Lower Lobe Research Articles

Microscopic polyangiitis, an onset with diffuse alveolar hemorrhage

Introduction: antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis is a group of complex chronic diseases that cause morbidity, systemic organ damage, therapeutic overload, and risk of relapse. Microscopic polyangiitis (MPA) primarily affects small vessels in the lungs and kidneys, characterized by inflammation that can lead to necrosis of blood vessels, presence of ANCA in the bloodstream, and absence of necrotizing inflammation of the parenchyma in histopathology. Methods: we present the case of a 58-year-old female patient with hemoptysis, fever, and dyspnea. Results: laboratory tests show anemia, leukocytosis, positive p-ANCA, hematuria, and proteinuria. The CT scan reveals areas of increased attenuation with a ground-glass pattern and centrilobular nodular opacities occupying the middle lobe and both lower lobes. The patient also tested positive for MPO-ANCA, leading to the diagnosis of ANCA-positive vasculitis, specifically microscopic polyangiitis with pulmonary and renal involvement, pneumonia, and renal insufficiency. She received appropriate medical treatment, resulting in adequate resolution. Conclusions: microscopic polyangiitis requires interdisciplinary management, which, along with radiological findings, contributes to the early diagnosis and timely treatment of the pathology

Rapid diagnosis of alveolar echinococcosis from lung puncture sample using metagenomic next-generation sequencing: a case report

IntroductionAlveolar echinococcosis (AE), caused by the larval forms of Echinococcus multilocularis, is a zoonotic disease affecting the liver, lungs, lymph nodes, kidneys, brain, bones, thyroid, and other organs. Diagnosing AE in a non-endemic area is usually challenging. With the rapid development and increasing application of sequencing techniques in recent years, metagenomic next-generation sequencing (mNGS) has become a powerful tool for diagnosing rare infectious diseases.Case PresentationA 45-year-old woman was admitted to the hospital for the presence of pulmonary shadows for more than 3 months. The lung computed tomography (CT) at a local hospital revealed scattered solid and quasi-circular nodules in the left upper lobe, left lower lobe, right middle lobe, and right lower lobe. The largest nodule was located in the dorsal part of the right lung, measuring 2.0 × 1.7 × 1.5 cm. Moreover, abdominal CT revealed one space-occupying lesion each in the left and right lobes. The pathological analysis of the lung biopsy specimen revealed infiltration of lymphocytes, plasma cells, and eosinophils in the alveolar wall and interstitial area. No pathogenic bacteria were observed in the sputum smear and culture tests. There were no parasite eggs in the stool. The mNGS of the lung puncture tissue revealed 6156 sequence reads matching E. multilocularis; thus, the condition was diagnosed as AE. Albendazole 400 mg was administered twice daily, and the patient was stable during follow-up.ConclusionThis case emphasizes the role of mNGS in diagnosing AE. As a novel, sensitive, and accurate diagnostic method, mNGS could be an attractive approach for facilitating early diagnosis and prompt treatment of infectious diseases, especially when the infection was caused by rare pathogens.

Recurrent catamenial hemoptysis: diagnostic challenges and management strategies—a case report

Catamenial hemoptysis (CH) is a rare, known disease for which diagnosis is crucial and treatment is indefinite. In this case report, CH was identified 2 years ago while taking medical history of the patient. It has disclosed hemoptysis at night with breathlessness that was concurrent with her menses every month for the past 6 months. A series of radiological tests followed by a bronchoscopic examination during menses confirmed the diagnosis. A complex fluid-filled cystic lesion with few air foci in the right lower lobe superior segment with ground glass opacity was seen by a CT scan test. Subsequent bronchoscopy examination showed an active bleeding site at the right lower lobe superior segment. The bronchial wash tests were negative for microbial infections as well as for malignancies. Bronchial artery embolization (BAE) was done and it ceased the hemoptysis. However, it recurred after 2 years of the BAE procedure. The symptoms and amount of hemoptysis were milder; hence, repeated BAE was not required. Earlier, the patient refused hormonal therapy (HT) owing to its side effects, but this time, she accepted HT. After 2 months of HT, hemoptysis gradually ceased. If complications arise in the future, then surgical treatment along with HT (combination therapy) would be the course of treatment. The diagnosis of CH is challenging, and treatment procedures vary from patient to patient; hence, they are customised. Hormones regulate the CH recurrence even though the symptoms have ceased after treatment. Therefore, regular follow-up and close vigilance are crucial requirements.

