Diagnostic accuracy and safety of CT-guided fine needle aspiration biopsy in cavitary pulmonary lesions

Objective

CT-guided transthoracic biopsy is a well-established method in the cytologic or histologic diagnosis of pulmonary lesions. The knowledge of its diagnostic performance and complications for cavitary pulmonary lesions is limited. The purpose of this study was to determine the diagnostic accuracy and safety of CT-guided fine needle aspiration biopsy (FNAB) in cavitary pulmonary lesions.

Materials and methods

102 consecutive patients with pulmonary cavitary lesions received CT-guided FNAB with use of an 18-gauge (n = 35) or 20-gauge (n = 67) Chiba for histology diagnosis. The sensitivity, specificity, and diagnostic accuracy of FNAB were calculated as compared with the final diagnosis. Complications associated with FNAB were observed. The diagnostic accuracy and complications were compared between patients with different lesion sizes and different cavity wall thickness.

Results

The overall sensitivity, specificity, and accuracy of FNAB were 96.3%, 98.0%, and 96.1%, respectively. The sensitivity, specificity, and diagnosis accuracy in different lesion size (<2 cm vs ≥2 cm), or different cavity wall thickness (<5 mm vs ≥5 mm) were not different (P > 0.05; 0.235). More nondiagnostic sample was found in wall thickness <5 mm lesions (P = 0.017). Associated complications included pneumothorax in 9 (8.8%) patients and alveolar hemorrhage in 14 patients (13.7%) and hemoptysis in 1 patient (1%). No different rate of complications was found with regard to lesion size, wall thickness, length of the needle path and needle size (P > 0.05).

Conclusion

CT-guided FNAB can be effectively ad safely used for patients with pulmonary cavitary lesions.     

Virtual bronchoscopy-guided transbronchial biopsy for aiding the diagnosis of peripheral lung cancer

Objective

The aim of this study was to evaluate the clinical value of virtual bronchoscopy (VB) in aiding diagnosis of peripheral lung cancer by transbronchial biopsy (TBB). In addition, we sought to systematically analyze the factors that affect the diagnostic sensitivity of VB-guided TBB for the evaluation of peripheral lung cancers.

Materials and methods

A hundred and twenty-two peripheral lung cancers from 122 patients (82 men and 40 women, 38-84 years; median 68.5 years) who were performed VB-guided TBB were evaluated retrospectively. VB was reconstructed from 1- or 0.5-mm slice thickness images of multi-detector CT (MDCT). Experienced pulmonologists inserted the conventional and ultrathin bronchoscopes into the target bronchus under direct vision following the VB image.

Results

A definitive diagnosis was established by VB-guided TBB in 96 lesions (79%). The diagnostic sensitivity of small pulmonary lesions ≤30 mm in maximal diameter (71%) was significantly lower than that of lesions >30 mm (91%, p = 0.008). For small pulmonary lesions ≤30 mm (n = 76), internal opacity of the lesion was the independent predictor of diagnostic sensitivity by VB-guided TBB, and the non-solid type lung cancers were significantly lower than the solid type and part-solid type lung cancers for diagnostic sensitivity (odds ratio = 0.161; 95% confidence interval = 0.033-0.780; p = 0.023).

Conclusion

Use of an ultrathin bronchoscope and simulation with VB reconstructed by high quality MDCT images is thought to improve pathological diagnosis of peripheral lung cancers, especially for solid and partly solid types. For small pulmonary lesions ≤30 mm, the lesion internal opacity is a significant factor for predicting the diagnostic sensitivity, and the sensitivity was low for small non-solid type of lung cancers.     

Tumorsize dependent detection rate of endorectal MRI of prostate cancer—A histopathologic correlation with whole-mount sections in 70 patients with prostate cancer

Purpose

To evaluate the value of T2w endorectal MRI (eMRI) for correct detection of tumor foci within the prostate regarding tumor size.

Materials and Methods

70 patients with histologically proven prostate cancer were examined with T2w eMRI before radical prostatectomy at a 1.5 T scanner. For evaluation of eMRI, two radiologists evaluated each tumor focus within the gland. After radical prostatectomy, the prostates were prepared as whole-mount sections, according to transversal T2w eMRI. For each slice, tumor surroundings were marked and compared with eMRI. Based on whole-mount section, 315 slices were evaluated and 533 tumor lesions were documented.

