Noncalcified Nodules Research Articles

Comparison Between Magnetic Resonance Imaging and Computed Tomography in the Detection and Volumetric Assessment of Lung Nodules: A Prospective Study.

Rationale and ObjectivesComputed tomography (CT) lung nodule assessment is routinely performed and appears very promising for lung cancer screening. However, the radiation exposure through time remains a concern. With the overall goal of an optimal management of indeterminate lung nodules, the objective of this prospective study was therefore to evaluate the potential of optimized ultra-short echo time (UTE) MRI for lung nodule detection and volumetric assessment.Materials and MethodsEight (54.9 ± 13.2 years) patients with at least 1 non-calcified nodule ≥4 mm were included. UTE under high-frequency non-invasive ventilation (UTE-HF-NIV) and in free-breathing at tidal volume (UTE-FB) were investigated along with volumetric interpolated breath-hold examination at full inspiration (VIBE-BH). Three experienced readers assessed the detection rate of nodules ≥4 mm and ≥6 mm, and reported their location, 2D-measurements and solid/subsolid nature. Volumes were measured by two experienced readers. Subsequently, two readers assessed the detection and volume measurements of lung nodules ≥4mm in gold-standard CT images with soft and lung kernel reconstructions. Volumetry was performed with lesion management software (Carestream, Rochester, New York, USA).ResultsUTE-HF-NIV provided the highest detection rate for nodules ≥4 mm (n = 66) and ≥6 mm (n = 32) (35 and 50%, respectively). No dependencies were found between nodule detection and their location in the lung with UTE-HF-NIV (p > 0.4), such a dependency was observed for two readers with VIBE-BH (p = 0.002 and 0.03). Dependencies between the nodule's detection and their size were noticed among readers and techniques (p < 0.02). When comparing nodule volume measurements, an excellent concordance was observed between CT and UTE-HF-NIV, with an overestimation of 13.2% by UTE-HF-NIV, <25%-threshold used for nodule's growth, conversely to VIBE-BH that overestimated the nodule volume by 28.8%.ConclusionUTE-HF-NIV is not ready to replace low-dose CT for lung nodule detection, but could be used for follow-up studies, alternating with CT, based on its volumetric accuracy.

Cerebral paragonimiasis: Clinicoradiological features and serodiagnosis using recombinant yolk ferritin.

Cerebral paragonimiasis (CP), caused by aberrant migration of Paragonimus worms, frequently invokes serious illness. The causal relationship between the lesion characteristics and patients’ symptoms has poorly been understood. CP serodiagnosis has not been properly evaluated to date. A total of 111 CP cases were diagnosed in our laboratory between 1982 and 2003. This study retrospectively assessed the clinical and imaging characteristics of the 105 patients along with the evaluation of diagnostic potentials of recombinant P. westermani yolk ferritin (rPwYF) by enzyme-linked immunosorbent assay (ELISA) employing patients’ sera and cerebrospinal fluids (CSFs). We analyzed 60 male and 45 female patients; 50 early-stage patients with non-calcified enhancing nodule(s) (median age, 38 years; interquartile range [IQR], 24.75–52; median symptom duration, 0.75 years; IQR, 0.2–2) and 54 chronic cases having calcified lesion(s) (median age, 33 years; IQR, 25–41; median symptom duration, 10 years; IQR, 5–20). One patient showed a normal neuroimage. The patients were largely diagnosed in their 30s. The parietal lobe was most commonly affected, followed by occipital, frontal, and temporal lobes. Twenty-six patients had lesions encompassing ≥ two lobes. The patients complained mainly of seizures, headaches, hemiparesis, and focal neurologic deficits (P < 0.001). Seizures and visual defects were predominant in patients with calcified lesion(s) (P < 0.001). The diagnostic sensitivity and specificity of rPwYF against serum/CSF were 100%/97% and 97.2%/92.5%, respectively. The specific IgG antibody levels against rPwYF in sera and CSFs showed a positive correlation (r = 0.59). The clinical manifestations of the early-stage patients might be associated with cortical lesions or meningeal irritation, while those in the chronic stage were caused by conglomerated space-occupying lesions. rPwYF would be useful for the serodiagnosis of both early and chronic CP cases.

Nationwide lung cancer screening with low-dose computed tomography: implementation and first results of the HUNCHEST screening program.

Lung cancer (LC) kills more people than any other cancer in Hungary. Hence, there is a clear rationale for considering a national screening program. The HUNCHEST pilot program primarily aimed to investigate the feasibility of a population-based LC screening in Hungary, and determine the incidence and LC probability of solitary pulmonary nodules. A total of 1890 participants were assigned to undergo low-dose CT (LDCT) screening, with intervals of 1 year between procedures. Depending on the volume, growth, and volume doubling time (VDT), screenings were defined as negative, indeterminate, or positive. Non-calcified lung nodules with a volume > 500 mm3 and/or a VDT < 400 days were considered positive. LC diagnosis was based on histology. At baseline, the percentage of negative, indeterminate, and positive tests was 81.2%, 15.1%, and 3.7%, respectively. The frequency of positive and indeterminate LDCT results was significantly higher in current smokers (vs. non-smokers or former smokers; p < 0.0001) and in individuals with COPD (vs. those without COPD, p < 0.001). In the first screening round, 1.2% (n = 23) of the participants had a malignant lesion, whereas altogether 1.5% (n = 29) of the individuals were diagnosed with LC. The overall positive predictive value of the positive tests was 31.6%. Most lung malignancies were diagnosed at an early stage (86.2% of all cases). In terms of key characteristics, our prospective cohort study appears consistent to that of comparable studies. Altogether, the results of the HUNCHEST pilot program suggest that LDCT screening may facilitate early diagnosis and thus curative-intent treatment in LC. • The HUNCHEST pilot study is the first nationwide low-dose CT screening program in Hungary. • In the first screening round, 1.2% of the participants had a malignant lesion, whereas altogether 1.5% of the individuals were diagnosed with lung cancer. • The overall positive predictive value of the positive tests in the HUNCHEST screening program was 31.6%.

