Endobronchial ultrasound-guided transbronchial needle aspiration of lymph nodes in the radiologically and positron emission tomography-normal mediastinum in patients with lung cancer

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) can reliably sample enlarged mediastinal lymph nodes in patients with non-small cell lung cancer (NSCLC), and in practice is mostly used to sample nodes visible on CT or positron emission tomography (PET). Few data are available on the use of endoscopic procedures to stage the mediastinum in clinical stage 1 lung cancer. The aim of the present study was to determine the results of EBUS-TBNA in sampling mediastinal lymph nodes in patients with lung cancer and a radiographically normal mediastinum and no PET activity. From January 2004 to May 2007, patients highly suspicious for NSCLC with CT scans showing no enlarged lymph nodes (no node > 1 cm) and a negative PET finding of the mediastinum underwent EBUS-TBNA. Identifiable lymph nodes at locations 2r, 2L, 4r, 4L, 7, 10r, 10L, 11r, and 11L were aspirated. All patients underwent subsequent surgical staging. Diagnoses based on aspiration results were compared with those based on surgical results. One hundred patients (mean age, 52.4 years; 59 men) were included. After surgery, 97 patients (mean age, 52.9 years; 57 men) had NSCLC confirmed and were included in the analysis. In this group, 156 lymph nodes ranging 5 to 10 mm in size were detected and sampled. Malignancy was detected in nine patients but missed in one patient. Mean diameter of the punctured lymph nodes was 7.9 mm. The sensitivity of EBUS-TBNA for detecting malignancy was 89%, specificity was 100%, and the negative predictive value was 98.9%. No complications occurred. In conclusion, EBUS-TBNA can be used to accurately sample and stage patients with clinical stage 1 lung cancer and no evidence of mediastinal involvement on CT and PET. Potentially operable patients with no signs of mediastinal involvement may benefit from presurgical staging with EBUS-TBNA.     

Significance of multiple carcinoid tumors and tumorlets in surgical lung specimens: analysis of 28 patients

BACKGROUND: The clinical significance of multiple carcinoid tumorlets in surgical lung specimens has not been systematically analyzed. We reviewed our experience to determine the range of clinical circumstances associated with this finding. METHODS: We reviewed clinical records, available imaging, and pathology materials from patients evaluated at Mayo Clinic Rochester (from 1987 to 2000) with two or more carcinoid tumors or tumorlets in lung specimens. RESULTS: Twenty-eight of 294 patients with a diagnosis of carcinoid tumor or tumorlet had two or more lesions. Twenty-six patients (93%) were women; mean age was 65 years. Patients were categorized into three groups: multiple nodules (n = 17), solitary lung nodules on preoperative imaging (n = 7), and airflow limitation (n = 4). Approximately half of patients with multiple nodules had respiratory complaints; two patients had Cushing syndrome. Ten patients (58.8%) were suspected of having pulmonary metastases, including 7 patients with previously diagnosed malignancies. Intrathoracic lymph node metastases were present in three patients, none of whom had recurrent disease. One patient had a carcinoid tumor resected 8 years later. Extrathoracic metastases developed in another patient 3 years after presentation, and the patient was alive with disease 2 years later. Only one patient with airflow limitation had a syndrome resembling diffuse idiopathic pulmonary neuroendocrine cell hyperplasia. CONCLUSIONS: Our series represents the largest compilation of multiple carcinoid tumors or tumorlets. Our analysis reveals that multiple carcinoid tumors or tumorlets occur most commonly in patients with multiple nodules resembling metastatic disease. Significant airflow limitation is rare. Long-term survival is excellent, although patients have persistent disease.     