Results

Based on the T2w eMRI, 213 tumor lesions were described. In 137/213, histology could prove these lesions. EMRI was able to visualize 0/56 lesions with a maximum size of <0.3 cm (detection rate 0%), between 0.3 and 0.5 cm 4/116 (3%), between 1 and 0.5 cm 22/169 (13%), between 2 and 1 cm 61/136 (45%) and for >2 cm 50/56 (89%). False positive eMRI findings were: <0.3 cm n = 0, 0.5-0.3 cm n = 12, 0.5-1 cm n = 34, 1-2 cm n = 28 and >2 cm n = 2.

Conclusion

T2w eMRI cannot exclude prostate cancer with lesions smaller 10 mm and 0.4 cm³ respectively. The detection rate for lesions more than 20 mm (1.6 cm³) is to be considered as high.     

Percutaneous needle aspiration biopsy (PCNAB) of lung lesions: 5 years results with focusing on repeat PCNAB

Purpose

To evaluate 5 years results of percutaneous needle aspiration biopsy (PCNAB) for lung lesions and usefulness of the reaspiration or rebiopsy of lung lesions (repeat PCNAB).

Materials and methods

Six hundred and fifteen cases of PCNAB (591 initial PCNAB and 24 repeat PCNAB) performed under the CT or fluoroscopy guidance in 591 patients was enrolled. The procedure was done using an automated biopsy gun with a 20-G needle (519 cases) or a 20-G aspiration needle (96 cases). The pathologic results, type and rate of complications in the initial and repeat PCNAB were evaluated. The pathologic agreement rate between the initial and repeat PCNAB, and reasons of the repeat PCNAB were also evaluated.

Results

Of the 615 PCNAB cases, 345 cases yielded tumors and 270 cases yielded non-tumorous lesions. Of the tumorous lesions, 307 cases were primary lung malignancies, 34 cases were metastases, and 4 were benign tumors. The repeat PCNAB rate was 4.1% (24/591). There was no statistically significant difference between automated gun biopsy and needle aspiration as a biopsy tool for calling repeat PCNAB (p = 0.4034). The causes for a repeat PCNAB were inconclusive (n = 14) and unexpected pathologic results (n = 10). Of the 14 pathologically inconclusive cases on initial PCNAB, 9 cases revealed malignancy after the repeat PCNAB. Of the 10 cases with unexpected pathologic results on initial PCNAB, 3 cases yielded different pathologic results on repeat PCNAB from initial PCNAB. The cumulative complication rate of PCNAB was 11.4% (70/615).

Conclusion

PCNAB was useful for the diagnosis of pulmonary lesions. Repeat PCNAB might be helpful for the exact diagnosis of lung lesions where initial PCNAB yields inconclusive or unexpected pathologic results.     

Does tumor type affect local control by radiofrequency ablation in the lungs?

Objective

: To retrospectively evaluate the effect of tumor type on local control by radiofrequency ablation in the lungs.

Materials and methods

: This study included 252 lung tumors (mean size, 13.5 mm) in 105 patients (73 men and 32 women; mean age, 66.6 years) who underwent radiofrequency ablation with a multitined expandable electrode. Those tumors comprised five tumor types: primary lung cancer (n = 35) and pulmonary metastases from colorectal cancer (n = 117), lung cancer (n = 23), renal cell carcinoma (n = 49), and hepatocellular carcinoma (n = 28). Local control was evaluated with contrast-enhanced computed tomography. The overall local control rates were estimated as well as those for each tumor type using the Kaplan-Meier analysis. Local control rates for a given tumor type were compared with those for the four other types. Then, multivariate multilevel analysis was performed using the variables of tumor type, tumor size, contact with a vessel or bronchus, and procedure period.

Results

: The overall local control rates were 97%, 86%, 81%, and 76% at 6, 12, 18, and 24 months, respectively. Local control rates varied among the tumor types, and metastatic colorectal cancer showed significantly (P = .023) higher local control rates than those of the four other types. However, multivariate analysis indicated that the relative risk of local progression for a given tumor type was comparable to the risks for the four other types.

Conclusion

: Tumor type per se did not significantly influence local control.     

Macrocystic pancreatic lesions: differentiation of benign from premalignant and malignant cysts by CT

Objective

To assess useful CT features for differentiating benign from premalignant and malignant macrocystic pancreatic lesions.