Abstract 12874: Impact of Calcified Nodule in Patients Undergoing Rotablator Atherectomy

Introduction: Impact on clinical outcome of the patient with calcified nodule remain unknown. Calcified nodule may cause suboptimal stent expansion, stent mal-apposition. Hypothesis: We hypothesized that the presence of calcified nodule in the heavy calcified lesion undergoing rotablator atherectomy (RA) assisted percutaneous coronary intervention (PCI) increased device-oriented composite endpoint (DoCE). Methods: We retrospective reviewed consecutives patient with heavy calcified lesion underwent RA assisted intravascular ultrasound (IVUS) guidance PCI between August 2016-April 2020. Pre-procedural IVUS imaging was mandatory. Calcified nodule was defined as convex shape of luminal surface and luminal side of calcium with protruding in the coronary artery lumen that assessed by IVUS. Primary outcome was cumulative 5-year composite device-oriented composite endpoint (DoCE), define as composite of CV death, myocardial infarction and clinically-driven target lesion revascularization (CDTLR). Results: Two-hundred consecutives patient with heavy calcified lesion underwent RA assisted intravascular ultrasound (IVUS) guidance PCI was enrolled. Calcified nodule was found in 87 patients (43.5%) with heavily calcified lesions. Cumulative 5-year DoCE was significantly higher in the presence of calcified nodule group than in the non-calcified nodule group (20.7% vs 8.8%, P=0.02). Calcified nodule group has the higher incidence of under-expansion and asymmetrical expansion of stent. The patient who had calcified nodule with eccentric calcification has significantly higher cumulative 5-year DoCE compared to calcified nodule with concentric calcification (p&lt;0.01). Conclusions: The presence of calcified nodule in the heavily calcified lesion underwent RA assisted PCI increased with cumulative 5-year DoCE.

P61.10 Swiss Pilot Low-Dose Computed Tomography Lung Cancer Screening Study

Low-dose computed tomography (LDCT) lung cancer screening is endorsed by United States guidelines and has recently been shown effective in a large European randomized controlled trial. Nevertheless, the actual realization of a lung cancer screening program is challenging and depends on country-specific factors. This pilot study aimed to evaluate implementation, execution and performance of LDCT lung cancer screening in Switzerland. Starting from October 2018, asymptomatic participants aged 55-74 years with more than 30 pack-years smoking history were enrolled at a tertiary hospital in Switzerland. Participants with history of lung cancer, major (palliative) health problems or those that had a thorax CT scan 18 months prior to enrollment were excluded. First line we evaluated lung cancer risk according NLST guidelines. Secondly, we estimated lung cancer risk using the PLCOm2012 model risk calculater with a threshold of 5%. Lung nodules were assessed according Lung-RADS 1.1 {ACoR. Lung-Screening Reporting and Data System (LungRADS) Version 1.1. 2019}. Participants were predominantly recruited through flyers, a newspaper article and pulmonary specialists. Screening consisted of one LDCT-scan and follow-up was recommended for suspicious nodules only. LDCT assessment was performed by two radiologists, one of them a board certified chest radiologist. Enrollment and follow-up are currently ongoing. To date, 75 participants with a median age of 62 years (interquartile range [IQR] 56-67 years) were included. The median number of pack years smoked was 49 (IQR 41-58 pack years) and 25 (33%) were female. The median PLCOm2012 6-year lung cancer probability was 2.7% (IQR 2.6-2.9%) and 19 (26%) participants had stopped smoking before enrollment. Of the 75 participants, 61 (81%) were found to have calcified or non-calcified lung nodules. 6 participants required follow up imaging of suspect nodules which resulted in a recall rate of 8%. At baseline, lung cancer was found in 2 (2.7%) participants. The lung cancers were one squamous cell carcinoma (stage IIIA) and one adenocarcinoma (stage IV). In this Swiss LDCT lung cancer screening pilot study using modified inclusion criteria, lung nodules were found in a significant number of participants of whom 2.7 % were diagnosed with lung cancer to date. To date, the recall rate for follow-up imaging is 8%.

