Subpleural Lesions Research Articles

Usability of Transthoracic Shear Wave Elastography in Differentiation of Subpleural Solid Masses.

In this study, the effectiveness of transthoracic ultrasound elastography in the benign and malign distinction of subpleural/pleural solid lesions was investigated.Between July 2015 and December 2016, 33 consecutive patients with subpleural solid lesions detected via computed tomography (CT) of the thorax were identified and prospectively included in this study. The average for each lesion's shear wave velocity (SWV) value was detected, and benign and malignant lesions' SWV values are statistically compared. The CT and pathology results were used as a reference to compare these values. A receiver operating characteristic analysis was used to determine the cutoff value for benign/malignant neoplasms.The 33 patients (10 female, 23 male) included in the study had a mean age of 56.2 ± 15.40 years (range, 17-84 years), and the mean SWV value of the lesions in 13 (39%) cases evaluated benign after a CT scan, histopathological examination, or both 2.18 ± 0.49 m/s. The mean SWV value of the lesions which were histopathologically diagnosed as malign in 23 (61%) cases was 3.50 ± 0.69 m/s. (P < 0.001). When the cutoff value was set as 2.47 m/s for the SVW value, sensitivity and specificity were determined to be 97.7%.The present study has shown that transthoracic ultrasound shear wave elastography can be an effective radiological examination method in the benign and malign differentiation of subpleural lesions and has the potential for use in the routine clinical application of transthoracic ultrasound elastography, a noninvasive method for evaluating the malignancy potentials of such lesions.

SPONTANEOUS PNEUMOTHORAX AND RIGHT SIDED HEART FAILURE: AN UNUSUAL PRESENTATION OF INFECTIVE ENDOCARDITIS

SESSION TITLE: Critical Care 4 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Over the years, despite advancements in the treatment and diagnosis of Infective Endocarditis (IE), the incidence continues to rise. This is thought to be as a result of the progressive evolution in the various risk factors leading to IE. One example is the increasing rates of intravenous drug abuse leading to IE[1]. Right-sided IE has been shown to have significant mortality and morbidity amongst those diagnosed[1]. Spontaneous pneumothorax represents one of the less common presentations of right-sided IE secondary to Intravenous drug abuse (IVU); to date, there have only been 7 documented cases[2]. CASE PRESENTATION: A 29-year-old male presented to the ED with chief complaints of fever, shortness of breath (SOB) and bilateral pedal edema. He was a known IVU. His vitals in the ED were as follows: BP 117/66, HR 113, RR 20, T 97.1, SPO2 was 93% on RA. General physical examination was significant for severe respiratory distress. Respiratory exam revealed decreased air entry on the right lung with rhonchi and rales throughout the left lung. Tricuspid regurgitation murmur was auscultated. Laboratory investigations showed WBC 22600 cells/ul, Hb 6.6 g/dL, LA 5.3 mm/L, BNP 236 Pg/ml. Initial CXR showed a 30-40% right-sided pneumothorax with a left lower lung consolidation, a chest tube was immediately inserted. 2D-echocardiogram showed findings consistent with tricuspid valve vegetation. He was started on empiric antimicrobial therapy for treatment of methicillin-sensitive staph aureus. CT scan showed moderate right pneumothorax, a right chest tube in situ and numerous septic emboli. Patient had tricuspid valve replacement on his 3rd day of hospitalization, with a prolonged and eventful hospitalization. DISCUSSION: IE is a well-documented complication of IVU. The pulmonary complications of septic pulmonary embolism commonly described include: pulmonary infarction, pulmonary abscess, pleural effusion, and empyema[2]. The pathophysiology behind spontaneous pneumothorax in the setting of IE is thought to be rupture of sub-pleural lesions from multiple septic pulmonary emboli seeded from the right-sided vegetations with underlying pathogen as S. Aureus[2]. Right heart failure (RHF) can be secondary to pulmonary hypertension, right ventricular or tricuspid valve pathology, as well from primary diseases of the pericardium[3]. In this particular case our patient had both pulmonary hypertension from extensive pulmonary cavitation and tricuspid valve pathology as contributing factors to RHF. CONCLUSIONS: It is important to highlight as IDV continues to evolve as one of the most common causes of IE, we as clinicians must become aware of the unusual ways in which the complications may present. Patients who have a high index of suspicion for IDU presenting with worsening SOB and persistent fever, IE should be considered as apart of our differential list to allow timely implementation of appropriate management. Reference #1: Hussain, S. T., Witten, J., Shrestha, N. K., Blackstone, E. H., & Pettersson, G. B. (may 2017). Tricuspid valve endocarditis. Annals of cardiothoracic surgery, 6(3), 255-261. Retrieved December 27, 2017. https://doi.org/10.21037/acs.2017.03.09 Reference #2: Sheu, Chau-Chyun, et al. “Spontaneous Pneumothorax as a Complication of Septic Pulmonary Embolism in an Intravenous Drug User: A Case Report.” The Kaohsiung Journal of Medical Sciences, vol. 22, no. 2, 2006, pp. 89–93., https://doi.org/10.1016/s1607-551x(0970226-8). Reference #3: (n.d.). Retrieved December 27, 2017, from https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-14/Right-ventricular-failure# DISCLOSURES: No relevant relationships by kimberley cousins, source=Web Response No relevant relationships by Wayne Davis, source=Web Response No relevant relationships by Nitheesha Ganta, source=Web Response No relevant relationships by Funmilola Ogundipe, source=Web Response