Endoscopic ultrasound-guided fine-needle aspiration for non-small cell lung cancer staging: A systematic review and metaanalysis

BACKGROUND: Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) is a minimally invasive alternative technique for mediastinal staging of non-small cell lung cancer. A metaanalysis was performed to estimate the diagnostic accuracy of EUS-FNA for staging mediastinal lymph nodes (N2/N3 disease) in patients with lung cancer. METHODS: Relevant studies were identified using Medline (1966 to November 2005), CINAHL, and citation indexing. Included studies used histology or adequate clinical follow-up (> 6 months) as the "gold standard," and provided sufficient data for calculating sensitivity and specificity. Summary receiver operating characteristic curves metaanalysis was performed to estimate the pooled sensitivity and specificity. RESULTS: In 18 eligible studies, EUS-FNA identified 83% of patients (95% confidence interval [CI], 78 to 87%) with positive mediastinal lymph nodes (pooled sensitivity) and 97% of patients (95% CI, 96 to 98%) with negative mediastinal lymph nodes (pooled specificity). In eight studies that were limited to patients who had abnormal mediastinal lymph nodes seen on CT scans, the sensitivity was 90% (95% CI, 84 to 94%) and the specificity was 97% (95% CI, 95 to 98%). In patients without abnormal mediastinal lymph nodes seen on CT scans (four studies), the pooled sensitivity was 58% (95% CI, 39 to 75%). Minor complications were reported in 10 cases (0.8%). There were no major complications. CONCLUSIONS: EUS-FNA is a safe modality for the invasive staging of lung cancer that is highly sensitive when used to confirm metastasis to mediastinal lymph nodes seen on CT scans. In addition, among lung cancer patients with normal mediastinal adenopathy seen on CT scans, despite lower sensitivity, it has the potential to prevent unnecessary surgery in a large proportion of cases missed by CT scanning.     

Small cell carcinoma of the lung exclusively localized within the left descending pulmonary artery

We encountered a 69-year-old woman displaying a filling defect within the left descending pulmonary artery (PA) on a chest CT scan and pulmonary angiography. A subsequent 2-[18F]fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) scan demonstrated focal uptake in the left hilum. A cytologic examination of transbronchial needle aspiration specimens revealed small cell carcinoma. The patient underwent concurrent radiation therapy and chemotherapy with cisplatin and etoposide, resulting in tumor shrinkage and recanalization of the involved PA. This is the first case of small cell carcinoma localized exclusively within the PA, and positive findings on FDG-PET facilitated the unexpected diagnosis.     

Cardiac involvement in patients with sarcoidosis: diagnostic and prognostic value of outpatient testing

BACKGROUND: Cardiac sarcoidosis (CS) causes substantial morbidity and sudden death. Early diagnosis and risk stratification are warranted. METHODS: Ambulatory patients with sarcoidosis were interviewed to determine whether they experienced palpitations, syncope, or presyncope, and were evaluated with ECG, Holter monitoring, and echocardiography (transthoracic echocardiogram [TTE]). Those with symptoms or abnormal results were studied with cardiac MRI (CMRI) or positron emission tomography (PET) scanning. The diagnosis of CS was based on abnormalities detected by these imaging studies. Patients with CS were referred for risk stratification by electrophysiology study (EPS). RESULTS: Among the 62 patients evaluated, the prevalence of CS was 39%. Patients with CS had more cardiac symptoms than those without CS (46% vs 5%, respectively; p < 0.001), and were more likely to have abnormal Holter monitoring findings (50% vs 3%, respectively; p < 0.001) and TTE findings (25% vs 5%, respectively; p = 0.02). The degree of pulmonary impairment did not predict CS. Two of the 17 patients who underwent EPS had abnormal test findings and received implantable cardioverter-defibrillators. No patients died, had ventricular arrhythmias that triggered defibrillator therapy, or had heart failure develop during almost 2 years of follow-up. This diagnostic approach was more sensitive than the established criteria for identifying CS. CONCLUSION: CS is common among patients with sarcoidosis. A structured clinical assessment incorporating advanced cardiac imaging with PET scanning or CMRI is more sensitive than the established criteria for the identification of CS. Sarcoidal lesions seen on CMRI or PET scanning do not predict arrhythmias in ambulatory patients with preserved cardiac function, who appear to be at low risk for short-term mortality.     