Methods

Seventy-four patients with pathologically proven macrocystic pancreatic lesions were enrolled: 17 benign cysts (macrocystic serous cystadenoma, n = 12; congenital cyst; n = 5) and 57 premalignant and malignant cysts (mucinous cystic neoplasm, n = 28; intraductal papillary mucinous neoplasm of branch duct type, n = 20; tumor with cystic change, n = 9). Size, location, shape (lobulated, round or oval, or complex cystic with tubular cyst), wall thickness (thin, ≤1 mm; thick, >1 mm), internal surface (smooth or irregular), and other findings were analyzed with multiphasic CT with thin-section (2.5-3 mm) images. CT features between two groups were compared using univariate and multivariate stepwise logistic regression analyses.

Results

On univariate analysis, the differences for the shape (p = 0.007), wall thickness (p = 0.011), and internal surface (p = 0.012) between benign and premalignant and malignant cysts were significant. A lobulated shape, a thin wall and a smooth internal surface were more frequent in benign cysts, whereas a round or oval shape or a complex cystic shape with tubular cyst, a thick wall and an irregular internal surface were more frequent in premalignant and malignant cysts. On multivariate analysis, the shape (p = 0.002) and wall thickness (p = 0.025) were significant CT features for differentiating benign from premalignant and malignant cysts.

Conclusion

Shape and wall thickness are the main CT features for differentiating benign from premalignant and malignant macrocystic pancreatic lesions.     

US-guided interventional joint procedures in patients with rheumatic diseases—When and how we do it?

Objective

To describe the main indications and the technical steps to perform ultrasound guided procedures in patients with rheumatic diseases. To access procedures accuracy, safety and effectiveness.

Materials and methods

27 patients with pain related to articular complications of rheumatic diseases and according to previous radiographic or US exam were submitted to several US-guided procedures. 42% of patients (n = 11) had rheumatoid arthritis, 11% (n = 3) spondyloarthropathies, 18% (n = 5) psoriatic arthritis, 15% (n = 4) undifferentiated arthritis, 3% (n = 1) Sjögren syndrome and 11% (n = 3) had gout.Described procedures are synovial biopsies, intra-articular injections of corticosteroids, radiation synovectomy and synovial cysts drainage procedures. When a therapeutical procedure was made, patients were evaluated by 2 rheumatologists.Corticosteroids used were Prednisolone and Triamcinolone. Yttrium-90 was used for synovectomy.

Results

In all cases success was achieved with correct needle placement inside the joint. After injection/aspiration symptoms successfully solved with all patients improving their health status. No complications were recorded during follow-up period.

Conclusions

US-guidance is very reliable to afford a safety procedure always checking the injection, biopsy or aspiration. Guided-biopsy has high success rates obtaining several samples. Thus is also possible to use more powerful/long acting therapeutic drugs aggressive to extra-articular structures avoiding complications.     

Gadoxetate disodium-enhanced MR imaging: differentiation between early-enhancing non-tumorous lesions and hypervascular hepatocellular carcinomas

Purpose

To retrospectively assess imaging features that help differentiate early-enhancing non-tumorous (EN) hepatic lesions from hepatocellular carcinomas (HCCs) on gadoxetate disodium-enhanced MR imaging.

Materials and methods

Our institutional review board approved this retrospective study. We reviewed the studies of 158 patients (92 men and 65 women; age range: 29-91; mean age: 65.6 years) with chronic liver damage, who underwent gadoxetate disodium-enhanced MR imaging at 3T MR scanner. Hypervascular lesions identified during the hepatic artery phase were selected for a study cohort. The location, shape, size (maximum diameter and maximum area), and contrast enhancement signal intensity characteristics of the lesions were evaluated, then compared between the EN and HCC lesions.

Results

A total of 65 EN lesions (range: 3-60 mm, mean: 13.6 ± 10.6 mm) from 35 patients and 33 HCCs (range: 9-61 mm, mean: 19.3 ± 12.6 mm) from 20 patients were identified. Lesions were more frequently round or oval in shape for HCCs (n = 29; 88%) than ENs (n = 26; 40%) (P < 0.01). Unexpectedly, some ENs (n = 12; 18%) showed hypointensity on hepatocyte-phase, and 6 (50%) of them were T2 hyperintense. For lesions smaller than 2 cm (9 ENs and 21 HCCs) on hepatic arterial-phase images, the mean area of hypointensity in hepatocyte-phase (54.2 ± 33.1 mm²) was significantly smaller than those of the corresponding hyperintensity in hepatic arterial-phase (97.1 ± 42.0 mm²) for EN lesions (P = 0.019), whereas no significant difference in area was found for HCCs.

