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Recent advances in bronchoscopic lung volume reduction (BLVR) offer new therapeutic alternatives for patients with emphysema and hyperinflation. Endobronchial valves and coils are 2 potential BLVR techniques which have been shown to improve pulmonary function and the quality of life in patients with emphysema. Current patient selection for LVR procedures relies on 3 main inclusion criteria: low attenuation area (in %), also known as emphysema score, heterogeneity score, and fissure integrity score. Volumetric analysis in combination with densitometric analysis of the affected lung lobe or segment with quantitative CT to determine emphysema severity play an important role in treatment planning and post-operative assessment. Due to the variations in lung anatomy, manual corrections are often required to ensure successful and accurate lobe segmentation for pathological and post-treatment CT scan analysis. The advanced development and utilisation of quantitative CT do not simply represent regional changes in pulmonary function but aids in analysis for better patient selection with severe emphysema who are most likely to benefit from BLVR.

DECT allows characterisation of materials by measuring attenuation values at two different X-ray energy levels.2 After the administration of iodinated intravenous contrast, DECT can be used to create iodine maps of the lungs at the voxel level, equivalent to pulmonary perfusion, and allows calculation of perfused PMBV.3 In the current study, PMBV is defined as the blood volume in the peripheral 2 cm of lung tissue excluding the area adjacent to the mediastinum, which was selected automatically in order to assess the regions of lung proven to contain vessels of 500 µm in diameter or less on autopsy.4 Quantitative measurements of emphysema were obtained through non-contrast CT, defined as the percentage of lung voxels with Hounsfield units below −950. While the study presents strong evidence for a link between microvascular loss and diffuse emphysema, limitations include potential selection bias and the lack of a gold standard for PMBV assessment. DECT has shown good correlation with nuclear medicine-based imaging modalities in the assessment of pulmonary perfusion: A retrospective study of 123 patients with severe emphysema compared lobar iodine perfusion values acquired using DECT to lobar technetium (Tc99m) distribution obtained through CT perfusion scintigraphy (SPECT-PS).9 The study showed good agreement between DECT and SPECT-PS, aligning with earlier studies,10 11 and highlighted the potential role for DECT in preoperative assessment for lung volume reduction procedures.9 Beyond the investigation of COPD and emphysema, DECT has also been applied to patients with COVID-19 pneumonitis to demonstrate microvascular perfusion abnormalities in affected patients.12 13 Another earlier study of the MESA COPD cohort recruited 144 participants to assess pulmonary microvascular blood flow (PMBF) using gadolinium-enhanced MRI, co-registering the images with CT to identify areas of morphologically emphysematous lung.

Regional lung cancer screening (LCS) is underway in England, involving a “lung health check” (LHC) and low-dose CT scan for those at high risk of cancer. Incidental findings from LHCs or CTs are usually referred to primary care. We describe the proportion of participants referred from the West London LCS pilot to primary care, the indications for referral, the number of general practitioner (GP) attendances and consequent changes to patient management, and provide an estimated cost-burden analysis for primary care. A small proportion (163/1542, 10.6%) of LHC attendees were referred to primary care, primarily for suspected undiagnosed chronic obstructive pulmonary disease (55/163, 33.7%) or for QRISK® (63/163, 38.7%) assessment. Ninety one of 159 (57.2%) participants consenting to follow-up attended GP appointments; costs incurred by primary care were estimated at £5.69/LHC participant. Patient management changes occurred in only 36/159 (22.6%) referred participants. LHCs result in a small increase to primary care workload provided a strict referral protocol is adhered to. Changes to patient management arising from incidental findings referrals are infrequent.