DISSEMINATED ACTINOMYCOSIS PRESENTING AS PNEUMONIA WITH MULTIPLE PULMONARY NODULES AND PELVIC OSTEOMYELITIS

TOPIC: Chest Infections TYPE: Fellow Case Reports INTRODUCTION: Actinomycosis is a chronic granulomatous infectious disease caused by filamentous gram-positive anaerobic bacteria. Due to better oral hygiene and susceptibility to multiple oral antibiotics, it is rare. It occurs predominantly in males due to inapt oral hygiene and increased oral trauma [1]. A case of disseminated actinomycosis manifesting as pneumonia with multiple pulmonary nodules and pelvic osteomyelitis is presented here. CASE PRESENTATION: A 53-year-old healthy male was admitted to our medical center for five weeks of right hip & low back pain (LBP), fevers, productive cough with white phlegm, generalized malaise, weight loss, and progressively worsening dyspnea. He was an active smoker with 30 pack-years of smoking, sexually active with his girlfriend, and worked at a farm. He was treated two weeks prior by the emergency department for LBP with muscle relaxants and steroids. He returned in five days with no improvement and was diagnosed with right upper lobe (RUL) pneumonia requiring admission and treatment with antibiotics. Workup showed leukocytosis of 22,600/mL, C reactive protein of 16 mg/dl, procalcitonin of 4.63 ng/mL, and a negative human immunodeficiency virus test. Computed tomography (CT) of the chest, abdomen, and pelvis revealed RUL consolidation with multiple bilateral noncalcified nodules and a 17 x 11.8 x 10.5 cm multilevel lobulated cystic mass centered around the right diffusely permeative iliac bone with lateral extension into adjacent gluteal musculature (Figure A-B). On arrival, clinical examination revealed an ill, thin male with warm, tender right hip able to only raise the leg up to 20 degrees. A right gluteal abscess aspirate revealed 20 ml purulent fluid, and the right iliac biopsy was positive for osteomyelitis with acute & chronic granulomatous inflammation. Surgical debridement of the pelvic lesion was followed by bronchoscopy (RUL bronchioalveolar lavage {BAL}, lymph node biopsies). Aspiration cytology revealed Splendore-Hoeppli phenomenon, sulfur granules, and Actinomyces bacterial colonies (Figure C). BAL culture grew Actinomyces odontolyticus (>100,000 colonies/mL). His poor dentition was the source of this disseminated infection. His recovery was successful with tooth extraction, six weeks of ceftriaxone followed by 42 weeks of oral amoxicillin. DISCUSSION: Actinomycosis is the most misdiagnosed disease even by experienced clinicians. Disseminated actinomycosis is exceedingly rare, especially from the hematogenous spread as in our patient [1]. The source can be a disease at any location. Lungs are a common site, whereas musculoskeletal involvement is infrequent [2]. CONCLUSIONS: Clinicians should be aware of this indolent presentation with the extent of the disease appreciated. It should be considered in a patient with bad oral hygiene, pneumonia, and pelvic osteomyelitis. REFERENCE #1: Wong VK, Turmezei TD, Weston VC. Actinomycosis. BMJ. 2011;343:d6099. REFERENCE #2: Apothéloz C, Regamey C. Disseminated infection due to Actinomyces meyeri: case report and review. Clin Infect Dis. 1996;22(4):621-5. DISCLOSURES: No relevant relationships by Jonathan Ross Ang, source=Web Response No relevant relationships by Phillip Beck, source=Web Response No relevant relationships by Andres Bran, source=Web Response No relevant relationships by Michael Hunter, source=Web Response No relevant relationships by SACHIN PATIL, source=Web Response

FP13.02 Costal Pleura-attached Noncalcified Nodules Newly Seen on Annual Low-Dose CT Screenings

It has previously been demonstrated that solid costal pleura-attached noncalcified nodules (CP-NCN) with average diameter<10.0 mm and lentiform, oval, semicircular (LOS) or triangular shapes and smooth margins on baseline CT do not need short-term follow-up and instead can be recommended to return for annual repeat screening. Determine whether the same criteria apply for new CP-NCNs seen on annual repeat screening rounds.

Defining growth in small pulmonary nodules using volumetry: results from a \u201ccoffee-break\u201d CT study and implications for current nodule management guidelines

ObjectivesAn increase in lung nodule volume on serial CT may represent true growth or measurement variation. In nodule guidelines, a 25% increase in nodule volume is frequently used to determine that growth has occurred; this is based on previous same-day, test–retest (coffee-break) studies examining metastatic nodules. Whether results from prior studies apply to small non-metastatic nodules is unknown. This study aimed to establish the interscan variability in the volumetric measurements of small-sized non-metastatic nodules.MethodsInstitutional review board approval was obtained for this study. Between March 2019 and January 2021, 45 adults (25 males; mean age 65 years, range 37–84 years) with previously identified pulmonary nodules (30–150 mm3) requiring surveillance, without a known primary tumour, underwent two same-day CT scans. Non-calcified solid nodules were measured using commercial volumetry software, and interscan variability of volume measurements was assessed using a Bland–Altman method and limits of agreement.ResultsOne hundred nodules (range 28–170 mm3; mean 81.1 mm3) were analysed. The lower and upper limits of agreement for the absolute volume difference between the two scans were − 14.2 mm3 and 12.0 mm3 respectively (mean difference 1.09 mm3, range − 33–12 mm3). The lower and upper limits of agreement for relative volume difference were − 16.4% and 14.6% respectively (mean difference 0.90%, range − 24.1–32.8%).ConclusionsThe interscan volume variability in this cohort of small non-metastatic nodules was smaller than that in previous studies involving lung metastases of varying sizes. An increase of 15% in nodule volume on sequential CT may represent true growth, and closer surveillance of these nodules may be warranted.Key Points• In current pulmonary nodule management guidelines, a threshold of 25% increase in volume is required to determine that true growth of a pulmonary nodule has occurred.• This test–retest (coffee break) study has demonstrated that a smaller threshold of 15% increase in volume may represent true growth in small non-metastatic nodules.• Closer surveillance of some small nodules growing 15–25% over a short interval may be appropriate.