Diffuse pulmonary arteriovenous malformation presenting with secondary polycythemia and headaches: a case report

BackgroundPulmonary arteriovenous malformations are a relatively uncommon medical condition, affecting roughly 1 in every 2500 individuals. Of those suffering from pulmonary arteriovenous malformations, 80% have an underlying genetic condition: hereditary hemorrhagic telangiectasia.Case presentationWe present the case of a 20-year-old Pakistani male with a history of persistent slower-onset frontal headaches that increased in severity within the course of the day. His hemoglobin was 18 g/dl, indicating polycythemia, for which he had undergone seven venesections in a month previously. His physical examination was unremarkable. His computed tomography scan depicted multiple dilated tortuous vessels with branching linear opacities in the right lower lobe of the lungs. The multiple feeding arteries were supplied by the right main pulmonary artery, and the large draining veins led to the right inferior pulmonary vein. This was identified as a diffuse pulmonary arteriovenous malformation. He was recommended for a right pulmonary artery angiogram. It showed multiple tortuous vessels with a nidus and large draining veins—features of a diffuse arteriovenous malformation in the right lower lobe of the lung consistent with the computed tomography scan. Embolization of two of these vessels feeding the arteriovenous malformation was conducted, using Amplatzer Vascular plug 2, whereas multiple pushable coils (five coils) were used for embolizing the third feeding vessel. This achieved 70–80% successful embolization of right pulmonary AVM; however, some residual flow was still seen in the arteriovenous malformation given the complexity of the lesion. Immediately after, his oxygen saturation improved from 78% to 96%.ConclusionDiffuse pulmonary arteriovenous malformations, as seen in this patient, are rare, accounting for less than 5% of total pulmonary arteriovenous malformations diagnosed. The patient presented with a complaint of progressive frontal headaches, which can be attributed to low oxygen saturation or the presence of a cerebral arteriovenous malformation. There was no history of hereditary hemorrhagic telangiectasia in the patient’s family. Furthermore, although most patients with hereditary hemorrhagic telangiectasia and hence pulmonary arteriovenous malformation have complaints of iron-deficiency anemia, our patient in contrast was suffering from polycythemia. This can be explained as a compensatory mechanism in hypoxemic conditions. Moreover, the patient had no complaint of hemoptysis or epistaxis, giving a varied presentation in comparison with a typical pulmonary arteriovenous malformation.

Radiation diagnosis of single lung hemangioendothelioma in combination with atypical carcinoid – literature review and clinical observation

A clinical case of epithelioid hemangioendothelioma (EHEL) in combination with atypical lung carcinoid (AC) is presented. According to computed tomography (CT), magnetic resonance imaging (MRI) in the lower lobe of the right, a solid-fluid formation was easily identified, associated with the lower lobe artery, slightly accumulating 18F-FDG. CT and PET monitoring for 6 years did not reveal any negative dynamics of the lesion. After suffering from Covid-19 associated pneumonia, the patient developed episodes of hemoptysis and shortness of breath. CT and PET scans revealed an increase in the size of a focal formation in C6 of the right lung, a significant increase in metabolic activity, and accumulation of radionuclide in the mediastinal lymph nodes and the spinous process of the ThII vertebral body. Lower bilobectomy revealed EHEL and a previously unrecognized atypical carcinoid with metastases to the bifurcation lymph nodes.

