Surrounding Ground Glass Research Articles

Radiographic analysis provides evidence for the etiology of pulmonary cysts in COVID-19

AbstractBackground and aimImaging of patients with COVID-19 has provided unique insights into the pathophysiology of the infection. Cysts are a rare manifestation of the disease in the lung. The aim of this research was to compare COVID-19-positive patients with cysts on CT to patients without cysts and propose a mechanism for cyst formation in this patient population based on radiographic observations.Materials and MethodsOur HIPAA-compliant IRB-approved research project involved a retrospective review of 219 chest CT scans identified in COVID-19-positive inpatients and emergency room patients at Columbia University Irving Medical Center from February 27, 2020 to July 17, 2020. A thoracic radiologist with over 20 years of experience reviewed the images on lung window settings and identified the presence of cysts, their distribution (central or pleural based), and if there was an accompanying pneumothorax. The extent of consolidation of the entire lung on a scale of 0–16 and the presence of fibrosis were also documented.ResultsCysts were identified in 10 of the 219 patients. CT scans with cysts were obtained on average on day 57 of symptoms (range 16–115 days) compared to CT scans of those without cysts that were obtained on average on day 19 (range 0–89 days). The distribution of cysts was heterogeneous; six patients had multiple cysts while four were isolated. Seven cysts were peripheral in distribution while three were central. Two patients with cysts developed a subsequent pneumothorax. Fifty percent of those with cysts had been intubated.ConclusionsPatients with COVID-19 develop cystic lung lesions for at least two reasons; pleural-based lesions are more likely areas of infarction and central lesions with surrounding ground glass are more likely related to infection and/or mechanical ventilation.

A radiomic-based predictive model of lung adenocarcinoma brain metastases and molecular subtypes.

2014 Background: Non-small cell lung cancer (NSCLC) comprises the largest portion of brain metastases (BM) from solid cancer with 40% of patients developing BM during the course of their disease. There are currently no reliable prediction tools for identifying patients at risk for BM, especially in the early-stage setting where MRI screening is not performed. Furthermore, in the later stage setting, brain MRI are only performed annually. Therefore, there is a critical need to identify high-risk patients for BM that could benefit from MRI surveillance. Methods: We identified 162 lung adenocarcinoma (LUAD) patients with (N = 66) or without (N = 96) BM that had treatment-naïve CT scans with a segmentable lesion. The tumor, surrounding ground glass opacity and necrosis were segmented via 3D slicer to create a volume of interest for radiomic texture analysis and 400 features were extracted. The Least Absolute Shrinkage and Selection Operator (LASSO) logistic regression feature selection method was used to select the most relevant features and models were built using the machine learning method XGBoost classifier. Training and testing sets with random splitting was used for cross validation. We report the accuracy, sensitivity, specificity, and area under the curve (AUC) for each model. Results: Among the extracted features that LASSO deemed as most discriminative for development of BM, we identified the most relevant features using XGBoost that predicted BM with 79% accuracy, 83% sensitivity, 72% specificity, and 79% AUC ( p= 0.01) in the overall population. The addition of ground glass opacity and necrosis to the model did not significantly improve performance. Furthermore, the model distinguished those with metachronous vs synchronous BM with 84% accuracy, 83% sensitivity, 86% specificity, and 83% AUC ( p = 0.04). Our model held up across molecular subtypes ( EGFR and KRAS mutant). Importantly, the model was predictive in early-stage patients with 92% accuracy, 96% sensitivity, 83% specificity, and 95% AUC ( p= 0.0005). Moreover, our model predicted for high vs. low overall survival, and was BM-specific as it was not predictive of other sites of metastases. We further developed a model from the CT features that correctly classified KRAS mutant vs. KRAS wild type LUAD with 77% accuracy, 73% sensitivity, 80% specificity, and 80% AUC ( p= 0.002). Conclusions: Utilizing a radiomics approach, we were able to predict BM from primary lung CT features including in stage I and II disease, predict synchronous vs metachronous BM, and distinguish distinct molecular LUAD subtypes. We are currently validating our BM prediction model in a large independent cohort and developing models to classify targetable LUAD-BM molecular alterations utilizing brain MRI scans. These studies will identify patients that require MRI surveillance in the early-stage setting and more intensive surveillance in the late-stage setting for BM.