Characterization of Newly Detected Costal Pleura-attached Noncalcified Nodules at Annual Low-Dose CT Screenings.

Background Solid costal pleura-attached noncalcified nodules (CP-NCNs) less than 10.0 mm with lentiform, oval, or semicircular (LOS) or triangular shapes and smooth margins on baseline low-dose CT scans from the Mount Sinai Early Lung and Cardiac Action Program (MS-ELCAP) were reviewed, and it was determined that they can be followed up at the first annual screening rather than having a shorter-term work-up. Purpose To determine whether the same criteria could be used for solid CP-NCNs newly identified at annual screening examinations. Materials and Methods With use of the same MS-ELCAP database, all new solid CP-NCNs measuring 30.0 mm or less were identified at 4425 annual screening examinations between 2010 and 2019. In addition, to ensure that no malignant CP-NCNs met the criteria, all solid malignant CP-NCNs of 30.0 mm or less in the International Early Lung Cancer Action Program, or I-ELCAP, database of 111 102 annual screening examinations from the 76 participating institutions between 1992 and 2019 were identified; Mount Sinai is one of these institutions. All identified solid CP-NCNs were reviewed-with the radiologists blinded to diagnosis-for shape (triangular, LOS, polygonal, round, or irregular), margin (smooth or nonsmooth), pleural attachment (broad or narrow), and the presence of emphysema and/or fibrosis within 10.0 mm of each CP-NCN. Intra- and interreader readings were performed, and agreements were determined by using the B-statistic. Results Of the 76 new solid CP-NCNs, 21 were lung cancers. Benign CP-NCNs were smaller than malignant ones (median diameter, 4.2 mm vs 11 mm; P < .001), had a different shape distributions, more frequently had smooth margins (67% vs 14%; P < .001), and less frequently had emphysema (38% vs 81%; P = .003) or fibrosis (3.6% vs 19%; P = .045) within a 10.0 mm radius. All 22 solid CP-NCNs less than 10.0 mm in average diameter with triangular or LOS shapes and smooth margins were benign, and none of the 21 solid malignant CP-NCNs had these characteristics. Intra- and interobserver agreement for triangular or LOS-shaped CP-NCNs with smooth margins was almost perfect (0.77 and 0.69, respectively). Conclusion The same follow-up recommendation developed for baseline costal pleura-attached noncalcified nodules (CP-NCNs) can be used for CP-NCNs newly identified at annual screening rounds. © RSNA, 2021.

Evaluation of the Effectiveness of Artificial Intelligence Chest CT Lung Nodule Detection Based on Deep Learning.

Lung cancer is one of the most malignant tumors. If it can be detected early and treated actively, it can effectively improve a patient's survival rate. Therefore, early diagnosis of lung cancer is very important. Early-stage lung cancer usually appears as a solitary lung nodule on medical imaging. It usually appears as a round or nearly round dense shadow in the chest radiograph. It is difficult to distinguish lung nodules and lung soft tissues with the naked eye. Therefore, this article proposes a deep learning-based artificial intelligence chest CT lung nodule detection performance evaluation study, aiming to evaluate the value of chest CT imaging technology in the detection of noncalcified nodules and provide help for the detection and treatment of lung cancer. In this article, the Lung Medical Imaging Database Consortium (LIDC) was selected to obtain 536 usable cases based on inclusion criteria; 80 cases were selected for examination, artificial intelligence software, radiologists, and thoracic imaging specialists. Using 80 pulmonary nodules detection in each case, the pathological type of pulmonary nodules, nonlime tuberculous test results, detection sensitivity, false negative rate, false positive rate, and CT findings were individually analyzed, and the detection efficiency software of artificial intelligence was evaluated. Experiments have proved that the sensitivity of artificial intelligence software to detect noncalcified nodules in the pleural, peripheral, central, and hilar areas is higher than that of radiologists, indicating that the method proposed in this article has achieved good detection results. It has a better nodule detection sensitivity than a radiologist, reducing the complexity of the detection process.

Differentiating between active and latent tuberculosis with chest computed tomography

PurposeThe purpose of this study was to evaluate the capabilities of chest computed tomography (CT) in distinguishing between active and latent tuberculosis in patients positive for interferon-gamma release assay (IGRA) testing, and to compare the performance of CT with that of quantitative IGRA testing in a low incidence setting. Materials and methodsPatients with latent or active tuberculosis define by an IGRA positive test were retrospectively recruited. Sensitivity, specificity and accuracy were determined for CT variables and quantitative IGRA results. Final diagnosis of active tuberculosis was based on clinical data and microbiological culture. Univariable and multivariable analyses were performed using logistic regression model to identify CT variables associated with the diagnosis of active tuberculosis. ResultsA total of 92 patients with positive IGRA results who underwent CT examination were included. There were 54 men and 38 women with a mean age of 53.5±18 (SD) years (range: 40–68 years). Of them, 22 patients (24%) had positive Mycobacterium tuberculosis culture and 70 (76%) had latent tuberculosis. Among CT variables, consolidation had the greatest sensitivity (77%; 95%CI: 60–95%) and “tree-in-bud” the greatest specificity (97%; 95% CI: 93–100%) for the diagnosis of active tuberculosis. At univariable analysis “tree-in-bud”, splenic calcification and non-calcified lung nodules were the significant variables independently associated with active tuberculosis. At multivariable analysis, the adjusted odds ratio of “tree-in-bud” was 42.91 (95% CI: 5.62–327.42). Using an optimal threshold of 51 spots, quantitative IGRA yielded 64% sensitivity (95% CI: 44–84%) and 61% specificity (95% CI: 50–73%) for the diagnosis of active tuberculosis. ConclusionsIn a low incidence setting, chest CT, especially when “tree-in-bud” pattern is present, is superior to quantitative IGRA testing to identify patients with active tuberculosis among those with positive IGRA testing.