Diagnostic usefulness of fluorine-18-alpha-methyltyrosine positron emission tomography in combination with 18F-fluorodeoxyglucose in sarcoidosis patients

OBJECTIVES: L-[3-(18)F]-alpha-methyltyrosine ((18)F-FMT) is an amino-acid tracer for positron emission tomography (PET) and is used for tumor detection because malignant tumor cells accumulate (18)F-FMT based on the increased expression of an amino-acid transporter. This study was conducted to investigate the usefulness of (18)F-FMT PET in combination with fluorine-18-fluorodeoxyglucose ((18)F-FDG) PET for the diagnosis of sarcoidosis in patients with suspected malignancy. SETTING: Twenty-four sarcoidosis patients with suspected malignancy underwent (18)F-FDG and (18)F-FMT PET. The study included 17 patients with extrapulmonary manifestation mimicking malignant disease (13 patients with systemic lymphadenopathy, 3 of them with concomitant hepatosplenic processes; 3 patients with hepatosplenic processes without concomitant lymphadenopathy; and 1 patient with multiple bone lesions), 3 patients with occurrence of bilateral hilar lymphadenopathy in cancer patients, and 4 patients with multiple nodules mimicking pulmonary metastasis. RESULTS: All patients showed increased uptake of (18)F-FDG and no increase in the accumulation of (18)F-FMT in their lymphadenopathy. Standardized uptake values (SUVs) of (18)F-FDG and (18)F-FMT were 5.01 +/- 2.15 and 0.77 +/- 0.24, respectively (mean +/- SD). All extranodal lesions such as liver, spleen, and bone were visually positive on (18)F-FDG PET and negative on (18)F-FMT PET. No neoplasm was confirmed in all patients. In a control group of patients with lung cancer, SUVs for (18)F-FDG and (18)F-FMT were 6.34 +/- 2.52 and 1.54 +/- 0.82, respectively. CONCLUSION: The uptake of (18)F-FDG was positive in the sarcoid lesions, and therefore (18)F-FDG PET could not differentiate sarcoidosis from malignant disease. Use of (18)F-FMT PET in combination with (18)F-FDG PET may be the effective method to distinguish sarcoidosis from malignancy.     

Pulmonary hemodynamics in advanced COPD candidates for lung volume reduction surgery or lung transplantation

STUDY OBJECTIVES: To assess the pulmonary hemodynamic characteristics in COPD candidates for lung volume reduction surgery (LVRS) or lung transplantation (LT). DESIGN: Retrospective study. SETTING: One center in France. PATIENTS: Two hundred fifteen patients with severe COPD who underwent right-heart catheterization before LVRS or LT. RESULTS: Mean age was 54.6 years. Pulmonary function test results were as follows: FEV(1), 24.3% predicted; total lung capacity, 128.3% predicted; residual volume, 259.7% predicted. Mean pulmonary artery pressure (PAPm) was 26.9 mm Hg. Pulmonary hypertension (PAPm > 25 mm Hg) was present in 50.2% and was moderate (PAPm, 35 to 45 mm Hg) or severe (PAPm > 45 mm Hg) in 9.8% and in 3.7% of patients, respectively. Cardiac index was low normal. PAPm was related to Pao(2) and alveolar-arterial oxygen gradient in multivariate analysis. Cluster analysis identified a subgroup of atypical patients (n = 16, 7.4%) characterized by moderate impairment of the pulmonary mechanics (mean FEV(1), 48.5%) contrasting with high level of pulmonary artery pressure (PAPm, 39.8 mm Hg), and severe hypoxemia (mean Pao(2), 46.2 mm Hg). CONCLUSION: While pulmonary hypertension is observed in half of the COPD patients with advanced disease, moderate-to-severe pulmonary hypertension is not a rare event in these patients. We individualized a subgroup of patients presenting with a predominant vascular disease that could potentially benefit from vasodilators.     

Prognostic significance of thin-section CT scan findings in small-sized lung adenocarcinoma

OBJECTIVES: The purpose of this study is to evaluate the prognostic importance of thin-section (TS) CT scan findings in small-sized lung adenocarcinomas. PATIENTS AND METHODS: We reviewed TS-CT scan findings and pathologic specimens from 359 consecutive patients who underwent surgical resection for peripheral lung adenocarcinomas 相似文献   

Marginal zone B-cell lymphoma of bronchus-associated lymphoid tissue: imaging findings in 21 patients