MAC CALLING THE COP: ORGANIZING PNEUMONIA SECONDARY TO MYCOBACTERIUM AVIUM COMPLEX INFECTION

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Organizing pneumonia (OP) is an inflammatory lung disease involving the distal bronchioles, respiratory bronchioles, bronchiolar ducts & alveoli. OP may be cryptogenic (COP) or secondary to several factors such as drugs, infections, radiation therapy, malignancy or CTD.Mycobacterium Avium Complex (MAC) pulmonary infection is a challenging entity & diagnosis relies on the integration of clinical, radiological, microbiological & pathological results. The clinical course is heterogenous, ranging from asymptomatic cases to patients with refractory disease associated with considerable morbidity and mortality. CASE PRESENTATION: A 44-year-old female with history of COPD, DM 2, alcoholic cirrhosis, tobacco & opioid use disorder presented with worsening SOB & dry cough for a week. She was treated a year ago with 3 months of steroid therapy for COP with complete clinical and physiologic improvement and normalization of the chest film.She endorsed subjective fever & myalgias but denied hemoptysis, night sweats, weight loss, rashes, joint swelling or pain, sick contacts, recent travel & occupational exposure. Vitals were significant for fever, hypoxia, tachypnea & tachycardia. Physical exam revealed crackles in bilateral mid to lower lung fields. Laboratory results showed leukocytosis & thrombocytopenia. Serum chemistry was notable for elevated lactate but normal procalcitonin, cardiac enzymes & BNP. COVID19 PCR nasal swabs x 2 were negative. CTA showed patchy bilateral consolidations with surrounding ground glass opacities throughout lung fields & no evidence of PE. Patient was started on broad spectrum antibiotics. Infectious & Rheumatological work up turned out to be negative. Given negligible improvement & previous history of COP, she underwent VATS with wedge biopsy & histopathology confirmed florid organizing pneumonia. Glucocorticoid therapy was initiated. At 8 weeks, her tissue culture revealed the presence of MAC. Due to unfavorable clinical response to steroid therapy alone, it was decided to start Rifabutin, Ethambutol & Azithromycin to treat MAC pulmonary infection causing secondary OP. Patient showed clinical improvement & glucocorticoids were gradually tapered. Patient was referred to respiratory rehabilitation & scheduled for follow up at outpatient clinic. DISCUSSION: MAC pulmonary infection & secondary OP association has been rarely reported in the literature. OP is believed to be a consequence of alveolar epithelial injury. Both MAC pulmonary infection & OP have increased cytokine production leading to the inflammation suggesting a common pathway. Therefore, it may be possible for MAC to trigger an OP reaction. CONCLUSIONS: We recommend a systematic assessment of potential etiological agents triggering, what is considered to be COP. Further studies are warranted to establish a causal relationship between MAC & OP thus representing another manifestation of NTM-PD. REFERENCE #1: Cordier J-F. Cryptogenic organising pneumonia. Eur Respir J 2006;28:422–46 REFERENCE #2: Griffith DE, Aksamit T, Brown-Elliott BA, et al. An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. Am J Respir Crit Care Med 2007;175:367–416 REFERENCE #3: Carre PC, King TE, Mortensen R, et al. Cryptogenic organizing pneumonia: increased expression of interleukin-8 and fibronectin genes by alveolar macrophages. Am J Respir Cell Mol Biol 1994;10:100–5 DISCLOSURES: No relevant relationships by Muhammad Ahsan, source=Web Response No relevant relationships by Kristin Fless, source=Web Response No relevant relationships by Thomas Ng, source=Web Response No relevant relationships by ARCHANA SREEKANTAN NAIR, source=Web Response