Acute respiratory distress syndrome in patients with Coronavirus disease 19 is associated with an unusually high incidence of pulmonary embolism and microthrombotic disease, with evidence for reduced fibrinolysis. We describe seven patients requiring invasive ventilation for COVID-19-associated acute respiratory distress syndrome with pulmonary thromboembolic disease, pulmonary hypertension ± severe right ventricular dysfunction on echocardiography, who were treated with alteplase as fibrinolytic therapy. All patients were non-smokers, six (86%) were male and median age was 56.7 (50–64) years. They had failed approaches including therapeutic anticoagulation, prone ventilation (n = 4), inhaled nitric oxide (n = 5) and nebulised epoprostenol (n = 2). The median duration of mechanical ventilation prior to thrombolysis was seven (5–11) days. Systemic alteplase was administered to six patients (50 mg or 90 mg bolus over 120 min) at 16 (10–22) days after symptom onset. All received therapeutic heparin pre- and post-thrombolysis, without intracranial haemorrhage or other major bleeding. Alteplase improved PaO2/FiO2 ratio (from 97.0 (86.3–118.6) to 135.6 (100.7–171.4), p = 0.03) and ventilatory ratio (from 2.76 (2.09–3.49) to 2.36 (1.82–3.05), p = 0.011) at 24 h. Echocardiographic parameters at two (1–3) days (n = 6) showed right ventricular systolic pressure (RVSP) was 63 (50.3–75) then 57 (49–66) mmHg post-thrombolysis (p = 0.26), tricuspid annular planar systolic excursion (TAPSE) was unchanged (from 18.3 (11.9–24.5) to 20.5 (15.4–24.2) mm, p = 0.56) and right ventricular fractional area change (from 15.4 (11.1–35.6) to 31.2 (16.4–33.1)%, p = 0.09). At seven (1–13) days after thrombolysis, using dual energy computed tomography imaging (n = 3), average relative peripheral lung enhancement increased from 12.6 to 21.6% (p = 0.06). In conclusion, thrombolysis improved PaO2/FiO2 ratio and ventilatory ratio at 24 h as rescue therapy in patients with right ventricular dysfunction due to COVID-19-associated ARDS despite maximum therapy, as part of a multimodal approach, and warrants further study.

BackgroundMethods to improve stratification of small (≤15 mm) lung nodules are needed. We aimed to develop a radiomics model to assist lung cancer diagnosis.MethodsPatients were retrospectively identified using health records from January 2007 to December 2018. The external test set was obtained from the national LIBRA study and a prospective Lung Cancer Screening programme. Radiomics features were extracted from multi-region CT segmentations using TexLab2.0. LASSO regression generated the 5-feature small nodule radiomics-predictive-vector (SN-RPV). K-means clustering was used to split patients into risk groups according to SN-RPV. Model performance was compared to 6 thoracic radiologists. SN-RPV and radiologist risk groups were combined to generate “Safety-Net” and “Early Diagnosis” decision-support tools.ResultsIn total, 810 patients with 990 nodules were included. The AUC for malignancy prediction was 0.85 (95% CI: 0.82–0.87), 0.78 (95% CI: 0.70–0.85) and 0.78 (95% CI: 0.59–0.92) for the training, test and external test datasets, respectively. The test set accuracy was 73% (95% CI: 65–81%) and resulted in 66.67% improvements in potentially missed [8/12] or delayed [6/9] cancers, compared to the radiologist with performance closest to the mean of six readers.ConclusionsSN-RPV may provide net-benefit in terms of earlier cancer diagnosis.