Conclusion

EN lesions may occasionally present with hypointensity during the hepatocyte-phase; presenting a diagnostic dilemma. In this situation, EN lesions may be differentiated from HCCs when a hypointense area in hepatocyte-phase is smaller than the corresponding hypervascular area in hepatic-arterial phase.     

Correlation between high-resolution computed tomography and galactomannan antigenemia in adult hematologic patients at risk for invasive aspergillosis

Objectives

To analyse the predominant radiological pattern of pulmonary lesions in adult hematologic patients at risk for invasive aspergillosis (IA) together with the results of serial serum Aspergillus galactomannan antigen testing (GM).

Material and methods

In a prospective study for patients at high risk of aspergillus pulmonary infection, serum GM were performed 2-3 times per week during the periods of high risk for IA and high-resolution CT (HRCT) was performed in case of abnormal chest X-ray (CXR) and/or persistent fever after 5 days of antibiotic treatment. Changes on HRCT scan were classified as airway IA and angioinvasive IA. IA was classified as proven or probable in accordance with the definitions stated by the European Organization for Research and Treatment of Cancer/Mycosis Study Group (EORTC-MS). Positive GM testing was not considered as microbiological criterion.

Results

38 hematological patients were diagnosed of probable (n = 28) or proven (n = 10) IA. 55% patients had a neutrophil count less than 500 mm⁻³ (n = 21), and 37% patients ≥2 risk factors for IA. All probable IA were diagnosed by bronchoalveolar lavage (BAL). Proven IA was reached by positive histopathologic and culture results of samples obtained by autopsy (n = 4), percutaneous (n = 3) or transbronchial biopsy (n = 3). 18 patients had airway IA, and 60% had a GM level ≥1.5. 20 patients were diagnosed of angioinvasive IA from which 80% had a GM level ≥1.5.

Conclusion

Serum GM levels may be lower in patients with airway IA than in those with an angioinvasive form. HRCT and serum GM are complementary tests in the diagnosis of IA.     

CT-guided percutaneous lung biopsy: comparison of conventional CT fluoroscopy to CT fluoroscopy with electromagnetic navigation system in 60 consecutive patients

Purpose

To determine if use of an electromagnetic navigation system (EMN) decreases radiation dose and procedure time of CT fluoroscopy guided lung biopsy in lesions smaller than 2.5 cm.

Materials/methods

86 consecutive patients with small lung masses (<2.5 cm) were approached. 60 consented and were randomized to undergo biopsy with CT fluoroscopy (CTF) (34 patients) or EMN (26 patients). Technical failure required conversion to CTF in 8/26 EMN patients; 18 patients completed biopsy with EMN. Numerous biopsy parameters were compared as described below.

Results

Average fluoroscopy time using CTF was 28.2 s compared to 35.0 s for EMN (p = 0.1). Average radiation dose was 117 mGy using CTF and 123 mGy for EMN (p = 0.7). Average number of needle repositions was 3.7 for CTF and 4.4 for EMN (p = 0.4). Average procedure time was 15 min for CTF and 20 min for EMN (p = 0.01). There were 7 pneumothoracesin the CTF group and 6 pneumothoraces in the EMN group (p = 0.7). One pneumothorax in the CTF group and 3 pneumothoraces in the EMN group required chest tube placement (p = 0.1). One pneumothorax patient in each group required hospital admission. Diagnostic specimens were obtained in 31/34 patients in the CTF group and 22/26 patients in the EMN group (p = 0.4).

Conclusions

EMN was not statistically different than CTF for fluoroscopy time, radiation dose, number of needle repositions, incidence of pneumothorax, need for chest tube, or diagnostic yield. Procedure time was increased with EMN.     

Contrast enhanced ultrasound of splenic lymphoma involvement

Objective

The aim of this study was to compare the value of contrast-enhanced ultrasonography (CEUS) with standard B-mode ultrasound (US) for diagnosis of splenic lymphoma involvement.

Methods

From 04/2005 to 10/2008 n = 250 lymphoma patients were investigated by standard B-mode US. A homogeneous splenic echotexture was found in 199 patients (79%). To clarify the benefit of CEUS in this group a pilot series was performed with 16 of the 199 lymphoma patients. All patients with an abnormal splenic echotexture on standard B-Mode US (n = 51) including focal hypoechoic splenic lesions (n = 41) and an inhomogeneous splenic texture (n = 10) were studied by CEUS. CEUS data were retrospectively evaluated. The diagnoses included indolent lymphoma (n = 27), aggressive lymphoma (n = 14), and Hodgkin's disease (n = 10). Number and size of lesions were determined by B-mode US and CEUS. The visualisation of splenic lymphoma involvement by CEUS in comparison to B-mode US was classified as worse, equal, or better.