THE TALE OF A HALO SIGN

SESSION TITLE: Fellows Imaging Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Halo sign on chest imaging is characterized by a circular area of ground-glass attenuation around a central pulmonary nodule or mass. It is most commonly associated with invasive fungal infections; however, can also be seen in a wide range of neoplastic and inflammatory conditions. Here we present a case of angio-invasive neoplasm presenting with characteristic halo sign in an immunocompromised patient. CASE PRESENTATION: A 62-year-old male with alcoholic cirrhosis post orthotopic liver transplant on chronic immunosuppression with recurrent cirrhosis of his graft liver was initially admitted for management of acute hepatic encephalopathy. A CT scan of his chest showed numerous part solid centrilobular nodules bilaterally with central solid component and surrounding ground glass halo. Invasive fungal infection was suspected, and micafungin was initiated. Serum aspergillus antigen and beta D-glucan were negative. He underwent bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial biopsy (TBB). BAL was negative for bacterial, fungal and acid-fast bacilli cultures. Pathology from the TBB showed atypical epithelioid cells that could be reactive or due to a metastatic disease. A repeat CT scan performed after 10 days of antifungal therapy showed a significant increase in size of the previously noted centrilobular nodules with surrounding ground glass halo. Surgical open lung biopsy was considered but he was deemed to be a poor surgical candidate due to his frailty and comorbidities. Transbronchial cryobiopsy was then performed which showed poorly differentiated epithelioid neoplasm predominantly within the vascular spaces. Based on immunohistochemical staining positive for both cytokeratin and vascular markers, a differential diagnosis of epithelioid angiosarcoma vs. epithelioid sarcoma was made. After detailed discussion with him and his family in regards to his overall prognosis, he wished for no further testing or interventions and chose to go home with hospice. DISCUSSION: Halo sign indicates presence of hemorrhagic nodules. It was first described in immunocompromised patients with invasive pulmonary aspergillosis where the nodule itself is a focus of pulmonary infarction with surrounding alveolar hemorrhage. However, it has now been associated with a variety of pulmonary diseases including both infectious and non-infectious hemorrhagic nodules, tumor cell infiltration and few non-hemorrhagic etiologies. Metastatic lung disease from hyper vascular tumors such as angiosarcoma, chondrosarcoma and melanoma can form a halo of ground glass attenuation as a result of peritumoral hemorrhage or infiltration. Malignancy is a leading cause of death in post liver transplant patients and should always be considered in the evaluation of these patients. CONCLUSIONS: While evaluating halo sign a wide differential should be considered including malignancy in a post liver transplant patient. Reference #1: Georgiadou SP, Sipsas NV, Marom EM, Kontoyiannis DP. The diagnostic value of halo and reversed halo signs for invasive mold infections in compromised hosts. Clin Infect Dis. 2011;52(9):1144-1155. doi:10.1093/cid/cir122 Reference #2: Parrón M, Torres I, Pardo M, Morales C, Navarro M, Martínez-Schmizcraft M. Signo del halo en la tomografía computarizada de tórax: diagnóstico diferencial con correlación anatomopatológica [The halo sign in computed tomography images: differential diagnosis and correlation with pathology findings]. Arch Bronconeumol. 2008;44(7):386-392. DISCLOSURES: No relevant relationships by Sadia Benzaquen, source=Web Response No relevant relationships by Ena Gupta, source=Web Response No relevant relationships by ATUL MATTA, source=Web Response No relevant relationships by Corrado Minimo, source=Web Response No relevant relationships by Carlos Oberto, source=Web Response

High resolution CT features of novel coronavirus pneumonia in children

Objective To investigate the high resolution CT (HRCT) features of novel coronavirus pneumonia (NCP) in children . Methods A retrospective analysis was performed on the chest HRCT findings of 22 children diagnosed with 2019-nCov pneumonia by clinical and nucleic acid testing in Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology from January 25, 2020 to February 5, 2020. There were 12 boys and 10 girls, aged from 2 months to 14 years old, with a median age of 4 years, and 14 patients were under 5 years old. The characteristics of lung lesions on HRCT imaging such as distribution, shape, density, etc. and whether there were hilar and mediastinal lymph node enlargement and pleural changes were observed by 2 radiologists. Results In all of the 22 patients, 3 patients (3/22) had normal chest CT, and 19 patients (19/22) had infiltrated lesions in lung. Among them, 7 patients had unilateral lung involvement, 12 patients had bilateral involvement. The HRCT manifestations were as follows. Six patients showed ground glass shadow, including 4 cases showed light ground glass shadow and 2 had typical crazy paving sign. Four patients showed lung consolidation, with localized strip shadow and patchy high-density shadow. Six patients showed patchy lesions with surrounding ground glass shadow, including 1 case with white lung in the right. The bronchopneumonia-like changes in 3 cases, showed scattered spot-like or patchy uneven high-density shadows. The lesions in the lower lobe were more serious than those in the upper lobe, and the lesions in the lateroposterior zone of the lung were more common than those in the apical and central area of the lung. No enlarged lymph nodes and pleural effusion were seen in all patients, and 1 case had thickened interlobar pleura. Conclusions The HRCT manifestations of NCP in children are diversified, comprehensive judgments need to be made in combination with epidemiological data, clinical manifestations, and laboratory tests, but the chest HRCT can be used as an important basis for early clinical diagnosis and prevention and control interventions. Key words: Coronaviridae infections; 2019-novel coronavirus; Pneumonia; Child; Tomography, X-ray computed

HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS TRIGGERED BY ADENOVIRUS PNEUMONIA: A RARE COMPLICATION OF A COMMON DISEASE