BACKGROUND: Few articles have been published on imaging findings of marginal zone B-cell lymphoma of bronchus-associated lymphoid tissue (BALT) of the lung. We present CT scan and 18F-fluorodeoxyglucose (FDG) PET scan findings of the disease. METHODS: From March 1995 to February 2007, 21 pretreatment patients (male patients, 9; female patients, 12; age range, 35 to 76 years; mean [+/- SD] age, 54 +/- 10.4 years) were seen who had pathologic diagnoses of marginal zone B-cell lymphoma of BALT. After CT scans were reviewed searching for specific patterns and distribution of parenchymal lung lesions, patients were classified as having the following four different patterns: (1) single nodular or consolidative; (2) multiple nodular or areas of consolidation; (3) bronchiectasis and bronchiolitis; and (4) diffuse interstitial lung disease (DILD) patterns. In six patients, in whom PET/CT scanning was performed, the pattern and the extent of maximum standardized uptake values (mSUVs) of FDG uptake were described. RESULTS: A single nodular or consolidative pattern was observed in 7 of 21 (33%) patients, multiple nodular or areas of consolidation were observed in 9 patients (43%), bronchiectasis and bronchiolitis were observed in 3 patients (14%), and DILD was observed in 2 patients (10%). On PET scans (n = 6), lesions showed heterogeneous FDG uptake in five patients and homogeneous uptake in one patient, with mSUVs ranging from 2.2 to 6.3 (mean mSUV, 4.2 +/- 1.48). CONCLUSIONS: Marginal zone B-cell lymphomas of BALT manifest diverse patterns of lung abnormality on CT scans, but single or multiple nodules or areas of consolidation are the main patterns that occur in a majority (76%) of patients. Most lesions show heterogeneous but identifiable FDG uptake on PET scans.     

Impalpable pulmonary nodules with ground-glass opacity: Success for making pathologic sections with preoperative marking by lipiodol

BACKGROUND: The developments in high-resolution CT scanning have increased the chance of detecting small bronchioloalveolar carcinoma (BAC) or atypical adenomatous hyperplasia (AAH) that appears as a ground-glass opacity (GGO). However, these lesions are not only difficult to localize during surgery, but they are also hard to make pathologic sections of because they are usually impalpable. Here, we report a method of making pathologic sections for impalpable GGO lesions. METHODS: Twenty-nine impalpable GGO lesions < 1 cm in size were marked by 0.4 to 0.5 mL of lipiodol under CT scan before surgery. The lesions were resected under C-arm fluoroscopy. The radiopaque areas marked by lipiodol within the formalin-fixed specimens were cut serially under conventional fluoroscopy for pathologic examinations. RESULTS: The mean (+/- SD) size of the lesions was 0.5 +/- 0.2 cm (range, 0.2 to 1 cm), and the mean depth from the pleural surface was 1.6 +/- 1.4 cm (range, 0.2 to 6 cm). The mean number of sections submitted for pathologic examinations was 2.3 +/- 1.7 per lesion (range, 1 to 7 per lesion). While 11 of the 29 lesions (38%) were invisible even on the cut surface of the specimens, all were demonstrated in hematoxylin-eosin sections. The pathologic diagnosis was BAC in 17 lesions, AAH in 10 lesions, and organized pneumonia in 2 lesions. The use of lipiodol did not affect the pathologic findings. CONCLUSIONS: The use of fluoroscopy to cut sections from resected specimens after preoperative marking with lipiodol was useful for making pathologic sections of impalpable GGOs < 1 cm in size.     

A clinical model to estimate the pretest probability of lung cancer in patients with solitary pulmonary nodules