Slotted meandered waveguide antenna for X-band radar applications

ABSTRACT This work presents a unique one-dimensional (1D) FSA powered by rectangular meander waveguide which finds usage in bird monitoring and detection in wind farms. Large scan volume, high frequency sensitivity, lower side lobe level and excellent directivity are few of the varied advantages of the suggested approach. The suggested travelling-wave FSA operates in the X-band uses a periodically loaded standard WR90 waveguide and is vertically polarised. The propagation properties and fundamental ideas of the meander-line unit are thoroughly studied for frequency-scanning based applications. The scanning performance over frequency range is enhanced by using the proposed meandering feeding mechanism. Dumbbell-shaped radiating slots are utilised in the waveguide. The beam width in the elevation plane is narrowed by embedding an E-plane horn antenna over it. Using CST microwave studio, the proposed FSA with 10 radiating elements is simulated in order to predict the scanning performance over the frequency range of 9.425 to 10.025 GHz. The results demonstrate a gain above 21 dBi and a high 55-degree scanning coverage performance. The lower SLL is observed around 13 dB. Aluminium is used in the fabrication of the suggested approach. When the FSA is evaluated after manufacture, measurements and simulations accord quite well.

First real-time imaging of bronchoscopic lung volume reduction by electrical impedance tomography

BackgroundBronchoscopic lung volume reduction (BLVR) with one-way endobronchial valves (EBV) has better outcomes when the target lobe has poor collateral ventilation, resulting in complete lobe atelectasis. High-inspired oxygen fraction (FIO2) promotes atelectasis through faster gas absorption after airway occlusion, but its application during BLVR with EBV has been poorly understood. We aimed to investigate the real-time effects of FIO2 on regional lung volumes and regional ventilation/perfusion by electrical impedance tomography (EIT) during BLVR with EBV.MethodsSix piglets were submitted to left lower lobe occlusion by a balloon-catheter and EBV valves with FIO2 0.5 and 1.0. Regional end-expiratory lung impedances (EELI) and regional ventilation/perfusion were monitored. Local pocket pressure measurements were obtained (balloon occlusion method). One animal underwent simultaneous acquisitions of computed tomography (CT) and EIT. Regions-of-interest (ROIs) were right and left hemithoraces.ResultsFollowing balloon occlusion, a steep decrease in left ROI-EELI with FIO2 1.0 occurred, 3-fold greater than with 0.5 (p < 0.001). Higher FIO2 also enhanced the final volume reduction (ROI-EELI) achieved by each valve (p < 0.01). CT analysis confirmed the denser atelectasis and greater volume reduction achieved by higher FIO2 (1.0) during balloon occlusion or during valve placement. CT and pocket pressure data agreed well with EIT findings, indicating greater strain redistribution with higher FIO2.ConclusionsEIT demonstrated in real-time a faster and more complete volume reduction in the occluded lung regions under high FIO2 (1.0), as compared to 0.5. Immediate changes in the ventilation and perfusion of ipsilateral non-target lung regions were also detected, providing better estimates of the full impact of each valve in place.Trial registrationNot applicable.