Chest Ultrasound- Update 2018

The scope of applications of chest ultrasound has been significantly widened in the last few years. Effusions as little as 5 ml can be identified without problems in a standing or sitting position laterodorsal in the angle between the chest wall and the diaphragm.Portable ultrasound systems are being used to an increasing extent in preclinical sonography, at the site of trauma, in the ambulance of the emergency physician or in helicopters. In the emergency room, at the intensive care unit and in clinical routine, chest ultrasound has proved its worth as a strategic instrument to be used directly after the clinical investigation. Several diagnoses such as pneumothorax, (no sliding sign, no B-lines, no lung pulse, lung point) pneumonia (liver like consolidation with bronchoaerogram) rib fractures (step in cortical bone and hematoma) pulmonary embolism (typical subpleural lesions) can be established immediately. In combination with echocardiography and leg vein compression ultrasound (triple organ ultrasound), the accuracy is more than 90%. The evidence of interstitial syndrome has shown a significant correlation with extravascular lung water in cases of pulmonary edema and noncardiogenic pulmonary edema.Chest ultrasound helps in the diagnosis and staging of lung cancer. Contrast ultrasound (CEUS) is a new tool for the differentiation of sub pleural lung lesions. Ultrasound guided interventions (biopsy, drainage) are very successful. The rate of complications is low when the procedure is performed by trained therapists.Ultrasound is a fixed element of several international guidelines.

Localization of Pulmonary Ground-Glass Opacities with Folate Receptor-Targeted Intraoperative Molecular Imaging.

Intraoperative localization and resection of ill-defined pulmonary ground-glass opacities (GGOs) during minimally invasive pulmonary resection is technically challenging. Current preoperative techniques to facilitate localization of GGOs include microcoil and hook wire placement, both of which have logistic limitations, carry safety concerns, and do not help with margin assessment. In this clinical trial, we explored an alternative method involving near-infrared molecular imaging with a folate receptor-targeted agent, OTL38, to improve localization of GGOs and confirmation of resection margins. In a human trial, 20 subjects with pulmonary GGOs who were eligible for video-assisted thoracoscopic surgery (VATS) resection received 0.025 mg/kg of OTL38 before the resection. The primary objectives were to (1) determine whether use of OTL38 allows safe localization of GGOs and assessment of margins during VATS and (2) determine patient, radiographic, and histopathologic variables that predict the amount of fluorescence during near-infrared imaging. We observed no toxicity. Of the 21 GGOs, 20 accumulated OTL38 and displayed fluorescence upon in situ or back table evaluation. Intraoperatively, near-infrared imaging localized 15 of 21 lesions whereas VATS alone localized 10 of 21 (p= 0.05). The addition of molecular imaging affected care of nine of 21 subjects by improving intraoperative localization (n= 6) and identifying close margins (n= 3). This approach was most effective for subpleural lesions measuring less than 2 cm. For lesions deeper than 1.5 cm from the pleural surface, intraoperative localization using fluorescent feedback was limited. This approach provides a safe alternative for intraoperative localization of small, peripherally located pulmonary lesions. In contrast to alternative localization techniques, use of OTL38 also allows confirmation of adequate margins. Future studies will compare this approach to alternative localization techniques in a clinical trial.