BACKGROUND: Estimating the clinical probability of malignancy in patients with a solitary pulmonary nodule (SPN) can facilitate the selection and interpretation of subsequent diagnostic tests. METHODS: We used multiple logistic regression analysis to identify independent clinical predictors of malignancy and to develop a parsimonious clinical prediction model to estimate the pretest probability of malignancy in a geographically diverse sample of 375 veterans with SPNs. We used data from Department of Veterans Affairs (VA) administrative databases and a recently completed VA Cooperative Study that evaluated the accuracy of positron emission tomography (PET) scans for the diagnosis of SPNs. RESULTS: The mean (+/- SD) age of subjects in the sample was 65.9 +/- 10.7 years. The prevalence of malignant SPNs was 54%. Most participants were either current smokers (n = 177) or former smokers (n = 177). Independent predictors of malignant SPNs included a positive smoking history (odds ratio [OR], 7.9; 95% confidence interval [CI], 2.6 to 23.6), older age (OR, 2.2 per 10-year increment; 95% CI, 1.7 to 2.8), larger nodule diameter (OR, 1.1 per 1-mm increment; 95% CI, 1.1 to 1.2), and time since quitting smoking (OR, 0.6 per 10-year increment; 95% CI, 0.5 to 0.7). Model accuracy was very good (area under the curve of the receiver operating characteristic, 0.79; 95% CI, 0.74 to 0.84), and there was excellent agreement between the predicted probability and the observed frequency of malignant SPNs. CONCLUSIONS: Our prediction rule can be used to estimate the pretest probability of malignancy in patients with SPNs, and thereby facilitate clinical decision making when selecting and interpreting the results of diagnostic tests such as PET imaging.     

Ultrasound vs. CT in detecting chest wall invasion by tumor: a prospective study

BACKGROUND: Lung cancer is one of the leading causes of cancer-related deaths worldwide. Accurate staging is important for patient management and clinical research. The recognition of chest wall involvement preoperatively is important for staging and surgical planning. Multiple modalities are available to assess the chest wall involvement preoperatively, including CT scanning, MRI, and ultrasound (US) examination. The purpose of this study was to evaluate the sensitivity and specificity of the US examination in determining the chest wall involvement of lung cancer compared to that of CT scan and surgery. METHODS: A total of 136 patients with clinical suspicion of chest wall involvement were recruited. Ninety patients met the inclusion criteria and underwent CT scanning, transthoracic US, and surgical exploration. A final determination regarding chest wall involvement was made after reviewing the final pathology results and surgical staging. RESULTS: Chest wall invasion by tumor was noted in 26 patients during surgery and final pathologic examination of the tissue. Of these patients, US correctly identified 23 patients tumor invasion, while CT scanning identified 11 patients with tumor invasion. There were 3 false-positive results and 3 false-negative results with US examination, compared to 15 false-negative results and no false-positive results with CT scanning. CONCLUSIONS: US has better sensitivity (89%) and specificity (95%) in assessing chest wall involvement by a lung tumor compared to CT scan examination (sensitivity, 42%; specificity, 100%).     

Conventional transbronchial needle aspiration decreases the rate of surgical sampling of intrathoracic lymphadenopathy

BACKGROUND: Previous studies have suggested a decreased need for the surgical biopsy of intrathoracic lymph nodes (LNs) due to improved diagnostic rates utilizing transbronchial needle aspiration (TBNA) with endobronchial ultrasound and endoscopic ultrasound. The goal of this study was to determine whether conventional TBNA using combined cytologic and histologic analysis of tissue specimens impacted the rates of surgical diagnostic biopsies of patients with intrathoracic lymphadenopathy. METHODS: Retrospective review at a single academic center. All mediastinal and hilar tissue samples submitted for pathologic analysis over an 8.4-year period were analyzed. Patients were categorized into a "before" group and an "after" group based on two different time periods. The before group underwent only cytologic analysis of Wang needle (19-gauge or 21-gauge) aspirates. The after group had cytologic analysis of aspirates as well as histologic analysis of needle "core" (19 gauge) biopsy specimens. The groups were compared for the rate of intrathoracic LNs sampled by surgical means vs TBNA and the number of times that TBNA averted the need for a surgical diagnostic procedure. RESULTS: The success of TBNA increased significantly in the after group compared to that in the before group. The yield for the successful sampling of mediastinal and hilar LNs increased from 53 to 91% (p < 0.001) in the before group vs the after group. TBNA averted a surgical biopsy in 35% of the before cases compared to 66% of the after cases (p < 0.001). CONCLUSIONS: Conventional TBNA using large-bore needles with both cytology and surgical pathology evaluation decreases the need for surgical sampling of the mediastinum to diagnose thoracic lymphadenopathy.     

Pulmonary Nodular Ground-Glass Opacities in Patients With Extrapulmonary Cancers: What is Their Clinical Significance and How Can We Determine Whether They Are Malignant or Benign Lesions?