Results

All patients with a homogeneous spleen on B-mode US (n = 16) had no visible focal lesions on CEUS. Study patients with focal lesions (n = 41) had a hypoechoic (n = 22) or isoechoic (n = 19) enhancement during the arterial phase, and a hypoechoic enhancement during the parenchymal phase (n = 41). The visualisation of focal splenic lymphoma was equal (n = 32), better (n = 6), or worse (n = 3). In all study patients with an inhomogeneous spleen on B-mode US (n = 10) no focal lesions were found by CEUS and the value of CEUS therefore was classified as worse.

Conclusion

CEUS has no clear advantage for diagnosis of splenic lymphoma involvement.     

MRI findings of pancreatic lymphoma and autoimmune pancreatitis: A comparative study

Purpose

To clarify whether there are differences in MRI findings between pancreatic lymphomas and autoimmune pancreatitis (AIP).

Materials and methods

MRI of 8 patients with pancreatic lymphomas and 21 patients with AIP were retrospectively reviewed. For multifocal pancreatic lymphomas (n = 2) and AIP (n = 4), the largest 2 lesions were evaluated. Ten pancreatic lymphomas and 25 AIP were compared on three bases: the signal intensity on T2-weighted images, internal homogeneity, and presence or absence of capsule-like rim. In 8 lymphomas and 19 AIP, the enhancement pattern on dynamic MRI was compared, as well.

Results

On T2-weighted images, pancreatic lymphomas comprised 5, 5 and 4 lesions with low (iso), slightly high, and moderately high intensity, respectively, while the numbers for AIP were 14, 10, and 1 (P < 0.01). Nine of 10 (90%) lymphomas appeared homogenous, and 11 of 25 (44%) AIP were homogenous (P < 0.05). A capsule-like rim was present in 9 of 25 (36%) AIP, but was not seen in lymphomas (P < 0.05). On dynamic MRI, 18 of 19 (94.7%) AIP showed persistent (n = 5) or delayed enhancement (n = 13), and 6 of 8 (75%) lymphomas showed low intensity without delayed enhancement (P < 0.001).

Conclusion

MRI findings for pancreatic lymphomas and AIP were significantly different, which may be helpful for the differential diagnosis of these two diseases.     

Value of diffusion-weighted MR imaging in the differentiation between benign and malignant cervical lymph nodes

Purpose

To evaluate echo-planar diffusion-weighted MR imaging (DWI) in the differentiation between benign and malignant cervical lymph nodes.

Materials and methods

35 consecutive patients with 55 enlarged (>10 mm) cervical lymph nodes underwent MR imaging at 1.5-T. DWI was performed using a single-shot echo-planar (SSEPI) MR imaging sequence with b values (b: diffusion factor) of 0, 500 and 1000 s/mm². Apparent diffusion coefficient (ADC) maps were reconstructed for all patients and ADC values were calculated for each lymph node. Imaging results were correlated with histopathologic findings after neck dissection or surgical biopsy, findings in PET/CT or imaging follow-up. Mann-Whitney test was used for statistical analysis and a receiver operating characteristic (ROC) curve analysis was performed.

Results

Cervical lymph node enlargement was secondary to metastases from squamous cell carcinomas [n = 25], non-Hodgkin’s lymphoma [n = 6], reactive lymphadenitis [n = 20], cat scratch lymphadenitis [n = 2] and sarcoidosis [n = 2]. The mean ADC values (×10⁻³ mm²/s) were 0.78 ± 0.09 for metastatic lymph nodes, 0.64 ± 0.09 for lymphomatous nodes and 1.24 ± 0.16 for benign cervical lymph nodes. ADC values of malignant lymph nodes were significantly lower than ADC values of benign lymph nodes. 94.3% of lesions were correctly classified as benign or malignant using a threshold ADC value of 1.02 × 10⁻³ mm²/s.

Conclusion

According to our first experience, DWI using a SSEPI sequence allows reliable differentiation between benign and malignant cervical lymph nodes.     

Evaluation of anterior knee laxity on MRI

Purpose

Evaluation of the ACL and anterior knee laxity on MR during anterior tibial translation.