Circulating genetically abnormal cells combined with artificial intelligence for accurate and non-invasive early detection on NSCLC.

3056 Background: Non-small-cell carcinoma (NCSLC) is the most common type of early lung cancer. Early detection of NSCLC is still a diagnostic challenge. Current clinical management of patients with pulmonary nodule is inefficient and may lead to misclassification, thus increasing healthcare expenses. Further, a few previous studies showed liquid biopsy and artificial intelligence (AI) platform on computed tomography (CT) imaging contributes to early NSCLC detection. Still, there is something lacking in a precise and authorized lung nodule classifier to minimize discomfort of patients. This study aims to evaluate the possibility and effectiveness of combining circulating genetically abnormal cells (CACs) with an AI platform on CT imaging to improve the diagnostic route for NSCLC. Methods: A prospective cohort of 101 in-patients was enrolled from Sep. 1, 2020 to Jan. 15, 2021, with non-calcified pulmonary nodules, ranging from 0.5 to 3 cm in diameter, indicated by CT. The participants' pulmonary nodules will be assessed by two evaluation tools: CAC detection on full blood and AI platform on CT imaging. The diagnostic performances of the two tools were evaluated in a blinded validation study respectively and combined in an open-label retrospective analysis. Results: 68 of enrolled patients were confirmed as NSCLC by pathology. The diagnostic performance of CACs for NSCLC detection was 80.9% for sensitivity and 87.3% for positive predictive value (PPV) while overall accuracy reaches 79.2%. AI platform showed a slight disadvantage as 78.6% for PPV and 73.5% for accuracy. 9 false-negative patients on CAC results could be reversed with a combination of AI platform on CT imaging, while sensitivity rises to 94.1%. However, of 33 benign nodules patients, 8 wrong diagnoses by CAC detection could decrease to 2 when combined with the results from the AI platform, which may avoid unnecessary biopsies. Conclusions: Coupling CAC with an AI platform on CT imaging could be a useful strategy to improve the diagnostic route for NSCLC and avoid unnecessary biopsies.[Table: see text]

Malignant Testicular Paraganglioma: The Importance of Adequate Clinical Follow-Up

Background: Paragangliomas (PGL) are rare neuroendocrine tumors derived from neural crest cells. The presence of metastases is the only absolute criterion of malignancy. Clinical Case: A 59 y.o. male patient reports the appearance of a tumor in the right inguinal region operated in 2014 with tumor removal and right orchiectomy, with anatomopathological (AP) outcome spermatic cord adenomathoid tumor and immunohistochemistry (IHC) compatible with PGL: Ki-67 1% (S 100 diffusely positive protein), diffusely positive chromogranin A, weak positive CD99. However, no new tests were performed in the follow-up. After 5 years, the patient started to present sporadic episodes of sweating, palpitations and increased tension levels after doxazosin suspension. Investigation for reoccurrence with Urinary Catecholamines: Noradrenaline (VR< 97 mcg/24h) 112/179, Adrenaline (VR< 27 mcg/24h) 4/4, Dopamine (< 500 mcg/24h) 184/ 342, Plasma Metanephrines: Normetanephrines (VR< 196 pg/ml) 880.7/ 2402 Metanephrines (VR< 65 pg/ml) 44.6/ 53.1. Tests was performed: chest CT Multiple bilateral non-calcified pulmonary nodules with contrast enhancement, measuring 1.2 cm. Abdominal CT: Two retroperitoneal solid lesions located anteriorly to the inferior vena cava and aorta, in a discretely paramedian position on the right, intense arterial enhancement, with a hypoattenuating center. The largest lesion is located just below the emergence of the renal arteries and after the head of the pancreas and third portion of the duodenal. It measures 4.4 x 3.2 x 4.4 cm (LL x AP x CC). The smallest lesion is immediately inferior to the largest and measures 3.1 x 2.6 x 3.6 cm (LL x AP x CC). The lesions have contact with retroperitoneal vascular structures, notably with the inferior vena cava and with the vascular pedicle of the right kidney. Scintigraphy with MIBG: Radiopharmaceutical hyperconcentration in focal areas in the projections of lung fields, in greater number on the left, with intensity of uptake varying from mild to moderate; two contiguous focal areas in the median projection of mesogastrics, in moderate/acentuated degree. Patient was reoperated and removed abdominal lesions with new conclusive AP for PGL whit PASS 3, currently performing therapeutic MIBG for thoracic injury control. Clinical Lesson: Patients with lesions suggestive of PGL but without confirmatory AP should request IHC and clinical follow-up will be according to the findings in it.