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Adenovirus (ADV) pneumonia is a common disease with many extrapulmonary complications. We report a case of a 71-year old lady with history of follicular lymphoma who developed ADV pneumonia triggering hemophagocytic lymphohistiocytosis (HLH) CASE PRESENTATION: A 71-year-old female presented to our hospital with fever and cough. Chest X-ray revealed pneumonia. Additional labs upon admission showed pancytopenia. Six months prior to presentation, she was diagnosed with follicular lymphoma and she completed six cycles of R-CHOP (last cycle being four weeks prior to presentation). A PET-CT scan performed five days prior to admission revealed complete metabolic response, and a complete blood count was normal. Empiric antibiotics did not result in improvement prompting a CT scan of the chest that showed dense consolidation in the left lower lobe, ground glass opacities in upper lobes and trace pleural effusions. Bronchoscopy was performed. Bronchial wash cultures grew ADV. Other bacterial, fungal and viral serology/cultures were all negative. ADV was also isolated from serum. Patient remained febrile and had progressive pancytopenia with counts reaching a nadir of 0.0K/uL neutrophils, 5.8 g/dL hemoglobin and 34K/uL platelets. Further labs showed elevated ferritin at >40,000ng/ml , elevated soluble IL-2 receptor alpha and transaminitis. HLH was suspected and steroids were started empirically. Bone Marrow biopsy confirmed HLH without evidence of lymphoma or metastatic carcinoma. Patient continued to decline, she developed rectus sheath hematoma, hypotension, acute kidney injury and delirium. Family decided to withdraw all active treatments and take the route of comfort care which eventually lead to her unfortunate demise on day nine of admission. DISCUSSION: ADV pneumonia can occur in both immunocompetent and immunocompromised hosts(1). Both outbreaks and sporadic cases have been described. ADV-pneumonia can be fatal with poor prognostic factors including: viremia, multilobar infiltrates and parapneumonic effusions(2, 3). CT commonly shows dens consolidation with surrounding ground glass opacities. ADV infection induced HLH has been well described in children. This phenomenon is rare in adults with only a few reported cases, mostly described in hematopoietic stem cell transplant recipients. Older age, markedly elevated ferritin and underlying lymphoma are considered poor prognostic factors in HLH. Our patient’s history of follicular lymphoma had probably put her at higher risk for developing this immunological catastrophe. She had all of the aforementioned poor prognostic of both ADV-pneumonia and HLH. CONCLUSIONS: Our case signifies that HLH should be suspected in the setting of ADV infection and pancytopenia. Early diagnosis and treatment might be associated with better outcomes in this rare-life threatening- hematological complication. Reference #1: Shen CF, Wang SM, Ho TS, Liu CC. Clinical features of community acquired adenovirus pneumonia during the 2011 community outbreak in Southern Taiwan: role of host immune response. BMC infectious diseases. 2017;17(1):196. Reference #2: Gu L, Qu J, Sun B, Yu X, Li H, Cao B. Sustained Viremia and High Viral Load in Respiratory Tract Secretions Are Predictors for Death in Immunocompetent Adults with Adenovirus Pneumonia. PloS one. 2016;11(8):e0160777. Reference #3: Yoon H, Jhun BW, Kim SJ, Kim K. Clinical characteristics and factors predicting respiratory failure in adenovirus pneumonia. Respirology (Carlton, Vic). 2016;21(7):1243-50. DISCLOSURES: No relevant relationships by Muhammad Hamza, source=Web Response No relevant relationships by Khalid Mohamed Ahmed, source=Web Response No relevant relationships by Mahum Shahid, source=Web Response No relevant relationships by Qazi Ahmed Waqas, source=Web Response

The Association Between Imaging Features of TSCT and the Expression of PD-L1 in Patients With Surgical Resection of Lung Adenocarcinoma

ObjectivesProgrammed death-ligand 1 (PD-L1) expression might serve as a predictive biomarker for immune checkpoint inhibitors in lung cancer. However, the relationship between PD-L1 expression and imaging features of lung cancer has not been fully understood. Patients and MethodsA total of 350 patients with pathologically confirmed adenocarcinoma who received surgical treatment and had preoperative thin section computed tomography (CT) examination were included. Quantitative CT features including the mean CT value and tumor mass were measured on multiplanar reconstructed images. PD–L1-positive tumor was defined as the tumor proportion score > 5%. ResultsSeventy-four of 350 (21.1%) specimens were detected as PD–L1-positive tumors. PD-L1 expression was adversely associated with epidermal growth factor receptor mutation status (P < .001) and was significantly associated with invasive adenocarcinomas rather than preinvasive lesions and minimally invasive adenocarcinomas (P < .001). Multivariate analysis identified absence of surrounding ground glass opacity (P = .022), shape (P = .008), pleural indentation (P = .007), tumor mean CT value (P = .004), and the ratio of consolidation mass to tumor mass (P = .003) as being significantly associated with the expression of PD-L1. To improve the diagnostic accuracy, a joint model that combined 5 imaging traits was conducted. The area under the curve of the joint model was 0.783, with a sensitivity of 81.1% and specificity of 64.1%, respectively. ConclusionPD-L1 expression was associated with pathologic invasiveness of adenocarcinomas and CT features, which suggested the possibility of predicting PD-L1 expression status via imaging features.