BACKGROUND: The clinical significance of pulmonary nodular ground-glass opacities (NGGOs) in patients with extrapulmonary cancers is not known, although there is an urgent need for study on this topic. The purpose of this study, therefore, was to investigate the clinical significance of pulmonary NGGOs in these patients, and to develop a computerized scheme to distinguish malignant from benign NGGOs. METHODS: Fifty-nine pathologically proven pulmonary NGGOs in 34 patients with a history of extrapulmonary cancer were studied. We reviewed the CT scan characteristics of NGGOs and the clinical features of these patients. Artificial neural networks (ANNs) were constructed and tested as a classifier distinguishing malignant from benign NGGOs. The performance of ANNs was evaluated with receiver operating characteristic analysis. RESULTS: Twenty-eight patients (82.4%) were determined to have malignancies. Forty NGGOs (67.8%) were diagnosed as malignancies (adenocarcinomas, 24; bronchioloalveolar carcinomas, 16). Among the rest of the NGGOs, 14 were atypical adenomatous hyperplasias, 4 were focal fibrosis, and 1 was an inflammatory nodule. There were no cases of metastasis appearing as NGGOs. Between malignant and benign NGGOs, there were significant differences in lesion size; the presence of internal solid portion; the size and proportion of the internal solid portion; the lesion margin; and the presence of bubble lucency, air bronchogram, or pleural retraction (p < 0.05). Using these characteristics, ANNs showed excellent accuracy (z value, 0.973) in discriminating malignant from benign NGGOs. CONCLUSIONS: Pulmonary NGGOs in patients with extrapulmonary cancers tend to have high malignancy rates and are very often primary lung cancers. ANNs might be a useful tool in distinguishing malignant from benign NGGOs.     

Endobronchial ultrasound

During flexible fiberoptic bronchoscopy (FB), a solitary pulmonary nodule (SPN) is sampled by means of transbronchial needle aspiration (TBNA), brush, or transbronchial lung biopsy under fluoroscopy; and mediastinal lymph nodes are sampled using "blind" TBNA. Endobronchial ultrasound (EBUS) was developed to help visualize the lesion at the time of biopsy in order to improve the diagnostic yield. METHODS: There are two types of EBUS techniques: using a radial probe (RP) with a rotating transducer at the distal tip, which produces a 360 degrees image to the long axis of the bronchoscope; and using an EBUS bronchoscope with a linear transducer at its distal tip, producing a 50 degrees image parallel to its long axis. RESULTS: In biopsies of SPNs < 2 cm using an RP, EBUS demonstrates a higher diagnostic yield than conventional FB techniques. With mediastinal and hilar nodal stations, except for the subcarina, EBUS shows a higher yield over blind TBNA. The current procedural terminology code for EBUS is 31620, a "ZZZ" code submitted in addition to other performed procedures (31622-31638). In 2007, an estimate of physician Medicare reimbursement for EBUS is $70.49. Reimbursement is locality dependent and based on economic-exchange conversion factors. Incorporating an ultrasound image into the report substantiates the use of this technique. Limitations: The physician must learn ultrasound image interpretation and the EBUS technique, and be skilled in TBNA. Maintaining competency requires frequent performance of EBUS. CONCLUSION: EBUS-directed biopsy improves the yield over conventional FB for SPNs < 2 cm and for most mediastinal or hilar nodal stations. This reduces the need to conduct additional diagnostic procedures.     