Primary lung chordoma: a case report

BackgroundChordoma, a rare malignant tumor arising from notochordal tissue, usually occurs along the spinal axis. Only a few published reports of primary lung chordomas exist. Herein, we present a case of primary lung chordoma and discuss important considerations for diagnosing rare chordomas.Case presentationWe report a case of primary lung chordoma in a 39-year-old male with a history of testicular mixed germ-cell tumor of yolk sac and teratoma. Computed tomography revealed slow-growing solid lesions in the left lower lobe. We performed wedge resection for suspected germ-cell tumor lung metastasis. Histologically, large round or oval cells with eosinophilic cytoplasm were surrounded by large cells with granular, lightly eosinophilic cytoplasm. Tumor cells were physaliphorous. Immunohistochemistry was positive for brachyury, S-100 protein, epithelial membrane antigen, vimentin, and cytokeratin AE1/AE3, suggesting pulmonary chordoma. Re-examination of the testicular mixed germ-cell tumor revealed no notochordal elements. Although some areas were positive for brachyury staining, hematoxylin and eosin (HE) staining did not show morphological features typical of chordoma. Complementary fluorescence in situ hybridization (FISH) of the lung tumor confirmed the absence of isochromosome 12p and 12p amplification. Thus, a final diagnosis of primary lung chordoma was established.ConclusionsIn patients with a history of testicular mixed germ cell tumors, comparison of histomorphology using HE and Brachyury staining of lung and testicular tumors, and analyzing isochromosome 12p and 12p amplification in lung tumors using FISH is pivotal for the diagnosis of rare lung chordomas.

Ischemic strokes due to pulmonary arteriovenous malformations: A systematic review.

Pulmonary arteriovenous malformations (PAVMs) can cause acute ischemic strokes (AISs) through paradoxical embolism. The clinical and imaging features of AIS due to PAVMs have not been studied. We report a case and perform a systematic review of the clinical and imaging characteristics of patients with AIS due to PAVMs. This may provide clues to screen patients with AIS for PAVMs and treat them appropriately to prevent further strokes. MEDLINE, EMBASE, and Web of Science databases were searched from inception to October 2023. We included patients of any age with AIS attributed to PAVM. Studies without clinical data were excluded. Demographics, AIS characteristics (location and arterial territories), and PAVM characteristics (location, size, and treatment) were recorded. A 47-year-old female presented with acute vertigo and gait imbalance. Magnetic resonance imaging showed AIS in the right cerebellum. CT chest confirmed a PAVM in the right lower lobe. Endovascular coil closure was performed. We identified 102 patients from 96 records. The mean age was 47.4 ± 17 years (67% female). Seventy percent had single AIS and 30% had multiple. The location was anterior circulation in 50%, posterior in 37%, and both in 13%. The most common arterial territory was middle-cerebral (51%), followed by posterior-cerebral (25%). PAVMs were mostly single (78%) and in the lower lobes (66%). Thirty-three had hereditary hemorrhagic telangiectasia (HHT) (33%). PAVM-related strokes occur at a young age and may have a high propensity for multifocality and posterior circulation location. Patients with PAVMs and AIS should be screened for HHT and venous thromboses.

Successful Removal of a Boiled Soybean Using Flexible Bronchoscopy

Background: In developed countries, the number of patients experiencing aspiration for foreign bodies is increasing due to the aging population. Most cases are managed with flexible bronchoscopy; however, training is challenging for many bronchoscopists because of the limited number of available facilities and the few opportunities to perform the procedure. Case Presentation: An 87-year-old patient with a history of pulmonary non-tuberculous mycobacteria was admitted to our hospital for bacterial pneumonia. The day after admission, the patient reported aspirating a boiled soybean during breakfast. A chest computed tomography revealed an oval shadow, approximately 10 mm in size, in the bronchus of the right lower lobe, suspected to be the aspirated soybean. Using a flexible bronchoscope, we successfully removed the boiled soybean with a brush, curettage, and basket forceps without complications. Conclusions: There is no standardized method for removing foreign bodies; the procedure should be adapted according to the type of foreign body, the site of obstruction, cost, and the medical resources available in the hospital.

Computed tomography (CT) quantitative assessment of single lobe emphysema correlates with chronic obstructive pulmonary disease (COPD) severity: a cross-sectional study with retrospective data collection.

