Underwent Lung Biopsy Research Articles

Immune check-point inhibitor-related pneumonitis: acute lung injury with rapid progression and organising pneumonia with less severe clinical disease.

To improve understanding of the pathology of immune check-point inhibitor (ICI)-related pneumonitis, clinical, radiographic and histopathological features and outcomes were investigated in a cohort of patients who were treatment-naive before receiving ICI inhibition, who underwent lung biopsy, and in whom other potential causes of lung injury were excluded. Patients were retrospectively identified via searches of institutional pathology and clinical records. Patients treated with other modalities for cancer and patients with lung infections or other aetiologies that could cause pneumonitis were excluded. Clinical records were reviewed by pulmonologists. Imaging studies at presentation and follow-up were reviewed by a thoracic radiologist. Pathology was reviewed by thoracic pathologists. Six patients with ICI-related pneumonitis were identified. Two patients presented with respiratory failure requiring mechanical ventilation, diffuse ground glass opacities (GGOs) on chest computed tomography (CT) and acute lung injury (ALI) pattern on transbronchial lung biopsies and had fatal outcomes, despite treatment. The remaining four patients presented with less severe symptoms, predominantly consolidations and patchy ground glass and part solid opacities on chest CT, organising pneumonia (OP) or chronic interstitial inflammation histologically, and showed favourable responses to treatment and remission within months. This study highlights two radiological-pathological patterns of ICI-related pneumonitis with different behaviour: (1) severe respiratory symptoms and diffuse GGOs on imaging correlating with ALI pattern histologically and poor prognosis; and (2) mild respiratory symptoms and consolidations or patchy subsolid opacities on imaging correlating histologically with OP or chronic interstitial inflammation and good outcomes.

Chest computed tomography findings of ground-glass nodules with enhancing central vessel/nodule in pediatric patients with BMPR2 mutations and plexogenic arteriopathy.

Germline mutation in bone morphogenetic protein type II (BMPR2) is the most common cause of idiopathic/heritable pulmonary hypertension in pediatric patients. Despite the discovery of this gene there are no known descriptions of the CT or CT angiography findings in these children. To correlate the clinical presentation, pathology and chest CT findings in pediatric patients with pulmonary hypertension caused by mutations in the BMPR2 gene. We performed a search to identify pediatric patients with a BMPR2 mutation and CT or CT angiography with the clinical history of pulmonary hypertension. Three pediatric radiologists reviewed the children's CT imaging findings and ranked the dominant findings in order of prevalence via consensus. We identified three children with pulmonary hypertension and confirmed germline BMPR2 mutations, two of whom had undergone lung biopsy. We then correlated the imaging findings with histopathology and clinical course. All of our patients with BMPR2 mutations demonstrated a distinct CT pattern of ground-glass nodules with a prominent central enhancing vessel/nodule. These findings correlated well with the pathological findings of plexogenic arteriopathy.

Diagnosis of Pulmonary Veno-Occlusive Disease in the Absence of Hemodynamic Abnormalities

<h3>Introduction</h3> Sarcoidosis is a granulomatous disorder of unknown etiology that can lead to pulmonary hypertension (PH). Pulmonary veno-occlusive disease (PVOD) is a subset of PH characterized by intimal proliferation and obliteration of the intralobular veins. We present this case of a patient with sarcoidosis, who had symptoms and imaging consistent with PVOD, which preceded hemodynamic manifestations. <h3>Case Report</h3> A 52-year-old male nonsmoker presented with progressive shortness of breath, dry cough, and mild wheezing over the preceding seven months. He had no hypoxemia. He had a history of neurosarcoidosis, diagnosed nine years prior, for which he was in remission and off all immunosuppression. Physical examination was pertinent only for minimal lower extremity edema. Spirometry, diffusing capacity, 6-minute-walk-test, B-type Natriuretic Peptide (BNP), sarcoid markers, and infectious workup were normal. Chest computed tomography (CT) scan revealed interlobular septal thickening, ground glass opacities (GGOs), and lymphadenopathy, concerning for PVOD. Transthoracic echo (TTE) was normal. His right heart catheterization (RHC) was notable for a mean pulmonary artery pressure of 28 mmHg, a pulmonary capillary wedge pressure of 15 mmHg, and a pulmonary vascular resistance of 1.71 Woods units. The clinical picture was felt to represent PVOD, with imaging findings preceding hemodynamic changes. He was referred to the lung transplant program. Patient's symptoms rapidly progressed before he could undergo lung biopsy and he developed progressive hypoxemia. He underwent a successful bilateral lung transplant two weeks later. The explanted lung pathology revealed granulomatous PVOD. <h3>Summary</h3> In prior reports of sarcoidosis-associated PVOD, PH was noted on TTE or RHC correlating with symptoms well before diagnosis of PVOD. Additionally, in patients with hemodynamic or biopsy proven diagnoses of PH, the combination of GGOs, interlobular septal thickening, and mediastinal lymphadenopathy is 95% sensitive and 89% specific for PVOD. Our case suggests that CT imaging findings should raise the index of suspicion for PVOD, even in the absence of objective evidence of pulmonary vascular changes on TTE and RHC. In patients with symptoms of dyspnea, progressive hypoxemia, and these imaging findings, delayed evaluation for transplant may miss an opportunity for early intervention.