DILEMMA IN THE DIAGNOSIS OF COCCIDIOIDOMYCOSIS

SESSION TITLE: Chest Infections 3 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Coccidioidomycosis (CM) is a disease with broad spectrum of clinical manifestations that can affect immunocompromised as well as immunocompetent individuals. Patients can be asymptomatic or may have pneumonia like features. CM is endemic in several parts of the South-western US and South America. The incidence of CM is increasing all across the US and it poses several diagnostic challenges including delay in diagnosis and care. CASE PRESENTATION: A 30-year-old male with history of tobacco and marijuana smoking was admitted with fever, cough and intermittent hemoptysis for 3 weeks. He has history of travel to Aruba and Arizona 4 weeks prior to admission. He also has history of exposure to farm animals and used to hunt deer. He initially went to urgent care, diagnosed with pneumonia and was given Clarithromycin. However, his symptoms did not improve. On admission, exam showed minimal rales on both sides. CXR showed LLL opacity and bilateral hilar lymphadenopathy (LAD). CBC revealed eosinophilia 12.6%. He was started on Vancomycin, Zosyn and Azithromycin. Extensive work up was negative including tuberculosis, histoplasmosis, aspergillosis, coccidomycosis, legionella, brucellosis, blastomycosis, HIV. ACE level was negative. CT Thorax revealed cavitary lesion in the LLL with surrounding consolidation and multiple pulmonary nodules with surrounding ground glass opacity bilaterally. Significant LAD was seen in the mediastinum and in both pulmonary hila. Transbronchial biopsy showed focal proliferation of langerhans cells, CD1a reactive but negative S1-00 stain, consistent with Langerhans cell histiocytosis (PLCH) with dense eosinophilic infiltrate, however the eosinophilia was more extensive and not related to the positive CD1a areas which was thought to be secondary to chronic eosinophilic pneumonia. He was instructed to quit smoking and started corticosteroid 60 mg per day and Bactrim. However, his symptom did not improve and mediastinal LAD worsened. He had excisional biopsy of one of his mediastinal lymph nodes which showed suppurative necrotizing and non-necrotizing granulomatous inflammation. Numerous coccidioides fungal yeast were seen. He was started on Fluconazole and his symptoms improved. Repeat CXR showed resolution of opacities/cavity noted previously. DISCUSSION: Due to the versatile manifestation of this disease, the diagnosis is challenging, resulting in an extensive evaluation for malignancy and other infectious/granulomatous diseases. Serology can take weeks to months to develop, for this reason, obtaining fungal culture and tissue biopsy considered to be more valuable for diagnosis. Treatment involves Azole or Amphotericin B and duration depends on extent of infection and immune status of the patient. CONCLUSIONS: Physicians should have high suspicion for CM in patients with travel to endemic areas even if serology was negative and biopsy should be done to confirm the diagnosis. Reference #1: Wang Z, Wen S, Ying K. A case study of imported pulmonary coccidioidomycosis. Journal of Zhejiang University Science B. 2011;12(4):298-302. https://doi.org/10.1631/jzus.B1000261. Reference #2: Al-Daraji WI, Al-Mahmoud RMW, Ali MA. Disseminated Coccidioidomycosis: A Case Report from the United Kingdom. International Journal of Clinical and Experimental Pathology. 2009;2(5):494-497. DISCLOSURES: No relevant relationships by Housam Hegazy, source=Web Response No relevant relationships by Mili Shah, source=Web Response No relevant relationships by Bashar Sharma, source=Web Response No relevant relationships by Vikrant Tambe, source=Web Response

Radiological Features of IDO1+/PDL1+ Lung Adenocarcinoma: A Retrospective Single-institution Study.