PurposeSeveral factors are known to affect lung ablation zones. Questions remain as to why there are discrepancies between achieved and vendor-predicted ablation zones and what contributing factors can be modified to balance therapeutic effects with avoidance of complications. This retrospective study of lung tumour microwave ablation analyses day 1 post-treatment CT to assess the effects of lesion-specific and operator-dependent factors on ablation zones.Methods and MaterialsConsecutive patients treated at a tertiary centre from 2018 to 2021 were included. All ablations were performed using a single microwave ablation device under lung isolation. The lung tumours were categorised as primary or secondary, and their “resistance” to ablation was graded according to their locations. Intraprocedural pulmonary inflation was assessed as equal to or less than the contralateral non-isolated lung. Ablation energy was categorised as high, medium, or low. Ablation zone dimensions were measured on day 1 CT and compared to vendor reference charts. Ablations with multiple needle positions or indeterminate boundaries were excluded.ResultsA total of 47 lesions in 31 patients were analysed. Achieved long axes are longer than predicted by 5 mm or 14% (p < 0.01) without overall short axis discrepancy. Secondary tumours (p = 0.020), low-resistance location (p < 0.01), good lung inflation (p < 0.01), low (p = 0.003) and medium (p = 0.038) total energy produce lengthened long axes by 4–6 mm or 10–19%. High total energy results in shorter than predicated short axes by 6 mm or 18% (p = 0.010).ConclusionWe identified several factors affecting ablation zone dimensions which may have implications for ablation planning and the avoidance of complications.

Three-dimensional reconstruction of trachea: diverticulum arising from distal third of trachea on the right. Thin slice (1 mm) CT scan with three-dimensional reconstruction is helpful in the diagnosis of tracheal diverticula and in identifying the site of rupture. GC contributed to literature review.

Pattern recognition is a key tool that enables radiologists to evoke certain diagnoses based on a radiologic appearance. In Shakespeare’s Hamlet, Polonius tells his son Laertes to dress well because “apparel oft proclaims the man”; this phrase is now expressed in modern parlance as “the clothes maketh the man”. Similarly in radiology, appearances are everything, and in the case of radiologic signs, occasionally “the clothes maketh the sign”. The radiologic signs described in this pictorial review resemble items of clothing, fabric types, headwear, or accessories and are found in the musculoskeletal, pulmonary, gastrointestinal, and genitourinary systems. These “clothing signs” serve as a useful visual trigger to help radiologists to identify particular disease entities. Teaching Points • Pattern recognition enables radiologists to evoke a diagnosis based on radiologic appearance . • The radiologic signs described in this review resemble clothing, fabric, or accessories . • These “clothing signs” serve as visual triggers that evoke particular disease entities .

BackgroundTo investigate whether histologic subtyping from biopsies can predict local recurrence after thermal ablation for lung adenocarcinoma.MethodsPatients treated with CT-guided thermal ablation for lung adenocarcinoma that had pre-ablation needle biopsy with analysis of histologic components were identified. Age, gender, smoking status, treatment indication (primary stage 1 tumor versus salvage), histologic subtype, ground-glass radiographic appearance, tumor size, ablation modality, and ablation margin were evaluated in relation to time to local recurrence (TTLR). Cumulative incidence of recurrence (CIR) was calculated using competing risks analysis and compared across groups using Fine and Grey method with clustering. Multivariate analysis was conducted with stepwise regression.ResultsThere were 53 patients with 57 tumors diagnosed as adenocarcinoma on pre-ablation biopsy and with histologic subtype analysis. Of these, 19% (11) had micropapillary components, 14% (8) had solid components, and 26% (15) had micropapillary and/or solid components. In the univariate analysis, solid (subdistribution hazard ratio [SHR] = 4.04, p = 0.0051, 95% confidence interval [CI] = 1.52–10.7), micropapillary (SHR = 3.36, p = 0.01, CI = 1.33–8.47), and micropapillary and/or solid components (SHR = 5.85, p = 0.00038, CI = 2.21–15.5) were significantly correlated with shorter TTLR. On multivariate analysis, the presence of micropapillary and/or solid component (SHR = 11.4, p = 0.00021, CI: 3.14–41.3) was the only independent predictor of TTLR. The 1-, 2-, and 3-year CIR in patients with micropapillary and/or solid components was 33, 49, and 66% compared to 5, 14, and 18% in patients with no micropapillary or solid components on biopsy specimens.ConclusionMicropapillary and/or solid histologic components identified in pre-ablation biopsy are associated with shorter TTLR after thermal ablation of lung adenocarcinoma.