Clinical, radiological and pathological findings in patients with persistent lung disease following SARS-CoV-2 infection.

Some patients experience pulmonary sequelae after SARS-CoV-2 infection, ranging from self-limited abnormalities to major lung diseases. Morphological analysis of lung tissue may help our understanding of pathogenic mechanisms and help to provide consistent personalised management. The aim of this study was to ascertain morphological and immunomolecular features of lung tissue. Transbronchial lung cryobiopsy was carried out in patients with persistent symptoms and computed tomography suggestive of residual lung disease after recovery from SARS-CoV-2 infection. 164 patients were referred for suspected pulmonary sequelae after COVID-19; 10 patients with >5% parenchymal lung disease underwent lung biopsy. The histological pattern of lung disease was not homogeneous and three different case clusters could be identified, which was mirrored by their clinical and radiological features. Cluster 1 (“chronic fibrosing”) was characterised by post-infection progression of pre-existing interstitial pneumonias. Cluster 2 (“acute/subacute injury”) was characterised by different types and grades of lung injury, ranging from organising pneumonia and fibrosing nonspecific interstitial pneumonia to diffuse alveolar damage. Cluster 3 (“vascular changes”) was characterised by diffuse vascular increase, dilatation and distortion (capillaries and venules) within otherwise normal parenchyma. Clusters 2 and 3 had immunophenotypical changes similar to those observed in early/mild COVID-19 pneumonias (abnormal expression of STAT3 in hyperplastic pneumocytes and PD-L1, IDO and STAT3 in endothelial cells). This is the first study correlating histological/immunohistochemical patterns with clinical and radiological pictures of patients with post-COVID lung disease. Different phenotypes with potentially different underlying pathogenic mechanisms have been identified.

Association between idiopathic pulmonary hemosiderosis and celiac disease in pediatric patients: A scoping review of the literature over the past 50 years.

Idiopathic pulmonary hemosiderosis (IPH) is a rare cause of diffuse alveolar hemorrhage, the mechanism of which is currently unknown. Nearly one-third of pediatric patients with IPH test positive for Celiac disease (CD) serology. Several hypothetical mechanisms have been proposed to unify the coexistence of these two entities, also referred to as Lane-Hamilton syndrome (LHS). This manuscript is a scoping review of the medical literature. Medline, Embase, and PubMed Central databases were searched between 1971 and 2021 with appropriate search words to identify all cases of pediatric LHS. A total of 20 manuscripts with 23 pediatric patients with LHS were identified. The mean age was 11 years, and 13/23 (56.5%) of the children were boys. Hemoptysis was present in 57% of patients during diagnosis. Bronchoscopy with bronchoalveolar lavage demonstrating hemosiderin laden macrophages was the primary mode of diagnostic confirmation. Only three patients underwent lung biopsy. Any significant GI symptom was reported in a minority of patients (22%). Iron deficiency anemia on presentation was described in 83% of children. The majority of patients were malnourished. Serology for CD was positive in all patients, as was the histopathologic analysis of the small bowel biopsy. No patients had any other autoantibody positivity. The introduction of gluten free diet (GFD) was associated with a positive response in 20/23 patients. All pediatric patients with IPH should undergo screening for CD. Low serum ferritin in patients with IPH could be suggestive of coexisting CD. Strict GFD should be tried as the initial therapy.

