMCID: PMC5948318 DOI: 10.1016/j.rmed.2018.03.031] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 03/26/2018] [Accepted: 03/28/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Pleuroparenchymal fibroelastosis (PPFE) has been described in hypersensitivity pneumonitis (HP) yet its functional implications are unclear. Combined pulmonary fibrosis and emphysema (CPFE) has occasionally been described in never-smokers with HP, but epidemiological data regarding its prevalence is sparse. CTs in a large HP cohort were therefore examined to identify the prevalence and effects of PPFE and emphysema. Methods 233 HP patients had CT extents of interstitial lung disease (ILD) and emphysema quantified to the nearest 5%. Lobar percentage pleural involvement of PPFE was quantified on a 4-point categorical scale: 0 = absent, 1 = affecting <10%, 2 = affecting 10–33%, 3 = affecting >33%. Marked PPFE reflected a total lung score of ≥3/18. Results were evaluated against FVC, DLco and mortality. RESULTS Marked PPFE prevalence was 23% whilst 23% of never-smokers had emphysema. Following adjustment for patient age, gender, smoking status, and ILD and emphysema extents, marked PPFE independently linked to reduced baseline FVC (p = 0.0002) and DLco (p = 0.002) and when examined alongside the same covariates, independently linked to worsened survival (p = 0.01). CPFE in HP demonstrated a characteristic functional profile of artificial lung volume preservation and disproportionate DLco reduction. CPFE did not demonstrate a worsened outcome when compared to HP patients without emphysema beyond that explained by CT extents of ILD and emphysema. CONCLUSIONS PPFE is not uncommon in HP, and is independently associated with impaired lung function and increased mortality. Emphysema was identified in 23% of HP never-smokers. CPFE appears not to link to a malignant microvascular phenotype as outcome is explained by ILD and emphysema extents. In patients with HP, marked PPFE had a prevalence of 23% in our study cohort. 23% of never-smokers with HP demonstrated emphysema on CT imaging. Outcome in HP patients with CPFE is explained by CT extents of ILD and emphysema. PPFE is independently associated with a worsened outcome in HP.
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Affiliation(s)
- Joseph Jacob
- Department of Respiratory Medicine, University College London, London, UK; Centre for Medical Computing, University College London, London, UK.
| | - Arlette Odink
- Department of Radiology, Erasmus MC Rotterdam, The Netherlands
| | - Anne Laure Brun
- Imaging Department, Hôpital Cochin, Paris-Descartes University, France
| | - Claudio Macaluso
- Department of Respiratory Medicine, Ospedale "Luigi Sacco", University of Milan, Italy; Interstitial Lung Disease Unit, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Angelo de Lauretis
- Division of Pneumology, "Guido Salvini" Hospital, Garbagnate Milanese, Italy
| | - Maria Kokosi
- Interstitial Lung Disease Unit, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Anand Devaraj
- Department of Radiology, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Sujal Desai
- Department of Radiology, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Elisabetta Renzoni
- Interstitial Lung Disease Unit, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Athol U Wells
- Interstitial Lung Disease Unit, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK
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