In the past, many researchers have studied the correlation between quantitative parameters of computed tomography (CT) and parameters of pulmonary function test (PFT) in patients with chronic obstructive pulmonary disease (COPD) with good results. Most of these studies have focused on the whole-lung level. In this study, we analyzed the biphasic CT lung volume parameters and the percentage of emphysema volume in different lobes of the lungs of patients with different grades of COPD and assessed their relationship with different lung function indices. We retrospectively collected patients who underwent PFTs at The First Affiliated Hospital of Guangzhou Medical University from 1 July 2019 to 27 January 2020, and underwent chest respiratory dual-phase CT scans within 1 week, including 112 non-COPD patients and 297 COPD patients. We quantified the biphasic CT lung volume parameters and the percentage of emphysema volume in different lobes using a pulmonary image analysis tool. One-way analysis of variance (ANOVA) and Kruskal-Wallis H method were used to compare the quantitative CT parameters of each lung lobe in different groups. The correlation between quantitative CT parameters of different lung lobes and lung function indices was assessed using multiple linear regression. Among the 3 biphasic CT lung volume parameters, only volume change/inspiratory lung volume (∆LV/LVin) in the non-COPD control, mildly to moderately severe, and severe to extremely severe groups had statistical differences in each lobe level (all P<0.05). Correlation was significant between LVin and different lung function indices and between low attenuation areas percent below the threshold of -950 in the inspiratory phase [low attenuation area below -950 in the inspiratory phase (%LAA-950in)] and lung function indices in the left lower lobe (all P<0.05). There was statistically significant correlation between expiratory lung volume and ∆LV/LVin and lung function indices in the right lower lung (all P≤0.001). In the remaining lobes, LVin, expiratory lung volume, ∆LV/LVin, and %LAA-950in correlated with only some of the lung function indices. The percentage of emphysema volume did not differ between lobes in the non-COPD control and severe to extremely severe COPD populations. LVin and %LAA-950in in the left upper lobe, expiratory lung volume and ∆LV/LVin in the right lower lobe were more reflective of the changes in lung function indices of the patients, whereas the correlation of the 3 biphasic CT lung volume parameters and the percentage of emphysema volume in the upper lobes of both lungs and the right middle lung with lung function indices was unclear.

Non-small cell lung carcinoma with clear cell features: a clinicopathologic, immunohistochemical, and molecular study of 31 cases.

Non-small cell lung carcinoma with predominantly clear cell features is a rare histologic presentation of lung carcinoma. We have examined 31 cases of lung carcinomas showing extensive clear cell features. The patients were 10 women and 21 men aged 47-92years (mean: 70years). The tumors showed a predilection for the right upper and lower lobes and measured from 0.8 to 9.5cm (mean: 4.2cm). By immunohistochemistry, 9 cases were typed as adenocarcinoma, 19 cases as squamous cell carcinoma, and 3 showed a "null" phenotype with complete loss of markers for adenocarcinoma or squamous cell carcinoma. Most cases that typed as adenocarcinoma showed a solid growth pattern. A subset of the solid adenocarcinoma cases showed a distinctive "pseudosquamous" morphology. Next-generation sequencing was performed in 20 cases and showed a variety of molecular alterations. The most common abnormalities were found in the TP53 gene (9 cases), FGFR gene family (8 cases), KRAS (5 cases), AKT1 (5 cases), and BRAF (3 cases). Clinical follow-up was available in 21 patients; 16/21 patients died of their tumors from 6months to 12years after initial diagnosis (mean: 4.2years, median: 1.5years). Four patients were alive and well from 4 to 27years (mean: 11.5years, median: 7.5years); all were pathologic stage 1 or 2. NSCLC with clear cell features can display aggressive behavior and needs to be distinguished from various other tumors of the lung that can show clear cell morphology. The identification of targetable molecular alterations in some of these tumors may be of value for therapeutic management.