Adolescent e-cigarette or vaping product use-associated lung injury: A case series and review of the literature.

Adolescent e-cigarette or vaping product use-associated lung injury (EVALI) has increased in prevalence, and while cases describing various pulmonary manifestations have been reported, reports on the presentations and outcomes in teenage patients are sparse. We retrospectively describe eight EVALI patients with different presentations, laboratory and imaging findings, treatment, and concomitant diagnoses. We review the literature and describe how our analysis adds to the literature. Eight males, aged 15-18 years of age presented with various symptoms. Four patients were Caucasian while four were of Hispanic origin. All patients presented with respiratory symptoms; six also had GI symptoms; five were hypoxemic; all but one patient admitted to using products containing tetrahydrocannabinol (THC). All patients had changes on imaging with ground-glass opacities. One patient underwent lung biopsy and bronchoscopy showing eosinophilic pneumonia. All patients received antimicrobial therapies without improvement until systemic steroids were administered. Six patients underwent pulmonary function testing, and five required medications for newly diagnosed persistent asthma. One patient developed pulmonary hypertension, which resolved after treatment. One patient required noninvasive ventilation. No patients were positive for SARS-CoV2. Two had coinfections with other microbes. Five patients required escalation of asthma therapies at follow-up with pulmonology. This analysis of eight adolescent males hospitalized for EVALI highlights the unpredictable spectrum of disease presentation and management. These patients can be misdiagnosed without proper screening and may have residual respiratory complications necessitating outpatient management by a pulmonologist.

Interobserver agreement regarding the Fleischner Society diagnostic criteria for usual interstitial pneumonia patterns on computed tomography.

ObjectiveTo assess interobserver agreement among radiologists regarding the current Fleischner Society diagnostic criteria for usual interstitial pneumonia (UIP) patterns on computed tomography (CT).Materials and MethodsUsing the Fleischner Society criteria for UIP CT patterns, five raters, working independently, categorized the high-resolution CT (HRCT) scans of 44 patients with interstitial lung disease who underwent lung biopsy. The raters also evaluated the presence, extent, and distribution of the most relevant imaging findings, as well as indicating their level of confidence in the most likely diagnosis and in up to three diagnostic hypotheses.ResultsThere was moderate to substantial interobserver agreement regarding the UIP patterns on HRCT—kappa statistic (κ) = 0.59-0.61. Interobserver agreement for the binary scores was substantial (κ = 0.77-0.79), whereas that for the presence of honeycombing was almost perfect (κ = 0.81-0.96). There was agreement regarding at least one of the three diagnostic hypotheses in only 36.4% of the cases. For the level of confidence in the most likely diagnosis, there was only slight to fair agreement (κ = 0.19-0.21).ConclusionInterobserver agreement regarding the current Fleischner Society CT criteria for UIP was moderate to substantial among raters with varying levels of experience. There was only slight to fair agreement regarding the diagnostic hypotheses and for the level of confidence in the most likely diagnosis.

Comparison of clinical features and prognosis in patients with cryptogenic and secondary organizing pneumonia