Paraneoplastic Hypercalcemia as the Initial Presenting Sign of Metastatic Renal Cell Carcinoma

Introduction: Malignant hypercalcemia can occur in patients with renal cell carcinoma as part of a paraneoplastic syndrome. The suggested mechanisms of malignant hypercalcemia include overproduction of parathyroid hormone-related peptide (PTHrP), interleukin-6 (IL-6), prostaglandins, and tumor necrosis factor-alpha (TNF-α). This report describes an unusual case of paraneoplastic hypercalcemia as the initial manifestation of metastatic renal cell carcinoma (RCC). Case presentation: A 44-year-old Caucasian male with no past medical history who presented to his PCP complaining of unintentional weight loss of 25 lbs, increasing fatigue, occasional right flank pain, and nausea. His family history is significant for multiple myeloma of his mother. The physical exam was unremarkable. Labs were remarkable for serum calcium of 11.5 mg/dL, Albumin of 4.5 g/dL, intact parathyroid hormone (PTH) of 9 pg/mL, undetectable PTHrP, 25 hydroxy VitD of 26.4 ng/mL, and 1, 25 hydroxy VitD of 18 pg/mL. Serum and urine protein electrophoresis and PSA were unremarkable. CXR revealed the right lower lobe noncalcified nodule of 15×11×7 mm. CT abdomen/Pelvis revealed a right renal mass of 13×14×12 cm without lymphadenopathy or local metastasis. The patient was referred to a medical oncologist and further workup including PET/CT scan that demonstrated increased uptake in right lung nodule of SUV 6, right renal mass uptake of SUV 72, and MRI brain without metastasis. The patient treated with right total nephrectomy that revealed a sarcomatoid renal cell carcinoma. Right lung nodule biopsy revealed a clear cell renal carcinoma. The patient further treated with two cycles of Gemcitabine/oxaliplatin and four cycles of nivolumab/ipilimumab. A repeated PET/CT scan showed a complete resolution of a right lung nodule. Repeated labs were unremarkable, including serum calcium of 8.7 mg/dL. Discussion: Hypercalcemia is a frequent occurrence in patients with RCC, but it is an unusual presenting symptom. The initial evaluation should focus on whether the hypercalcemia is parathyroid-dependent or medication-related. Basic laboratory investigations for hypercalcemia include PTH, PTHrP, and 1, 25(OH)2D. Bone-resorbing cytokines may be present in those patients in which the cause of the hypercalcemia is unclear. In our case, we could not determine the specific cytokine that caused hypercalcemia, as IL-6 and TNF-α were unavailable. If laboratory tests are unavailable, bone scan, CT scan, or PET-CT should be considered to evaluate for lytic bone lesions or underlying malignancy. Evaluation for carcinoma should be persistently pursued in a patient who has symptoms suggestive of paraneoplastic hypercalcemia. Finally, symptomatic malignant hypercalcemia can be treated with IV fluids and bisphosphonates. Approximately 50% of patients who undergo nephrectomy and/or tumor debulking will revert to normocalcemia.

Uncommon radiologic computed tomography appearances of the chest in patients with lymphangioleiomyomatosis

Lymphangioleiomyomatosis (LAM) is a rare destructive lung disease characterized by multiple thin-walled pulmonary cysts. The currently proposed diagnostic algorithm emphasizes the characteristic cystic appearance on high-resolution computed tomography (HRCT) so uncommon HRCT appearances present challenges to establishing the proper LAM diagnosis. The objective of this study is to accrue uncommon chest HRCT appearances, determine frequencies in both tuberous sclerosis complex (TSC)-associated LAM (TSC-LAM) and sporadic LAM (S-LAM) patients. 311 females referred to our hospital, including 272 S-LAM patients (mean age 39.2 years) and 39 TSC-LAM patients (mean age 38.3 years), were retrospectively evaluated. We found 2 types of radiologic findings likely to make HRCT cyst appearance atypical: characteristics of the cyst itself and uncommon findings in addition to cysts. We found that approximately 80% of LAM patients, whether TSC-associated or sporadic, showed typical HRCT appearance with mild to severe cystic destruction. The remaining 20% displayed unusual profiles in cyst appearance as well as additional findings aside from cyst: the former includes large cyst, thickened walls, and irregularly shaped whereas the latter includes ground glass attenuation and diffuse noncalcified nodules. It is important to be aware of various radiologic findings that make HRCT cystic appearance atypical of LAM.

Assessment of an Exhaled Breath Test Using High-Pressure Photon Ionization Time-of-Flight Mass Spectrometry to Detect Lung Cancer