Patients and methods

Three groups were identified based on clinical and arthrometric (KT-1000) data: normal ACL (n = 12), complete tear (n = 10) and partial tear (n = 20). MRI was performed without and with anterior tibial translation (pneumatic device) with morphological and laximetric analysis: drawer tests and dynamic evaluation of ligamentous tension.

Results

Intra- and inter-observer reproducibility was excellent, correlated to arthrometric data and clinical tests (Lachman, pivot shift). The difference between the drawer signs of normal subjects and patients with ACL tear was significant for a threshold value of 1,1 mm for the anterior drawer (sensitivity: 93,33%, specificity: 91,7%) and 2,8 mm for the posterior drawer (sensitivity: 86,7%, specificity: 100%). Dynamic evaluation of ligamentous tension was also reproducible, statistically correlated to the MR drawer tests and reliable for the diagnosis of ACL lesions. In this preliminary study, the distinction between complete and partial ACL tears could not be detected.

Conclusion

Anterior cruciate ligament function can be demonstrated on MR. The predictive value of this morphological and functional association should be determined in the management of patients with partial tears.     

Capillary telangiectasias of the pons. Does diffusion-weighted MR increase diagnostic accuracy?

Background and Purpose

Capillary telangiectasias are benign lesions of the brainstem which are sometimes difficult to distinguish from other lesions in standard MRI. The purpose of this study was to evaluate if diffusion-weighted imaging (DWI) could help to improve diagnostic accuracy.

Methods

148 MR examinations of patients with pontine lesions were evaluated retrospectively and revealed capillary telangiectasia (n = 18), presumed microvascular disease (n = 20), encephalitis disseminata (n = 21), pontine myelinolysis (n = 16), tumor (n = 20), acute infarction (n = 20), subacute infarction (n = 13) and chronic infarction (n = 20).All patients were examined using identical measurement parameters for DWI, Fluid attenuated inversion recovery, T2-weighted turbo spin-echo, and T1-weighted spin-echo before and after application of contrast agent in transverse orientation.

Results

All capillary telangiectasias showed low signal intensity in DWI and significant contrast enhancement after application of gadolinium. Hypointense signal on DWI was very rare for the remaining lesions: only 1 pontine myelinolysis, 1 tumor, 4 subacute infarctions, and 19 chronic infarctions also revealed low signal intensity on DWI. The combination of high signal intensity on T1-weighted post-contrast images and low signal intensity on DWI was found for all capillary telangiectasias, but only for 1/20 tumor and for 4/13 subacute infarctions. These lesions could be differentiated by their clinical course and/or MRI follow-up examinations.The results of the visual assessment were confirmed by quantitative evaluation.

Conclusion

DWI seems to be a useful adjunct for the diagnosis of capillary telangiectasias which will facilitate the differential diagnosis concerning tumorous, inflammatory and ischemic lesions.     

Risk factor analysis of pulmonary hemorrhage complicating CT-guided lung biopsy in coaxial and non-coaxial core biopsy techniques in 650 patients

Purpose

To evaluate the risk factors involved in the development of pulmonary hemorrhage complicating CT-guided biopsy of pulmonary lesions in coaxial and non-coaxial techniques.

Materials and methods

Retrospective study included CT-guided percutaneous lung biopsies in 650 consecutive patients (407 males, 243 females; mean age 54.6 years, SD: 5.2) from November 2008 to June 2013. Patients were classified according to lung biopsy technique in coaxial group (318 lesions) and non-coaxial group (332 lesions). Exclusion criteria for biopsy were: lesions <5 mm in diameter, uncorrectable coagulopathy, positive-pressure ventilation, severe respiratory compromise, pulmonary arterial hypertension or refusal of the procedure. Risk factors for pulmonary hemorrhage complicating lung biopsy were classified into: (a) patient's related risk factors, (b) lesion's related risk factors and (d) technical risk factors. Radiological assessments were performed by two radiologists in consensus. Mann–Whitney U test and Fisher's exact tests for statistical analysis. p values <0.05 were considered statistically significant.