BackgroundOrganizing pneumonia (OP) can be diagnosed pathologically, and cryptogenic OP (COP) and secondary OP (SOP) have been classified by cause and particular underlying context. Because it is clinically difficult to differentiate between COP and SOP, this study investigated characteristics that could distinguish between COP and SOP.MethodsThe medical records of patients who underwent lung biopsy for a diagnosis of OP at a single tertiary hospital from January 2016 to December 2018 were retrospectively reviewed.ResultsEighty-five patients had pathologically proven OP, including 16 diagnosed with COP and 69 diagnosed with SOP. The most common cause of SOP was infectious pneumonia, observed in 57 (82.6%) of the 69 patients, followed by cancer and radiation pneumonitis. The pathogens causing infectious pneumonia were identified in 45 (65.2%) patients. There were no differences in age, sex, and lung function between the COP and SOP groups. Median body mass index was significantly lower (P = 0.030), and median time from symptom onset to hospital admission significantly shorter (P = 0.006), in the SOP than in the COP group. Fever was more common in the SOP group (P = 0.024), and CURB 65, an index of pneumonia severity, tended to be higher in the SOP group (P = 0.017). Some laboratory results differed significantly between the two groups. Lymphocyte counts in bronchoalveolar lavage (BAL) fluid were significantly higher in the COP than in the SOP group (P = 0.012). Radiologic findings showed that effusion was more common in the SOP group (P = 0.036). There were no between-group differences in steroid use, 30 day and in-hospital mortality rates, and rates of OP outcomes and recurrences. Pneumonia recurrence rate was significantly higher in SOP patients who were than were not treated with steroids (P = 0.035).ConclusionsInfection is the main cause of SOP. Symptom onset is more rapid in patients with SOP than with COP. Some blood and BAL fluid test results differed significantly in the COP and SOP groups. Pleural effusion was more common in the SOP group but there were no differences in clinical course. Recurrence in patients with SOP was more common in those who were than were not treated with steroids.

Clinical value of an electromagnetic navigation system for CT-guided percutaneous lung biopsy of peripheral lung lesions.

BackgroundThe purpose of this study was to retrospectively evaluate the clinical value of an electromagnetic navigation system for CT-guided percutaneous lung biopsy of peripheral lung lesions.MethodsThis was a retrospective study. Patients with peripheral lung lesions in our institution between January 2019 and December 2020, who underwent lung biopsy assisted by the electromagnetic navigation system were included in Group A, and those who underwent lung biopsy using conventional CT-guided percutaneous lung biopsy were included in Group B. The general features and clinical and technical information of each patient were collected and evaluated in both groups.ResultsA total of 141 patients were included in Group A (78 males and 63 females; median age, 65 years; range, 32–79 years), and 96 patients were included in group B (57 males and 39 females; median age, 65 years; range, 34–80 years). The technical success rate was 100% in both groups. The technical efficacy rate was 92.9% and 90.6% in Groups A and B (P=0.525), respectively. There was no significant difference in surgical time and the number of CT scans between the two groups, and only grade 1–2 complications occurred in the patients.ConclusionsThe electromagnetic navigation system is an effective and safe auxiliary tool for CT-guided percutaneous lung biopsy of peripheral lung lesions.

Radiological and histological characteristics of patients with interstitial lung disease undergoing lung biopsy in a reference institution from eastern Colombia

Introduction: Interstitial lung disease (ILD) diagnosis requires a multidisciplinary approach and, in some cases, lung biopsy. Objective: To describe the sociodemographic and clinical characteristics, as well as the radiological and histological findings, of patients with ILD who required lung biopsy after a multidisciplinary board (pneumology, radiology, and pathology) of a reference center for respiratory diseases in Bucaramanga, Colombia, failed to reach the ILD diagnosis. Materials and methods: Cross-sectional study. The medical records of 56 patients treated at the Instituto Neumológico del Oriente who underwent lung biopsy between 2015 and 2019 were reviewed. Measures of central tendency and dispersion were calculated for demographic and clinical variables, respectively, to characterize them. A bivariate analysis was performed using Fisher’s exact test to determine whether there were differences in the distribution of the sociodemographic and clinical variables according to the radiological patterns and the final histological diagnosis. Results: Participants’ median age was 67 years (IQR: 59-72) and 55.35% were men. 43 patients had a radiological pattern inconsistent with usual interstitial pneumonia (UIP); 4 had a pattern consistent with possible UIP; and 9 had a pattern consistent with UIP. The most common histologic diagnoses were hypersensitivity pneumonitis (HP) (32.14%), nonspecific interstitial pneumonia (NSIP) (17.86%), and UIP (19.64%). Conclusion: In the study population, the primary reason for performing a lung biopsy was the presence of a radiologic pattern inconsistent with UIP, with HP being the predominant histopathological diagnosis. This is the first study to characterize patients with ILD who underwent lung biopsy in eastern Colombia, making a significant contribution to our understanding of the disease’s epidemiology in the country.