Exhaled breath is an attractive option for cancer detection. A sensitive and reliable breath test has the potential to greatly facilitate diagnoses and therapeutic monitoring of lung cancer. To investigate whether the breath test is able to detect lung cancer using the highly sensitive high-pressure photon ionization time-of-flight mass spectrometry (HPPI-TOFMS). This diagnostic study was conducted with a prospective-specimen collection, retrospective-blinded evaluation design. Exhaled breath samples were collected before surgery and detected by HPPI-TOFMS. The detection model was constructed by support vector machine (SVM) algorithm. Patients with pathologically confirmed lung cancer were recruited from Peking University People's Hospital, and healthy adults without pulmonary noncalcified nodules were recruited from Aerospace 731 Hospital. Data analysis was performed from August to October 2020. Breath testing and SVM algorithm. The detection performance of the breath test was measured by sensitivity, specificity, accuracy, and area under the receiver-operating characteristic curve (AUC). Exhaled breath samples were from 139 patients with lung cancer and 289 healthy adults, and all breath samples were collected and tested. Of all participants, 228 (53.27%) were women and the mean (SD) age was 57.0 (11.4) years. After clinical outcomes were ascertained, all participants were randomly assigned into the discovery data set (381 participants) and the blinded validation data set (47 participants). The discovery data set was further broken into a training set (286 participants) and a test set (95 participants) to construct and test the detection model. The detection model reached a mean (SD) of 92.97% (4.64%) for sensitivity, 96.68% (2.21%) for specificity, and 95.51% (1.93%) for accuracy in the test set after 500 iterations. In the blinded validation data set (47 participants), the model revealed a sensitivity of 100%, a specificity of 92.86%, an accuracy of 95.74%, and an AUC of 0.9586. This diagnostic study's results suggest that a breath test with HPPI-TOFMS is feasible and accurate for lung cancer detection, which may be useful for future lung cancer screenings.

The BUILT study: a single-center 5-year experience of Lung Cancer screening in Taiwan.

Background: There are no uniform guidelines on low-dose computed tomography (LDCT) follow-up in lung cancer screening. Few studies have analyzed the incidental abnormalities and role of tumor markers in lung cancer screening. The purpose of this study was to investigate the diagnostic performance of LDCT, optimal follow-up duration, incidental findings, and role of tumor markers in diagnosing lung cancer.Methods: We retrospectively analyzed subjects who underwent their first LDCT in Taipei Tzu Chi Hospital between September 1, 2015, and August 31, 2016. All chest CT scans until August 31, 2020, were recorded. A non-calcified nodule with a diameter ≥2 mm on LDCT was defined as a positive result. We extracted the data, including possible risk factors of lung cancer and follow-up outcomes.Results: A total of 1502 subjects were recruited. Of the 38 subjects who underwent biopsy, 31 had confirmed lung cancer. Lung cancer in all patients was diagnosed within 4 years. Univariate logistic regression analysis revealed that a family history of lung cancer in first-degree relatives and abnormal serum carcinoembryonic antigen (CEA) levels were the significant risk factors for lung cancer. A cumulative lung cancer incidence of 54.7 patients per 1000 person-years was determined solely via radiological follow-up. In total, 271 (18%) subjects exhibited incidental findings on baseline LDCT.Conclusion: The overall lung cancer detection rate in this study was 2.1% in the 5-year study period. A family history of lung cancer and abnormal serum CEA levels are important risk factors for lung cancer. A minimum of 4-year follow-up is required to track suspicious nodules. A purely radiological follow-up detects a high incidence of lung cancer.

Variability in interpretation of low-dose chest CT using computerized assessment in a nationwide lung cancer screening program: comparison of prospective reading at individual institutions and retrospective central reading.

To evaluate the degree of variability in computer-assisted interpretation of low-dose chest CTs (LDCTs) among radiologists in a nationwide lung cancer screening (LCS) program, through comparison with a retrospective interpretation from a central laboratory. Consecutive baseline LDCTs (n = 3353) from a nationwide LCS program were investigated. In the institutional reading, 20 radiologists in 14 institutions interpreted LDCTs using computer-aided detection and semi-automated segmentation systems for lung nodules. In the retrospective central review, a single radiologist re-interpreted all LDCTs using the same system, recording any non-calcified nodules ≥ 3mm without arbitrary rejection of semi-automated segmentation to minimize the intervention of radiologist's discretion. Positive results (requiring additional follow-up LDCTs or diagnostic procedures) were initially classified by the lung CT screening reporting and data system (Lung-RADS) during the interpretation, while the classifications based on the volumetric criteria from the Dutch-Belgian lung cancer screening trial (NELSON) were retrospectively applied. Variabilities in positive rates were assessed with coefficients of variation (CVs). In the institutional reading, positive rates by the Lung-RADS ranged from 7.5 to 43.3%, and those by the NELSON ranged from 11.4 to 45.0% across radiologists. The central review exhibited higher positive rates by Lung-RADS (20.0% vs. 27.3%; p < .001) and the NELSON (23.1% vs. 37.0%; p < .001), and lower inter-institution variability (CV, 0.30 vs. 0.12, p = .003 by Lung-RADS; CV, 0.25 vs. 0.12, p = .014 by the NELSON) compared to the institutional reading. Considerable inter-institution variability in the interpretation of LCS results is caused by different usage of the computer-assisted system. • Considerable variability existed in the interpretation of screening LDCT among radiologists partly from the different usage of the computerized system. • A retrospective reading of low-dose chest CTs in the central laboratory resulted in reduced variability but an increased positive rate.

Management of Nodules Attached to the Costal Pleura at Low-Dose CT Screening for Lung Cancer.