A combination of immune-checkpoint inhibitors that target the programmed cell death 1 (PD1)/programmed cell-death ligand 1 (PDL1) pathway and indoleamine 2,3-dioxygenase 1 (IDO1) is a promising treatment for non-small-cell lung cancer. Herein, we investigated clinical features of IDO1+/PDL1+ primary lung adenocarcinoma. IDO1 and PDL1 expression in 388 resected primary lung adenocarcinoma samples was evaluated using immunohistochemistry, and the radiological features of patients with IDO1+/PDL1+ lung adenocarcinoma were analyzed. Of 388 specimens, 229 (59.0%) were IDO1+, 131 (33.8%) were PDL1+, and 109 (28.1%) were IDO1+/PDL1+ In multivariate analysis, vascular convergence and the absence of surrounding ground glass opacity were significantly associated with IDO1+/PDL1+ tumors. Fisher's exact test showed high consolidation/tumor ratio was also significantly associated with IDO1+/PDL1+ tumors. Moreover, maximum standardized uptake in 18F-fluorodeoxyglucose positron-emission tomography/computed tomography was significantly higher in patients with IDO1+/PDL1+ tumors than in those with IDO1- or PDL1- tumors. IDO1/PDL1 co-expression was significantly related to radiological invasiveness and malignancy in lung adenocarcinoma. This study may help select patients likely to benefit from combination therapy using immune-checkpoint inhibitors.

Radiological Features of Programmed Cell Death-Ligand 2-positive Lung Adenocarcinoma: A Single-institution Retrospective Study.

Programmed cell death-ligand 1 and 2 (PD-L1 and PD-L2) are ligands of the programmed cell death-1 (PD1) receptor. PD1/PD-L1 inhibitors have shown clinical efficacy in non-small cell lung cancer (NSCLC). However, relatively little is known about the expression of PD-L2, or its association with the clinicopathological features of NSCLC. Here, the radiological features of PD-L2-positive lung adenocarcinoma were evaluated. PD-L1 and PD-L2 expression were evaluated by immunohistochemical staining of surgically-resected specimens from 393 patients with primary lung adenocarcinoma who underwent preoperative thin-section computed tomography (CT), 222 of whom also underwent 18F-fluorodeoxyglucose positron-emission tomography/CT (18F-FDG-PET/CT). Among the 393 specimens, 132 (33.6%) and 266 (67.7%) were positive for PD-L1 and PD-L2 expression, respectively. Multivariate analysis showed that the absence of surrounding ground glass opacity and the presence of air bronchogram were significantly associated with PD-L2 expression; however, there was no significant association between PD-L2 expression and the consolidation/tumor ratio. In 222 18F-FDG-PET/CT, the maximum standardized uptake value was significantly higher in patients with PD-L2-positive compared to those with PD-L2-negative tumors. PD-L2-positive lung adenocarcinomas are less radiologically malignant and invasive than their PD-L1-positive counterparts.

Computed Tomographic Appearance of Organizing Pneumonia in an Oncologic Patient Population.

The aims of this study were to describe the computed tomographic features of organizing pneumonia (OP) in an oncologic patient population and to also identify features associated with lung cancer and patients undergoing hematopoietic stem cell transplant (HSCT). In retrospective computed tomographies from 151 patients with pathologically confirmed OP between January 2009 and September 2014, number of lesions, location, size, margin type, and consistency, as well as volume of lymphadenopathy and the presence and size of pleural effusions, were recorded. Associated malignancy was noted. Organizing pneumonia most commonly presented as a diffuse process (n = 62, 41%), frequently occupied both a central and peripheral location (n = 79, 53%), and commonly presented with a solid appearance (n = 67, 44%) or with ground glass opacity (n = 80, 53%). Pleural effusions were seen in 68 patients (45%). Organizing pneumonia less frequently contained air bronchograms, cavitation, necrosis, surrounding ground glass opacity, or adjacent bronchiectasis. In patients with lung cancer (n = 25, 17%), OP more likely presented as discrete lesions and occupied a peripheral location as compared with patients with other malignancies (Ps = 0.025 and 0.002). In HSCT patients (n = 29, 19%), a diffuse process was more commonly seen than in non-HSCT patients (P = 0.038). Organizing pneumonia more commonly presents as discrete lesions with a peripheral location in patients with lung cancer and as a diffuse process in patients who had undergone HSCT.

Computed Tomography Features of Lung Adenocarcinomas With Programmed Death Ligand 1 Expression