Podoplanin-positive myofibroblasts: a pathological hallmark of pleuroparenchymal fibroelastosis.

Pathological differential diagnoses of pleuroparenchymal fibroelastosis (PPFE) include usual interstitial pneumonia (UIP) and pulmonary apical cap (PAC); however, there are no specific immunostaining makers to distinguish between these diseases. We performed immunohistochemistry using several pleural mesothelial cell-related markers, including cytokeratin-5/6, CAM5.2, WT-1, calretinin, desmin and podoplanin, for PPFE (n = 4), UIP (n = 10) and PAC (n = 3) lung sections. Among the examined markers, in PPFE and PAC lungs podoplanin commonly showed positivity for spindle cells both in thickened pleura and subpleural fibroelastosis lesions; these cells were also stained with α-smooth muscle actin, a marker of myofibroblasts. However, even in elastic fibre-rich cases, UIP lungs did not show such podoplanin-positive myofibroblasts in pleura/subpleura and fibroblastic foci. These findings were also verified using immunofluorescence. By contrast, immunohistochemically as well as morphologically, the difference between PPFE and PAC was not apparent. The presence of podoplanin-positive myofibroblasts could be a pathological hallmark of PPFE, suggesting a pathogenic process distinct from UIP but common to PAC.

The diagnostic yield using ultrasound-guided needle-aspiration for subpleural primary lung cancer is not affected by the radiological properties of the lesions resulting from computed tomography.

It is well known that ultrasound-guided needle-aspiration (USGNA) for intrapulmonary subpleural lesion in contact with the pleura is useful and safe, and its diagnostic yield is high. However, reports concerned with the analyses of cases with intrapulmonary subpleural lesion which could not be diagnosed using USGNA are limited. The objective of this study is to clarify the radiological properties of subpleural primary lung cancer which obstruct diagnosis by USGNA. The consecutive cases with subpleural primary lung cancer whose radiological properties could be confirmed by thoracic computed tomography (CT) without contrast enhancement (CE), and examined by USGNA at our hospital between January 1999 and December 2014 have been analyzed. All cases were given pathological diagnoses of primary lung cancer. The diagnostic yield by USGNA was calculated, and the properties of the lesions of the subjects were analyzed by means of thoracic CT without CE images and pathological findings. 87 consecutive cases (41-86 year olds, 75 males, 12 females) were analyzed. The overall diagnostic yield by USGNA was 86.2%. There was no statistically significant difference regarding the diagnostic yield concerning radiological properties such as cavities, small airspaces and low density areas in the lesions and their sizes. However, the diagnostic yield for the cases with squamous cell carcinoma was statistically significantly low (p=0.02). Although the diagnostic yield of USGNA is not distorted by the radiological properties of lesions, it is statistically significantly low in cases with squamous cell carcinoma.

The importance of subpleural fibrosis in the prognosis of patients with idiopathic interstitial pneumonias

PurposeTo compare computer-aided diagnostic results with histological findings obtained by surgical biopsy and evaluate whether subpleural lesion volumes can aid identification of idiopathic pulmonary fibrosis (IPF).Materials and MethodsWe retrospectively analyzed computed tomography (CT) images of 79 patients (43 with fibrosing nonspecific interstitial pneumonia (fNSIP) and 36 with IPF) using the Gaussian Histogram Normalized Correlation (GHNC) system. We determined the H-pattern based on honeycomb and/or fibrosis with traction bronchiectasis on CT, and measured the H-pattern volume ratio at the biopsy sites and in the subpleural area. The biopsy site CT data were compared with biopsy specimens using Spearman’s correlation. H-pattern volumes in the subpleural area within 2mm under the pleura (H2) were analyzed to predict IPF diagnosis and patients prognosis. ResultsThe H-pattern volume ratio at the biopsy sites showed significant correlation with histological honeycomb (r=0.355, p<0.001), subpleural collapse (r=0.410, p<0.001), and heterogeneity (r=0.484, p<0.001). Multivariate regression analysis, adjusting for age, sex, and CT results, revealed that the H2 was a significant independent predictor of IPF diagnosis (odds ratio: 1.073; p=0.048). H2 correlated with patients’ survival after adjusting for age (p=0.003). ConclusionThe computer-aided H-pattern volume ratio of the subpleural area indicates subpleural abnormalities quantitatively and may help diagnose IPF.