Background Pulmonary nodule features have been used to differentiate benign from malignant nodules. Purpose To determine the frequency of solid noncalcified nodules attached to the costal pleura (CP-NCNs) at baseline low-dose CT and to identify key features of benignity. Materials and Methods A retrospective review was performed of baseline low-dose CT scans obtained in 8730 participants in the Mount Sinai Early Lung and Cardiac Action Program screening cohort between 1992 and 2019. Participants with one or more solid CP-NCNs between 3.0 mm and 30.0 mm in average diameter were included. For each CP-NCN, the size, location, shape (lentiform, oval, or semicircular [LOS]; triangular; polygonal; round; or irregular), margin (smooth or nonsmooth), and attachment to the costal pleura (broad or narrow) were documented. The manifestation of emphysema and fibrosis within a 10-mm radius of the CP-NCN was determined. Multivariable logistic regression analysis, with synthetic minority oversampling techniques, was used. Results The 569 eligible participants (average age, 62 years ± 9 [standard deviation]; 343 women) had 943 solid CP-NCNs, of which 934 (99.0%) were benign and nine (1.0%) were malignant. Multivariable analysis showed that five shapes could be consolidated into three (LOS and/or triangular, round and/or polygonal, and irregular shape); pleural attachment was not a significant independent predictor (odds ratio, 1.24; P = .70); and interaction terms of size with shape (odds ratio, 0.73; P = .005) and margin were significant (odds ratio, 0.80; P = .001). All 603 CP-NCNs less than 10.0 mm with LOS or triangular shapes and smooth margins were benign. Conclusion All baseline noncalcified solid nodules attached to the costal pleura less than 10.0 mm in average diameter with lentiform, oval, semicircular, or triangular shapes and smooth margins were benign; thus, for these nodules, an annual repeat scan in 1 year, rather than a more immediate work-up, is recommended. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Godoy in this issue.

A CASE REPORT OF PRIMARY AMYLOIDOMA OF THE LUNG

SESSION TITLE: Fellows Lung Pathology Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Primary amyloidoma of the lung is rare and is usually found incidentally on chest radiographs in asymptomatic, elderly patients. Amyloid nodules may be solitary or much more commonly multiple. We present a case of primary amyloidoma of the lung. CASE PRESENTATION: A 79-year-old man, former smoker, with a history of COPD, DM, HTN, CKD, GERD, and adenocarcinoma of the colon presented with a few days of history of cough, dyspnea, and lethargy. Four days prior he was treated as an outpatient for pneumonia with levofloxacin and metronidazole. CT chest showed mild emphysema, RUL lung mass, and multiple bilateral non-calcified lung nodules. CT guided biopsy of RUL mass was consistent with amyloidoma. TTE did not show evidence of cardiac involvement. Immunoglobulin levels were unremarkable. SPEP and UPEP revealed no evidence of monoclonal protein. This was thought to be a localized process rather than diffuse parenchymal amyloidosis and decision was made to manage conservatively with surveillance rather than surgical excision. DISCUSSION: The term amyloid was first used by Rudolf Virchow in 1854.1 Amyloidosis is a heterogeneous group of diseases characterized by the deposition of misfolded insoluble proteins in extracellular tissue. Amyloidosis can be primary or secondary, and the deposition of amyloid proteins can be localized or systemic. Localized pulmonary amyloidosis was first described by Lesser in 1877. ¬¬2 It is divided into three main anatomical areas; tracheobronchial, parenchymal, and mediastinal.3 Tracheobronchial is the most common form of localized pulmonary amyloidosis.4 Patients can be asymptomatic or present with cough, dyspnea, and hemoptysis. A chest radiograph is nondiagnostic. CT findings ranges from a solitary nodule, multiple nodular lesions to more diffuse disease, with no pathognomonic features. Solitary amyloidoma of the lung may be confused with primary lung carcinoma. Multiple lesions may be difficult to differentiate from metastatic disease. Demonstration of apple-green birefringence with Congo red stain under polarized light is the gold standard for diagnosis. Isolated pulmonary amyloidoma is diagnosed by excluding other organ involvement. The treatment of pulmonary amyloidosis ranges from observation to bronchoscopic or surgical resection depending on the severity of the disease. Localized amyloidosis is usually treated with local interventions. Excisional therapy is the standard approach for tracheobronchial amyloidosis. Nd: YAG laser can be used to treat some nodular forms of tracheobronchial amyloidosis. Radiotherapy can be a viable option for the treatment of solitary pulmonary amyloidoma. CONCLUSIONS: Solitary pulmonary nodular amyloidosis is a rare diagnosis. Exclusion of systemic involvement is crucial in the management of these patients. The treatment ranges from observation to bronchoscopic or surgical resection based on the severity of the disease. Reference #1: 1. Saleiro S, Hespanhol V, Magalhães A. Endobronchial amyloidosis. J Bronchol. 2008;15:95–99. Reference #2: 2. Gillmore JD, Hawkins PN. Amyloidosis and the respiratory tract. Thorax. 1999;54:444–51. Reference #3: 3. Lachmann HJ, Hawkins PN. Amyloidosis and the lung. Chron Respir Dis. 2006;3:203–14. 4. Sugihara E, Dambara T, Okamoto M, Sonobe S, Koga H, Inui A, et al. Clinical features of 10 patients with pulmonary amyloidosis. J Bronchol. 2006;13:191–3. DISCLOSURES: No relevant relationships by Moises Cossio, source=Web Response No relevant relationships by Domingo Franco-Palacios, source=Web Response No relevant relationships by Kushagra Gupta, source=Web Response No relevant relationships by Shahzad Hussain, source=Web Response No relevant relationships by Katie Kennedy, source=Web Response No relevant relationships by Toribiong Uchel, source=Web Response