Aspergillus oryzae Isolated from Lung Tissue Sample in a Chronic Respiratory Illness Patient from South India

Opportunistic fungal infection by Aspergillus oryzae in patients with chronic respiratory condition is rare in India. A 52-year-old male with a history of diabetes mellitus, chronic smoking, and alcoholism presented with chronic cough, breathlessness, and recurrent blood in sputum. CT imaging revealed features consistent with old pulmonary tuberculosis sequelae and the presence of a right lung lower lobe aspergilloma. The patient underwent a right lower lobectomy, and histopathological examination confirmed severe acute and chronic bronchiolitis with bronchiectasis and organizing pneumonia, indicative of fungal ball formation. Microbiological analysis identified Aspergillus species, possibly A. flavus complex, with sequencing confirming A. oryzae. This case is unique as A. oryzae is typically associated with food fermentation and rarely implicated in invasive lung infections, especially outside regions of traditional exposure, like Japan. The rarity of this presentation underscores the importance of considering unusual pathogens in clinical practice and utilizing advanced diagnostic techniques such as sequencing for accurate identification. The successful outcome of this case, with prolonged antifungal therapy based on microbiological confirmation and clinical follow-up, suggests the importance of personalized treatment strategies. This case report adds to the growing body of evidence on the clinical significance and pathogenic potential of A. oryzae. It underscores the importance of continued vigilance and research in fungal infections.

CURRENT DRUG THERAPY OPTIONS FOR DISSEMINATED HER2-POSITIVE BREAST CANCER AT THE KAZAKH SCIENTIFIC RESEARCH INSTITUTE OF ONCOLOGY AND RADIOLOGY: A CLINICAL CASE

Relevance: Distant outcomes of treatment for Her2neu-positive metastatic breast cancer are improving due to access to innovative drug therapies. The study aimed to demonstrate the initial experience of treating a patient with progressive disseminated hormone receptor-positive breast cancer expressing HER2 (3+) and nearly exhausted options for anti-tumor drug therapy using trastuzumab deruxtecan. Methods: The paper describes a clinical case of a female patient born in 1977 who was diagnosed with Stage IV breast cancer (T1N1M1), invasive ductal carcinoma, and treated at the Kazakh Institute of Oncology and Radiology (Almaty, Kazakhstan). Immunohistochemical luminal subtype “B” with Her2neu (3+) expression. Metastatic involvement of skeletal bones with pain syndrome, lungs, liver, axillary, parasternal, and para-mediastinal lymph nodes. Since June 2023, monoclonal antibody conjugate trastuzumab deruxtecan therapy was initiated. The efficacy of fifth-line therapy was assessed using RECIST 1.1 before and during treatment. According to RECIST 1.1., target lesions included a conglomerate of hyperplastic axillary lymph nodes on the right, measuring 1.6 cm, parasternal lymph node 1.6 cm, a lesion in the parenchyma of the lower lobe of the left lung 1.3 cm, lesions (n=2) in the parenchyma of segment 2 of the left liver lobe 1.8 cm and 3.6 cm. Non-target lesion: hyperplastic para-mediastinal lymph nodes SLD 9.9 cm. Results: Pain syndrome was completely relieved after treatment. According to RECIST 1.1. in April 2024, after 11 courses of therapy, target lesions showed size reduction: conglomerate of hyperplastic axillary lymph nodes on the right decreased to 1.0 cm, lesion in the parenchyma of the lower lobe of the left lung increased to 2.7 cm, parasternal lymph node was not visualized, lesions (n=2) in the parenchyma of segment 2 of the left liver lobe measured 1.6 cm and 2.7 cm. Non-target lesion: hyperplastic para-mediastinal lymph nodes were not visualized. Conclusion: According to the clinical study data (DESTINY-Breast02), applying antibody-drug conjugate (ADC) demonstrates better objective response and progression-free survival time in patients previously treated with trastuzumab and taxanes.

Pulmonary cryptococcosis in non-HIV-infected individuals: HRCT characteristics in 58 patients.