Risk of Pleural Recurrence in Early Stage Lung Cancer Patients after Percutaneous Transthoracic Needle Biopsy: A Meta-analysis

Percutaneous transthoracic needle biopsies (PTNB) are widely used for the diagnosis of a peripheral pulmonary nodules, but the risk of pleural recurrence in lung cancer patients remains undetermined. Our meta-analysis aims to answer the question whether PTNB strategy increases the risk of recurrence. PubMed, EMBASE, The Cochrane Library, and China National Knowledge Infrastructure (CNKI) were searched from inception to January 9, 2016. A total of 1242 patients from 5 studies were included. The results showed that PTNB does not increase risk of total recurrence (Odds Ratio,0.78; 95% CI, 0.53 to 1.15) or pleural recurrence (Odds Ratio,1.58; 95% CI, 0.41 to 6.12) compared with non-PTNB strategies in early stage lung cancer patients. Subgroup analysis showed that PTNB was associated with increased pleural recurrence (Odds Ratio, 10.76; 95% CI, 2.92 to 39.70) in patients with sub-pleural lesions but not in patients without sub-pleural lesions (Odds Ratio, 0.96; 95% CI, 0.24 to 3.89). In conclusion, PTNB should not be recommended in lung cancer patients with sub-pleural lesions. However, PTNB is recommendable to use in other patients without sub-pleural lesions to whom pathological diagnosis is necessary, especially in patients with relevant comorbidities.

Unique and Redundant Functions of p70 Ribosomal S6 Kinase Isoforms Regulate Mesenchymal Cell Proliferation and Migration in Pulmonary Fibrosis.

The p70 ribosomal S6 kinase (p70S6K) is a downstream substrate that is phosphorylated and activated by the mammalian target of rapamycin complex and regulates multiple cellular processes associated with pulmonary fibrogenesis. Two isoforms of the p70S6K have been identified (S6K1 and S6K2), but their relative contributions in mediating pulmonary fibrosis are unknown. To interrogate the roles of the p70S6K isoforms, we overexpressed transforming growth factor (TGF)-α in mice deficient for the S6K1 or S6K2 genes and measured changes in lung histology, morphometry, total lung collagen, lung function, and proliferation between wild-type and isoform-deficient mice. Deficiency of S6K1, but not S6K2, had a significant effect on reducing proliferation in subpleural fibrotic lesions during TGF-α-induced fibrosis. Migration was significantly decreased in mesenchymal cells isolated from the lungs of S6K1 knockout mice compared with wild-type or S6K2 knockout mice. Conversely, increases in subpleural thickening were significantly decreased in S6K2-deficient mice compared with wild type. Deficiency of S6K2 significantly reduced phosphorylation of the downstream S6 ribosomal protein in lung homogenates and isolated mesenchymal cells after TGF-α expression. However, deficiency of neither isoform alone significantly altered TGF-α-induced collagen accumulation or lung function decline in vivo. Furthermore, deficiency in neither isoform prevented changes in collagen accumulation or lung compliance decline after administration of intradermal bleomycin. Together, these findings demonstrate that the p70S6K isoforms have unique and redundant functions in mediating fibrogenic processes, including proliferation, migration, and S6 phosphorylation, signifying that both isoforms must be targeted to modulate p70S6K-mediated pulmonary fibrosis.

Comparison of radial endobronchial ultrasound with a guide sheath and with distance by thin bronchoscopy for the diagnosis of peripheral pulmonary lesions: a prospective randomized crossover trial.