Results

Incidence of pulmonary hemorrhage was 19.6% (65/332) in non-coaxial group and 22.3% (71/318) in coaxial group. The difference in incidence between both groups was statistically insignificant (p = 0.27). Hemoptysis developed in 5.4% (18/332) and in 6.3% (20/318) in the non-coaxial and coaxial groups respectively. Traversing pulmonary vessels in the needle biopsy track was a significant risk factor of the development pulmonary hemorrhage (incidence: 55.4% (36/65, p = 0.0003) in the non-coaxial group and 57.7% (41/71, p = 0.0013) in coaxial group). Other significant risk factors included: lesions of less than 2 cm (p value of 0.01 and 0.02 in non-coaxial and coaxial groups respectively), basal and middle zonal lesions in comparison to upper zonal lung lesions (p = 0.002 and 0.03 in non-coaxial and coaxial groups respectively), increased lesion's depth from the pleural surface (p = 0.021 and 0.018 in non-coaxial and coaxial groups respectively), increased distance of traversed lung in the needle track of more than 2.5 cm (p = 0.001 in both groups). Insignificant risk factors were patient's age, gender or emphysema in both groups (p value >0.1 in both groups). Concomitant incidence of pneumothorax was 32.3% (21/65) in non-coaxial group and 36.6% (26/71) in coaxial group. Pulmonary hemorrhage in the majority of cases was treated conservatively.

Conclusion

Pulmonary hemorrhage complicating CT-guided core biopsy of pulmonary lesions, showed insignificant difference between coaxial and non-coaxial techniques. Significant risk factors of pulmonary hemorrhage included small and basal lesions, increased lesion's depth from pleural surface, increased length of aerated lung parenchyma crossed by biopsy needle and passing through vessels within the lung during puncture.     

Comparing culprit lesions in ST-segment elevation and non-ST-segment elevation acute coronary syndrome with 64-slice multidetector computed tomography

Background

Classifying acute coronary syndrome (ACS) as ST elevation ACS (STE-ACS) or non-ST elevation ACS (NSTE-ACS) is critical for clinical prognosis and therapeutic decision-making. Assessing the differences in composition and configuration of culprit lesions between STE-ACS and NSTE-ACS can clarify their pathophysiologic differences.

Objective

This study focused on evaluating the ability of 64-slice multidetector computed tomography (MDCT) to investigate these differences in culprit lesions in patients with STE-ACS and NSTE-ACS.

Methods

Of 161 ACS cases admitted, 120 who fit study criteria underwent MDCT and conventional coronary angiography. The following MDCT data were analyzed: calcium volume, Agatston calcium scores, plaque area, plaque burden, remodeling index, and plaque density.

Results

The MDCT angiography had a good correlation with conventional coronary angiography regarding the stenotic severity of culprit lesions (r  =  0.86, p < 0.001). The STE-ACS culprit lesions (n = 54) had significantly higher luminal area stenosis (78.6 ± 21.2% vs. 66.7 ± 23.9%, p = 0.006), larger plaque burden (0.91 ± 0.10 vs. 0.84 ± 0.12, p = 0.007) and remodeling index (1.28 ± 0.34 vs. 1.16 ± 0.22, p = 0.021) than those with NSTE-ACS (n = 66). The percentage of expanding remodeling index (remodeling index >1.05) was significantly higher in the STE-ACS group (81.5% vs. 63.6%, p = 0.031). The patients with STE-ACS had significantly lower MDCT density of culprit lesions than patients with NSTE-ACS (25.8 ± 13.9 HU vs. 43.5 ± 19.1 HU, p < 0.001).

Conclusions

Sixty-four-slice MDCT can accurately evaluate the stenotic severity and composition of culprit lesions in selected patients with either STE-ACS or NSTE-ACS. Culprit lesions in NSTE-ACS patients had significantly lower luminal area stenosis, plaque burden, remodeling index and higher MDCT density, which possibly reflect differences in the composition of vulnerable culprit plaques and thrombi.     

Computed tomographic features of 23 sporadic cases with Legionella pneumophila pneumonia

Objective

To describe the chest computed tomographic (CT) findings of Legionella pneumophila pneumonia.

Methods

CT scans obtained from 23 sporadic cases of L. pneumophila pneumonia were retrospectively reviewed. Chest CT findings were analyzed with regard to the patterns and distributions of pulmonary abnormalities. We also analyzed the histopathology of lungs from guinea pigs with experimentally induced L. pneumophila pneumonia.

Results

Consolidation and ground-glass opacity (GGO) were the main findings of CT scans in L. pneumophila pneumonia. The distribution of opacities was categorized as non-segmental (n = 20) and segmental (n = 4). Non-segmental distribution may follow an onset of segmental distribution. Pleural effusion was observed in 14 (58.3%) patients, of which 13 were accompanied with non-segmental distribution. Abscess formation was observed in only one immunocompromised patient. In the animal pneumonia model, the lesions comprised of terminal bronchioles, alveolar spaces, and interstitia. Small bacilli were observed to be contained by many macrophages within the alveoli.