The aim of this study is to delineate the distinctive high-resolution computed tomography features of pulmonary cryptococcosis in non-HIV-infected patients. This retrospective analysis encompasses high-resolution computed tomography scans from 58 patients with histologically confirmed pulmonary cryptococcosis, focusing on the diagnostic challenges and the factors that lead to misdiagnosis. Analysis of computed tomography scans from these patients indicated that nodular or mass-like presentations were evident in 32 cases (55.2%), consolidation presentations in 7 cases (12.1%), and mixed presentations in 19 cases (32.8%). Lesions were predominantly located in the lower lobes of the lungs (40 cases, 69.0%) and in peripheral zones (55 cases, 94.8%). Notable radiographic signs included the presence of the burr sign in 55 cases (94.8%), lobulation sign in 53 cases (91.4%), halo sign in 53 cases (91.4%), and air bronchogram in 46 cases (79.0%). Moreover, 24 cases (41.4%) exhibited necrosis or cavitation, mediastinal lymphadenopathy was noted in 6 cases (10.3%), and pleural effusion was present in 5 cases (8.6%). Lesions were devoid of calcification. Pulmonary cryptococcosis ought to be contemplated in the differential diagnosis when computed tomography imaging exhibits patterns including, but not limited to, lower lobe and peripheral distribution, a broad base abutting the pleura, clustered growth with a propensity for fusion, air bronchogram within lesions, and peripheral halo sign.

Optimizing Choice of Skin Surrogates for Surface-Guided Stereotactic Body Radiotherapy of Lung Lesions Using Four-Dimensional Computed Tomography.

Image-guided radiotherapy supported by surface guidance can help to track lower lung lesions' respiratory motion while reducing a patient's exposure to ionizing radiation. However, it is not always clear how the skin's respiratory motion magnitude and its correlation with the lung lesion's respiratory motion vary between different skin regions of interest (ROI). Four-dimensional computed tomography (4DCT) images provide information on both the skin and lung respiratory motion and are routinely acquired for the purpose of treatment planning in our institution. An analysis of 4DCT images for 57 patients treated in our institution has been conducted to provide information on the respiratory motion magnitudes of nine skin ROIs of the torso, a tracking structure (TS) representing a lower lung lobe lesion, as well as the respiratory motion correlations between the nine ROIs and the TS. The effects of gender and the adipose tissue volume and distribution on these correlations and magnitudes have been analyzed. Significant differences between the ROIs in both the respiratory motion magnitudes and their correlations with the TS have been detected. An overall negative correlation between the ROI respiratory magnitudes and the adipose tissue has been detected for ROIs with rib cage support. A weak to moderate negative correlation between the adipose tissue volume and ROI-to-TS respiratory correlations has been detected for upper thorax ROIs. The respiratory magnitudes in regions without rib support tend to be larger for men than for women, but no differences in the ROI-to-TS correlation between sexes have been detected. The described findings should be considered when choosing skin surrogates for lower lung lesion motion management.

Beyond the Marrow: Unveiling Uncommon Sites of ALL Relapse with 18F-FDG PET/CT

AbstractExtramedullary infiltration of acute lymphoblastic leukemia/lymphoma (ALL) to genital organs is extremely rare. Here, we present a case report of an asymptomatic 49-year-old female, known case of precursor B-cell ALL, who was incidentally detected with thickened and heterogeneously hyperechoic endometrium on sonography. Contrast magnetic resonance imaging detected large polypoidal enhancing lesions showing intense diffusion restriction occupying the endometrial cavity and similar lesions in the left adnexa, left ovary, and fallopian tube which were suspicious for leukemic infiltration because of the clinical history and atypical appearance of the lesions. 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) was done which revealed intensely metabolically active lesion in the endometrial cavity, left adnexa, omental nodules, retroperitoneal lymph node, pancreatic lesion, and few irregular nodules in the right lower lobe. Biopsy findings confirmed extramedullary relapse of ALL. Hence, 18F-FDG PET/CT can act as a good whole body survey to look for extramedullary sites of relapse.