Transbronchial biopsy (TBB) using radial endobronchial ultrasound with a guide sheath (REBUS-GS) has improved the diagnosis of peripheral pulmonary lesions (PPLs). Because of the high cost of the GS, REBUS with distance (REBUS-D) has certain advantages. The aim of this study was to compare the diagnostic yield of the REBUS-GS and REBUS-D by thin bronchoscopy for PPLs. Patients with PPLs were enrolled in a prospective randomized crossover study from August 2014 and July 2015. Once the lesion was localized, TBB using REBUS-GS and TBB using REBUS-D were performed sequentially in a randomized order in each patient. Each patient received four to five transbronchial biopsies with REBUS-GS as well as four to five transbronchial biopsies with REBUS-D. All brushing was performed through GS. A total of 54 patients were enrolled in this study. After excluding seven participants with PPLs that were not detected by REBUS, a total of 47 subjects underwent REBUS-TBB. The diagnostic yield of REBUS-GS-TBB and REBUS-D-TBB was 72.2% (39/54) and 75.9% (41/54) respectively (P=0.625). Moreover, there was no statistically significant difference in diagnostic yield between REBUS-GS and REBUS-D in different lobe lesions and lesion sizes. Two cases of adenocarcinoma were only diagnosed with REBUS-GS-TBB. Two cases of tuberculosis, one case of mucosa-associated lymphoid tissue lymphoma (MALT) and one case of adenocarcinoma were only diagnosed by REBUS-D-TBB. The mean biopsy time after visualization of PPLs for REBUS-GS-TBB and REBUS-D-TBB were 5.17±2.34 and 7.36±3.18 min (P=0.00053). Using thin bronchoscopy, the diagnostic yield for PPLs with REBUS-D-TBB is not inferior to the yield with REBUS-GS-TBB. The diagnosis rate of small subpleural lesions with REBUS-D is lower than the rate with REBUS-GS. Although it is associated with shorter operation time and less bleeding, REBUS-GS has a higher cost and sometimes leads to check failure due to small specimens and the impact of the bronchoscope curvature.

Assessment of transthoracic sonography in patients with interstitial lung diseases

This study was designed to recognize the sonographic features of interstitial lung diseases (ILD). Furthermore, the possible correlations of these features with the functional and radiological parameters of the disease were assessed. Forty-two patients with ILD were included; each patient underwent spirometry, Multi Detector CT chest (MDCT) and transthoracic sonography (TS). Fifteen healthy volunteers were also studied as controls. The sonographic features among ILD patients were B lines in 73.8% , abolished lung sliding in 23.8%, irregular and thickened pleura in 47.6%and 35.7% respectively and subpleural lesions in 38.1%.Increasing distance between the B lines was negatively correlated with both of Forced Vital Capacity % predicted , ground glass opacities and positively correlated with reticular opacities patterns on MDCT chest. TS can be used as an additional imaging method for assessment of ILD and as a marker to estimate the severity of disease.

Etiology of primary spontaneous pneumothorax.

ABSTRACTWith the advent of HRCT, primary spontaneous pneumothorax has come to be better understood and managed, because its etiology can now be identified in most cases. Primary spontaneous pneumothorax is mainly caused by the rupture of a small subpleural emphysematous vesicle (designated a bleb) or of a subpleural paraseptal emphysematous lesion (designated a bulla). The aim of this pictorial essay was to improve the understanding of primary spontaneous pneumothorax and to propose a description of the major anatomical lesions found during surgery.

Role of Arrival Time Difference Between Lesions and Lung Tissue on Contrast-Enhanced Sonography in the Differential Diagnosis of Subpleural Pulmonary Lesions.

The purpose of this study was to explore the diagnostic value of the arrival time difference between lesions and surrounding lung tissue on contrast-enhanced sonography of subpleural pulmonary lesions. A total of 110 patients with subpleural pulmonary lesions who underwent both conventional and contrast-enhanced sonography and had a definite diagnosis were enrolled. After contrast agent injection, the arrival times in the lesion, lung, and chest wall were recorded. The arrival time differences between various tissues were also calculated. Statistical analysis showed a significant difference in the lesion arrival time, the arrival time difference between the lesion and lung, and the arrival time difference between the chest wall and lesion (all P < .001) for benign and malignant lesions. Receiver operating characteristic curve analysis revealed that the optimal diagnostic criterion was the arrival time difference between the lesion and lung, and that the best cutoff point was 2.5 seconds (later arrival signified malignancy). This new diagnostic criterion showed superior diagnostic accuracy (97.1%) compared to conventional diagnostic criteria. The individualized diagnostic method based on an arrival time comparison using contrast-enhanced sonography had high diagnostic accuracy (97.1%) with good feasibility and could provide useful diagnostic information for subpleural pulmonary lesions.