Conclusion

Non-segmental distribution was significantly more frequent than segmental distribution in L. pneumophila pneumonia. It is possible that L. pneumophila infection initially results in segmental pneumonia, which progresses to typical non-segmental distribution.     

Abdominal aspergillosis: CT findings

Objective

In order to retrospectively evaluate the CT findings of abdominal aspergillosis in immunocompromised patients.

Materials and methods

CT scans were reviewed with regard to the sites, number, morphologic appearance, attenuation, and the contrast enhancement patterns of the lesions in six patients (5 women, 1 man; mean age, 43.4 years; range, 23-59 years) with pathologically proved abdominal aspergillosis by two gastrointestinal radiologists in consensus. Medical records were also reviewed to determine each patient's clinical status and outcome.

Results

All patients were immunocompromised state: 4 patients received immunosuppressive therapy for solid organ transplantation and 2 patients received chemotherapy for acute myeloid leukemia. Aspergillosis involved blood vessels (n = 3), liver (n = 2), spleen (n = 2), gastrointestinal tract (n = 2), native kidney (n = 1), transplanted kidney (n = 1), peritoneum (n = 1), and retroperitoneum (n = 1). CT demonstrated solid organ or bowel infarction or perforation secondary to vascular thrombosis or pseudoaneurysm, multiple low-attenuating lesions of solid organs presenting as abscesses, concentric bowel wall thickening mimicking typhlitis, or diffuse or nodular infiltration of the peritoneum and retroperitoneum.

Conclusion

Familiarity with findings commonly presenting as angioinvasive features or abscesses on CT, may facilitate the diagnosis of rare and fatal abdominal aspergillosis.     

CT Colonography: Role of a second reader CAD paradigm in the initial training of radiologists

Purpose

To evaluate the influence of CAD for the evaluation of CT colonography (CTC) datasets by inexperienced readers during the attendance of a dedicated hands-on training course.

Method and materials

Twenty-seven radiologists inexperienced in CTC (11 with no CTC training at all, 16 having previously reviewed no more than 10 CTC cases overall) attended a hands-on training course based on direct teaching on fifteen workstations (four Advantage Windows 4.4 with Colon VCAR software, GE; six CADCOLON, Im3D; five ColonScreen (Toshiba/Voxar) with ColonCAD™ API, Medicsight). During the course, readers were instructed to analyze 26 CTC cases including 38 colonic lesions obtained through low-dose MDCT acquisitions, consisting of 12 polyps sized less than 6 mm, 9 polyps sized between 6 and 10 mm, 12 polyps sized between 11 mm and 30 mm, and 5 colonic masses sized >3 cm. CTC images were reviewed by each reader both in 2D and 3D mode, respectively by direct evaluation of native axial images and MPR reconstructions, and virtual endoscopy or dissected views. Each reader had 15 min time for assessing each dataset without CAD, after which results were compared with those provided by CAD software. Global rater sensitivity for each lesion size before and after CAD usage was compared by means of two-tailed Student's t test, while sensitivity of each single reader before and after CAD usage was assessed with the McNemar test.

Results

For lesions sized <6 mm, global rater sensitivity was 0.1852 ± 0.1656 (mean ± SD) before CAD-assisted reading and 0.2345 ± 0.1761 after CAD (p = 0.0018). For lesions sized 6-9 mm, sensitivity was 0.2870 ± 0.1016 before CAD-assisted reading and 0.3117 ± 0.1099 after CAD (p = 0.0027). For lesions sized 10-30 mm, sensitivity was 0.5308 ± 0.2120 before CAD-assisted reading and 0.5637 ± 0.2133 after CAD (p = 0.0086), while for lesions sized >30 mm, sensitivity before CAD-assisted reading was 0.3556 ± 0.3105 and did not change after CAD usage (p = 1). Sensitivity of each single rater did not significantly differ before and after CAD for any lesion size category (McNemar test, p > 0.05). Specificity was not significantly different before and after CAD for any lesion size (>96% for all size categories).

Conclusion

CAD usage led to increased overall sensitivity of inexperienced readers for all polyps sizes, except for lesions >30 mm, but sensitivity of individual raters was not significantly higher compared with CAD-unassisted reading.