IntroductionThe development of immune checkpoint inhibitors against programmed death 1 has paved the way for a new era of treatment of lung cancer. Programmed death-ligand 1 (PD-L1) is expected to predict the response of immune checkpoint inhibitors in lung cancer. Predicting PD-L1 expression using a noninvasive method before immunotherapy would, therefore, help identify patients for whom immunotherapy can be successful. Patients and MethodsA total of 394 patients with resected lung adenocarcinoma who had undergone preoperative thin-section computed tomography (CT) were analyzed for PD-L1 expression by immunohistochemistry and evaluated to determine the association between PD-L1 expression and CT characteristics, including convergence, surrounding ground glass opacity (GGO), air bronchogram, notching, pleural indentation, spiculation, and cavitation. ResultsOf the 394 patients, 78 (19.8%) were positive and 316 (80.2%) were negative for PD-L1 expression. Univariate analysis demonstrated that PD-L1+ adenocarcinoma was significantly associated with the presence of convergence (P < .01), notching (P < .01), spiculation (P < .01), and cavitation (P < .01) and the absence of surrounding GGO (P < .01) compared with PD-L1− cases. On multivariate analysis, the presence of convergence (P < .01) and cavitation (P < .01) and the absence of surrounding GGO (P = .02) and air bronchogram (P = .03) were significantly associated with PD-L1 expression. ConclusionPD-L1+ adenocarcinoma cases showed convergence and cavitation more frequently than did PD-L1− cases. In contrast, surrounding GGO and air bronchogram were observed less frequently in PD-L1+ cases than in PD-L1− cases. These results will prove helpful in identifying PD-L1–expressing adenocarcinoma by CT before immunotherapy.

Radiological Features of the Surgically Resected Small-sized Small-cell Lung Cancer on Computed Tomography.

Surgical resection can be applied in cases of early-stage small-cell lung cancer (SCLC). Predicting the histology of SCLC and discriminating SCLC from other histologies would be useful for determining the optimal treatment strategies for small pulmonary nodules that have not been preoperatively diagnosed. The study population included 17 patients with resected SCLC and 296 patients with adenocarcinoma (ADC) whose preoperative CT were available. The tumors of all patients were smaller than 3.0 cm. Univariate and multivariate analyses demonstrated that SCLC was significantly associated with the presence of notching and the absence of surrounding ground glass opacity, air bronchogram, pleural indentation, and spiculation in comparison to ADC. The CT scans of patients with SCLC of less than 3.0 cm in size showed notching more frequently than those of patients with ADC, whereas surrounding GGO, air bronchogram, pleural indentation and spiculation were observed less frequently compared to ADC.

CT Features of Epidermal Growth Factor Receptor–Mutated Adenocarcinoma of the Lung: Comparison with Nonmutated Adenocarcinoma

IntroductionThe purpose of this study was to analyze the high-resolution computed tomography (HRCT) features of lung carcinoma on the basis of epidermal growth factor receptor gene (EGFR) mutation status. MethodsA total of 263 consecutive patients in whom lung adenocarcinoma was diagnosed at our institution between January 2010 and December 2011 were enrolled in the study. All patients underwent HRCT and analysis of EGFR mutation status. The HRCT findings were retrospectively analyzed for tumor size, multiple bilateral lung metastases, convergence of surrounding structures, surrounding ground-glass opacity, prominent peribronchovascular extension, air bronchogram, notch, pleural indentation, spiculation, cavity, and pleural effusions. ResultsEGFR mutations were demonstrated in 103 patients (39.2%); the remaining 160 patients (60.8%) had the nonmutated type of adenocarcinoma. Compared with the nonmutated group, the mutated group had significantly higher frequencies of multiple bilateral lung metastases (p = 0.0152), convergence of surrounding structures (p < 0.0001), ground-glass opacity (p = 0.0011), and notch (p = 0.0428), but significantly lower frequencies of cavitation (p = 0.0004) and pleural effusions (p = 0.0064). The frequencies of the other CT findings were similar between the two groups. The devised prediction HRCT score for EGFR mutation was 78.4% sensitive and 70.4% specific. ConclusionsEGFR-mutated adenocarcinoma showed significantly higher frequencies of multiple bilateral lung metastases, convergence of surrounding structures, surrounding ground glass opacity, and notch at HRCT compared with the non–EGFR-mutated type. Conversely, EGFR-mutated adenocarcinoma showed cavity and pleural effusions less frequently than the nonmutated type did.

Bodybuilders pneumonia.

Bodybuilders pneumonia.

Bronchial Leech Infestation in a 15-Year-Old Female

Foreign body aspiration (FBA) is a common incidence in young children. Leeches are rarely reported as FBA at any age. This study describes a 15-year-old female who presented with hemoptysis, hematemesis, coughs, melena, and anemia seven months prior to admission. Chest X-ray showed a round hyperdensity in the right lower lobe. A chest computed tomography (CT) demonstrated an area of consolidation and surrounding ground glass opacities in the right lower lobe. Hematological investigations revealed anemia. Finally, bronchoscopy was performed and a 5 cm leech was found within the right B7-8 bronchus and removed by forceps and a Dormia basket.