Bortezomib-induced severe pulmonary complications in multiple myeloma: A case report and literature review.

The proteasome inhibitor bortezomib is indicated for use in the treatment of multiple myeloma (MM) patients. The most common side effects are neurological and gastrointestinal, while severe pulmonary complications are rarely described. The present study reports the case of a 62-year-old man with immunoglobulin (Ig)G-type MM who was treated with bortezomib, thalidomide and dexamethasone. Subsequent to the administration of chemotherapy, the patient developed an acute respiratory distress syndrome. High-resolution computed tomography of the chest showed bilateral diffuse alveolar infiltrations and multiple subpleural lesions. A diagnosis of bortezomib-induced severe pulmonary complications was formed. Systemic corticosteroid therapy led to a rapid improvement in clinical conditions and radiological findings. In addition, the present study reviewed the characteristics, including medical history, clinical manifestations, treatment strategies and outcomes, of all 16 MM patients with bortezomib-induced severe pulmonary complications reported previously in Pubmed. It was indicated that patients who were male, of IgG type, with a relapse status and a previous history of auto-PBSCT had a higher possibility of developing bortezomib-induced severe pulmonary complications. Additionally, a relatively low dose rather than a high dose of corticosteroids could obtain a better outcome.

Artificial pneumothorax for pain relief during microwave ablation of subpleural lung tumors.

When microwave ablation (MWA) is used for subpleural lesions, severe pain was the common side effect under the local anesthesia conditions during the procedure and postprocedure. To study the pain relief effect of artificial pneumothorax in the treatment of subpleural lung tumors with MWA. From February 2012 to October 2014, 37 patients with 40 subpleural lung tumors underwent MWA, including 17 patients of 19 sessions given artificial pneumothorax prior to MWA (group-I), and 20 patients of 21 sessions without artificial pneumothorax (group-II). Patient's pain assessment scores (10-point visual analog scale [VAS]) at during-procedure, 6, 12, 24, and 48 h after the MWA procedure and mean 24 h morphine dose were compared between the two groups. Complications of the artificial pneumothorax were also summarized. Pain VAS were 0.53, 0.65, 1.00, 0.24, and 0.18 at during-procedure, 6, 12, 24, and 48 h for group-I and 5.53, 2.32, 2.82, 1.21, and 0.21 for group-II, respectively. Pain VAS in group I was significantly decreased at during-procedure, 6, 12, and 24 h after the MWA (P < 0.001). No statistical pain VAS difference was observed at 48 h after the MWA between the two groups (P > 0.05). The mean 24 h morphine dose was 5.00 mg in group-I and 12.63 mg in group-II (P = 0.000). "Artificial pneumothorax" related complications occurred in two patients from group-I, including one pleural effusion and one minor hemoptysis. No patient in group-I and group-II died during the procedure or in 30 days after MWA. Artificial pneumothorax is a safe and effective method for pain relief during MWA of subpleural lung tumors.

Lung ultrasonography: an effective way to diagnose community-acquired pneumonia

PurposeTo analyse the ultrasonographic findings of community-acquired pneumonia (CAP) and its efficacy for diagnosis of CAP compared with chest X-ray (CXR).MethodsPatients who presented to the Emergency Department with suspected CAP...

Transthoracic ultrasound in the assessment of pleural and pulmonary diseases: use and limitations

Interest in transthoracic ultrasound (US) procedures increased after the availability of portable US equipment suitable for use at the patient's bedside. It is possible to detect space-occupying lesions of the pleura, pleural effusion, focal or diffuse pleural thickening and subpleural lesions of the lung, even in emergency settings. Transthoracic US is useful as a guidance system for thoracentesis and peripheral lesion biopsy, where it minimises the occurrence of pneumothorax and haemorrhage. Transthoracic US imaging is strongly influenced by physical interaction of the ultrasonic beam at the tissue/air interface, which gives rise to reverberations classified as simple (A-line), "comet tail" and "ring down"(B-line) artifacts. Although these artifacts can be suggestive of a disease condition, they are essentially imaging errors present even in normal subjects and in empty-pleura post-pneumonectomy patients. In order to clarify some confusion and to report on the state of the art, we present a review of the literature on transthoracic US in diseases of the pleura and peripheral lung regions and our own clinical experience over 3 decades. The review focuses on quality assurance procedures and their value in diagnostic imaging and patient monitoring and warns against possible inappropriate indications and misleading information. Thoracic US is much more than "fishing for the moon in the well".