A case of lung metastasis from gastric cancer presenting as ground-glass opacity dominant nodules

BackgroundMost metastatic lung tumors present as solid nodules on chest computed tomography (CT). In contrast, ground-glass opacity on chest computed tomography usually suggests low-grade malignant lesions such as adenocarcinoma in situ or atypical adenomatous hyperplasia of the lung.Case presentationA 75-year-old woman with a history of gastric cancer surgery approximately 5 years prior was referred to the Department of Thoracic Surgery at our hospital because of two newly appearing pulmonary ground-glass opacity-dominant nodules on chest computed tomography. She had two ground-glass opacities in the right lower lobe, one in the S6 segment was 12 mm and the other in the S10 segment was 8 mm. On chest computed tomography 15 months prior to referral, the lesion in the S6 segment was 8 mm, and the lesion in the S10 segment was 2 mm. She was suspected to have primary lung cancer and underwent wide-wedge resection of the nodule in the S6 segment. In the resected specimen, polygonal tumor cells infiltrated the alveolar septa, with some tumor cells exhibiting signet ring cell morphology. Based on morphological similarities to the tumor cells of previous gastric cancers and the results of immunostaining, the patient was diagnosed with lung metastases of gastric cancer.ConclusionsPulmonary nodules in patients with a history of cancer in other organs, even if ground-glass opacity is predominant, should also be considered for the possibility of metastatic pulmonary tumors if they are growing rapidly.

Utility of using Indocyanine green to locate parathyroid adenoma and predict hypocalcemia

Introduction: Secondary hypocalcemia due to hypoparathyroidism is a frequent complication of parathyroidectomy, which has certain difficulties in terms of intraoperative localization of the gland, since the surgeon uses his sight, touch and experience, to reach the task of the surgical act. Clinical case: 62-year-old woman, who started her current condition 8 months ago when she was diagnosed with osteoporosis, with hypercalcemia and significant elevation of parathyroid hormone. Cervical ultrasound and 99mTc-MIBI scintigraphy were requested, showing a nodular image compatible with parathyroid adenoma in the left lower thyroid lobe. The patient underwent left inferior parathyroidectomy with the use of indocyanine green. Conclusion: The identification of a parathyroid adenoma intraoperatively with the aid of fluorescence appears to be a reproducible, safe and easy way to use when treating this type of endocrine pathology.

High-dimensional causal mediation analysis by partial sum statistic and sample splitting strategy in imaging genetics application.

Causal mediation analysis provides a systematic approach to explore the causal role of one or more mediators in the association between exposure and outcome. In omics or imaging data analysis, mediators are often high-dimensional, which brings new statistical challenges. Existing methods either violate causal assumptions or fail in interpretable variable selection. Additionally, mediators are often highly correlated, presenting difficulties in selecting and prioritizing top mediators. To address these issues, we develop a framework using Partial Sum Statistic and Sample Splitting Strategy, namely PS5, for high-dimensional causal mediation analysis. The method provides a powerful global mediation test satisfying causal assumptions, followed by an algorithm to select and prioritize active mediators with quantification of individual mediation contributions. We demonstrate its accurate type I error control, superior statistical power, reduced bias in mediation effect estimation, and accurate mediator selection using extensive simulations of varying levels of effect size, signal sparsity, and mediator correlations. Finally, we apply PS5 to an imaging genetics dataset of chronic obstructive pulmonary disease (COPD) patients ( N =8,897) in the COPDGene study to examine the causal mediation role of lung images ( p =5,810) in the associations between polygenic risk score and lung function and between smoking exposure and lung function, respectively. Both causal mediation analyses successfully estimate the global indirect effect and detect mediating image regions. Collectively, we find a region in the lower lobe of the right lung with a strong and concordant mediation effect for both genetic and environmental exposures. This suggests that targeted treatment toward this region might mitigate the severity of COPD due to genetic and smoking effects.