Familial idiopathic pulmonary fibrosis: clinical features and outcome

STUDY OBJECTIVES: Familial idiopathic pulmonary fibrosis (FIPF) has been defined as idiopathic pulmonary fibrosis (IPF) occurring in two or more members of a family. The clinical course of FIPF has not been fully defined. Accordingly, the current study was undertaken to establish clinical, radiologic, and histologic features, and survival in a consecutive series of patients with FIPF. DESIGN: Retrospective analysis of clinical, radiologic, and pathologic data from a consecutive series of patients with FIPF who were seen at Mayo Medical Center. Survival in patients with FIPF was contrasted to that of previously characterized patients with nonfamilial IPF who were evaluated at our institution. SETTING: Tertiary referral medical center. PATIENTS: We screened 47 patients and family members with FIPF from 15 families who were identified between the years 1992 and 2002. We further analyzed the subgroup of FIPF patients that was composed of 27 patients from 15 families in whom the complete clinical course was monitored at our institution. MEASUREMENTS: All patients exhibited clinical features that were compatible with IPF and either compatible high-resolution CT (HRCT) scan findings or histologic evidence of usual interstitial pneumonia. Clinical data, including symptoms, physical findings, HRCT scan findings, lung function test results, biopsy results, and survival were abstracted from the clinical records. RESULTS: Compared to patients with nonfamilial IPF, patients with FIPF did not demonstrate any notable differences in clinical, radiologic, or pathologic features. We observed that the total number of affected members in a family with FIPF was a significant risk factor for earlier mortality (p = 0.0157; hazard ratio, 1.434). Overall, however, patients with FIPF had a statistically similar outcome to those patients with nonfamilial IPF. CONCLUSIONS: Although uncommon, FIPF represents a distinct syndrome, which has clinical features and patient survival rates that are similar to those of nonfamilial IPF.     

Occult traumatic pneumothorax: diagnostic accuracy of lung ultrasonography in the emergency department

BACKGROUND: The role of chest ultrasonography (US) in the diagnosis of pneumothorax (PTX) has been established, but how it compares with lung CT scanning in the diagnosis of radiooccult PTX and in the determination of its topographic extension has not yet been completely evaluated. OBJECTIVE: To determine the diagnostic accuracy of chest US in the emergency department (ED) in the diagnosis of occult PTX in trauma patients and to define its ability to determine PTX extension. DESIGN: An 18-month prospective study. PATIENTS: A total of 109 conscious, spontaneously breathing patients who had been admitted to the ED for chest trauma or polytrauma. METHODS: All eligible patients underwent a standard anteroposterior supine chest radiograph (Rx) and a spiral CT lung scan within 1 h of ED admission. Lung US was carried out by an operator who was unaware of the other examination results, both for diagnosis and for the quantitative delimitation of the PTX. RESULTS: Twenty-five traumatic PTXs were detected in the 218 hemithoraxes (109 patients; 2 patients had a bilateral PTX) evaluated by spiral CT scan; of these, only 13 of 25 PTXs (52%) were revealed by chest Rx (sensitivity, 52%; specificity, 100%), while 23 of 25 PTXs (92%) were identified by lung US with one false-positive result (sensitivity, 92%; specificity, 99.4%). In 20 of 25 cases, there was agreement on the extension of the PTX between CT lung scan and lung US with a mean difference of 1.9 cm (range, 0 to 4.5 cm) in the localization of retroparietal air extension; chest Rx was not able to give quantitative results. CONCLUSIONS: Lung US scans carried out in the ED detect occult PTX and its extension with an accuracy that is almost as high as the reference standard (CT scanning).     

Automatic objective diagnosis of lymph nodal disease by B-mode images from convex-type echobronchoscopy

BACKGROUND: We investigated whether artificial neural networks (ANNs) could diagnose pathology of lymph nodes by feeding B-mode images from convex-type echobronchoscopy to ANNs. METHODS: Subjects comprised 91 patients who had undergone endobronchial ultrasonography transbronchial needle aspiration at our hospital between April 2005 and March 2007. Diagnosis was lymph node metastasis from lung cancer in 66 patients, and sarcoidosis in 25 patients. Layered ANNs consisting of input, middle layers, and output layers were prepared. Back-propagation was chosen as a learning algorithm. For the malignant findings, images obtained from six patients with lymph node metastasis of lung cancer (ie, adenocarcinoma, two patients; squamous cell carcinoma, two patients; small cell carcinoma, two patients) were used. As benign findings, typical images obtained from three patients with sarcoidosis were used. For each image used for supervised training, 5, 10, or 15 regions of interest were randomly selected. Repeated learning comprised either 500,000 or 1,000,000 repetitions. A total of five thoracic surgeons were asked to diagnose the pathology base on the same images. Accuracies were compared between ANNs and thoracic surgeons. RESULTS: The diagnostic accuracy of the surgeon with 5 years of experience and that of the surgeon with 1 year of experience were 78% and 51%, respectively, compared to 91% for the ANNs. CONCLUSION: Assessment of B-mode images by ANNs may offer a useful basis for automatic diagnostic methods.