An unusual case of hemoptysis

An unusual case of hemoptysis

A rare case of allergic bronchopulmonary mycosis caused byAlternaria alternata

A rare case of allergic bronchopulmonary mycosis (ABPM), caused by Alternaria alternata, is reported in an immunocompetent resident of Delhi. Her complaints included a generalized, urticarial skin rash and occasional pain in the right lower chest. Her differential count showed eosinophils, 22%; absolute eosinophil count (AEC), 2400 cells/μl; and total IgE, 4007 IU/ml. The computerised tomogram (CT) scan of her thorax showed an enhancing lesion with surrounding ground glass haziness in the right lower lobe. Histopathologic examination of the resected lung revealed a necrotizing granulomatous inflammation, parenchymal infiltration by eosinophils, lymphocytes, neutrophils, plasma cells and some exudative bronchiolitis suggestive of ABPM. Observation of KOH wet mounts of repeat sputum and BAL samples demonstrated the presence of septate, brownish hyphae and cultures of these specimens yielded A. alternata (identified by sequencing of the ITS region). Her serum showed a three-fold higher specific IgE to A. alternata antigens than control levels, and the type I cutaneous hypersensitivity response to antigens of A. alternata was strongly positive. She was treated successfully with oral glucocorticoids and itraconazole. To our knowledge, ABPM due to Alternaria alternata has not been reported previously.

Pulmonary Contusion in a College Football Athlete

HISTROTY: An 18 year old, collegiate football athlete sustained a blow to his anterior chest wall by another player's helmet. Initially, he described having the wind knocked out of him and left, anterior chest wall soreness, but no difficulty breathing. Over the next 12 hours, he developed mild dizziness, nausea and worsening chest pain, followed by shortness of breath and hemoptysis. Upon office evaluation the next day, he reported only anterior chest wall tenderness and pleuritic chest pain with cough and deep inspiration. PHYSICAL EXAMINATION: Vitals: BP: 118/64; HR: 64 bpm; RR: 12; Pulse Ox: 98% on room air GENERAL: 6'2“ 200lb male in no distress Neck: No tracheal deviation, JVD or sub-cutaneous emphysema Chest: No deformity or ecchymosis; tender to palpation over the inferior half of his sternum and medial aspects of ribs 9–12 PULMONARY EXAM: Breath sounds clear to auscultation bilaterally and present throughout all lung fields Cardiac: Regular rate and rhythm; no murmur, gallop or rub Abdomen: Mild LUQ ttp; nl bowel sounds Musculoskeletal: No obvious orthopedic injuries or scoliosis. No gross motor deficits. DIFFERENTIAL DIAGNOSIS: Pulmonary Contusion / Laceration Pneumothorax / Hemothorax Rib fracture/ Flail chest /Sternal fracture Cardiac Contusion Splenic Laceration TEST AND RESULTS: AP & Lat CXR with Left Rib Series: Clear lung fields bilaterally, no rib or sternal fracture CT chest: Right traumatic pneumatocele with adjacent focal area of surrounding ground glass airspace consolidation suggestive of hemorrhage. FINAL WORKING DIAGNOSIS: Pulmonary contusion with traumatic pneumatocele TREATMENT and OUTCOMED: The patient was withheld from play and given strict instructions to seek medical attention if symptoms worsen. Repeat CT at three weeks demonstrated resolution of the pulmonary contusion and a small residua density in the right paravertebral region. He was allowed to progress as tolerated and allowed to return to football at 4 weeks having an uneventful remainder of the season. He is to have a repeat CT at 6 months to confirm complete resolution of pneumatocele.

A Case of Bronchus-Associated Lymphoid Tissue(BALT) Lymphoma Treated with Lobectomy

The bronchus-asociated lymphoid tissue(BALT) lymphoma is a low-grade primary malignant lymphoma that originates from bronchus associated lymphoid tissue. A 67-year-old woman was admitted for evaluation of cough, sputum, rhinorrhea which had persisted for one month. Physical examination showed decreased breathing sound on the left upper lung field. High resolution chest computed tomography demonstrated consolidation which showed air-bronchogram and surrounding ground glass opacity in left upper lobe. These findings implicated inactive tuberculosis, organizing pneumonia, or bronchiolo-alveolar carcinoma. The histologic findings from percutaneous needle aspiration biopsy revealed aggregated atypical small lymphoid cells with lymphoepithelial lesions. With immunohistochemical staining, the atypical lymphoid cells reacted positively with CD 20 antibody and negatively with CD 3 antibody. Thus, we could diagnosed her as a patient with BALT lymphoma. After left upper lobectomy, she has been well without recurrence of the disease for 14 months. In this country of Republic of Korea, it was the 1st case of BALT lymphoma surgically treated when histological diagnosis had been done. Based on this case, we wanted to demonstrate the importance of early histological diagnosis and treatment of BALT lymphoma.