Thoracoscopic approach to bilateral pulmonary metastasis: is it justified?

There are few reports on optimal surgical approaches to bilateral pulmonary metastasis and the sequences used in the operation. The aim of this study was to evaluate the feasibility of the thoracoscopic bilateral approach to pulmonary metastasis. From June 2006 to February 2013, 61 patients underwent a planned bilateral pulmonary metastasectomy with one- (n = 52) or two-stage (n = 9) thoracoscopic surgery. We retrospectively analysed the outcomes of this group of patients to define the role and limitation of thoracoscopic surgery in bilateral disease. In 17 patients with bilateral single lesions on the computed tomography (CT) scans, we were able to resect more nodules than initially imaged in 7 patients (41.2%), and there were 2 patients (11.8%) who had more true metastatic lesions than expected. Among 44 patients who showed more than two bilateral multiple lesions on the CT scan, we were able to resect more than 10 nodules in 2 patients (4.5%). The overall accuracy rate for resected malignant nodules was 76.6%, and 9 patients (14.8%) actually had the disease confined to the unilateral thorax, with solitary (n = 8) and multiple (n = 1) metastases after bilateral exploration. The prognostic factors for unilateral disease were unilateral lesion on the positron emission tomography (PET) scan (P = 0.024). The values of FVC and FEV1 were, respectively, 14.4 and 15.4% reduction at 6 months postoperatively in patients who had three or more nodules resected. Sarcomatous histology (P = 0.039), a diameter larger than 3 cm (P = 0.042) and bilateral lesion on PET (P = 0.035) were the prognostic factors for intrathoracic recurrences. Bilateral pulmonary metastasectomy was performed safely with thoracoscopy in patients with bilateral oligo-metastatic sub-pleural lesions and the one-stage approach was a feasible option in bilateral single lesions. Preoperative PET scan could help predict intrathoracic recurrence after thoracoscopic metastasectomy.

Chest Tomosynthesis: Technical and Clinical Perspectives

The recent implementation of chest tomosynthesis is built on the availability of large, dose-efficient, high-resolution flat panel detectors, which enable the acquisition of the necessary number of projection radiographs to allow reconstruction of section images of the chest within one breath hold. A chest tomosynthesis examination obtains the increased diagnostic information provided by volumetric imaging at a radiation dose comparable to that of conventional chest radiography. There is evidence that the sensitivity of chest tomosynthesis may be at least three times higher than for conventional chest radiography for detection of pulmonary nodules. The sensitivity increases with increasing nodule size and attenuation and decreases for nodules with subpleural location. Differentiation between pleural and subpleural lesions is a known pitfall due to the limited depth resolution in chest tomosynthesis. Studies on different types of pathology report increased detectability in favor of chest tomosynthesis in comparison to chest radiography. The technique provides improved diagnostic accuracy and confidence in the diagnosis of suspected pulmonary lesions on chest radiography and facilitates the exclusion of pulmonary lesions in a majority of patients, avoiding the need for computed tomography (CT). However, motion artifacts can be a cumbersome limitation and breathing during the tomosynthesis image acquisition may result in severe artifacts significantly affecting the detectability of pathology. In summary, chest tomosynthesis has been shown to be superior to chest conventional radiography for many tasks and to be able to replace CT in selected cases. In our experience chest tomosynthesis is an efficient problem solver in daily clinical work.

Experimental VILI begins with subpleural lung lesions

We developed an experimental model of VILI, ventilating piglets at a strain (TV/FRC) >2.5. It is possible that lung inhomogeneities act as stress raisers within the lung parenchyma, locally multiplying pressures. In a healthy lung the pleural surface, vessels and bronchi are detected as natural lung inhomogeneities. We studied the development of VILI with CT scan to determine where the first lung lesion developed.