PS01.02 National Lung Cancer Screening Program in Taiwan: The TALENT Study

Lung cancer in never-smoker is a global rising threat especially in East Asia. Our recent proteogenomics study has revealed the demographically distinct signatures of oncogenesis and progression of this dreadful disease and provide new insights into the precision management of early lung cancer. Currently, early detection is the most effective way to improve lung cancer survival. Low-dose computed tomography (LDCT) has been proven effective for lung cancer screening. However, most of the lung cancer screenings focused on heavy smoker which may not be suitable for East Asian population. In Taiwan, lung cancer is the leading cause of cancer mortality and 53% were never-smoker. We therefore conducted a nationwide lung cancer LDCT screening focused on never-smoker (TALENT: Taiwan Lung Cancer Screening for Never Smoker Trial) aiming to develop an effective strategy for screening of lung cancer in never-smoker and establish a risk prediction model to identify high-risk population that may benefit from LDCT screening. Here we report on behalf of the TALENT study group the first round (T0) results. This is a prospective, multicenter study sponsored by The Ministry of Health and Welfare, Taiwan. The inclusion criteria were age between 55-75 years, never-smoker and having one of the following risks: family history of lung cancer within third-degree, passive smoking exposure, TB/COPD, cooking index ≥ 110, and not using ventilator during cooking. The LDCT was conducted according to the guideline suggested by ACR. A solid or part-solid (PS) nodule larger than 6 mm or pure ground glass nodule (GGN) larger than 5 mm in diameter was designated as positive on LDCT. The PBMC DNA was obtained for SNP typing analysis. Institutional Review Board approved the study and informed consent was obtained from each participating subject. From Feb. 2015 to July 2019, a total of 12,011 subjects (Table 1) were enrolled. Among them, 6,012 (50.1%) had lung cancer family history, 5,999 (49.9%) did not. In 12,011 scans, 2,094 (17.4%) were considered positive, there were 392 subjects (3.3%) underwent lung biopsies or surgeries at T0, lung cancer (2.6%) were diagnosed in 311 subjects, 254 (2.1%) were invasive lung cancer. All but one was adenocarcinoma and 96.5% were stage 0 or I, 81 had benign lung disease or malignancy other than primary lung cancer. The prevalence of lung cancer was 3.2% and 2.0% in subjects with and without lung cancer family history, respectively. The prevalence of invasive lung cancer was 2.6% and 1.6%, respectively. For subjects with lung cancer family history, the prevalence of lung cancer was 3.3%, 1.6% and 1.7% in those with 1st degree, 2nd degree and 3rd degree families had lung cancer, respectively. The TALENT study confirmed the effectiveness of LDCT screening in a pre-defined, never-smoker high-risk population. The T0 lung cancer detection rate was 2.6%, which was even higher than NLST study (1.1%) and NELSON study (0.9%). Most importantly, 96.5% patients were stage 0 or 1, that were potentially curable by surgery. Our study also revealed the high risk of family history, especially those subjects with 1st degree families had lung cancer.

Heterogeneous Pulmonary Phenotypes in Filamin A Mutation-Related Lung Disease

Background: Interstitial lung disease (ILD) has been recently reported in a few patients with pathogenic variants in the Filamin A (FLNA) gene with variable presentation and prognosis. This study evaluated the respiratory manifestations and clinical features in children with FLNA disease. Methods: We conducted a retrospective review of pediatric patients with variants in FLNA in a tertiary children's hospital. The clinical features, genotype, management, and outcomes were analyzed. Results: We identified 9 patients with variants in FLNA aged 15 months to 24 years, 4 females and 5 males. Six patients had abnormal chest imaging ranging from mild interstitial prominence to atelectasis, interstitial densities, and hyperinflation. Three patients with ILD presented during the neonatal period or early infancy with respiratory distress or respiratory failure requiring supplemental oxygen or assisted ventilation via tracheostomy. We report male twins with the same FLNA variant and lung disease, but different ages and clinical features at presentation eventually culminating in respiratory failure requiring assisted ventilation. All patients had FLNA variants identified by FLNA sequencing, had abnormal echocardiograms, and none of the patients underwent lung biopsy or lung transplantation. The outcomes were variable and could be as severe as chronic respiratory failure. Conclusion: The wide spectrum of respiratory manifestations and abnormal chest imaging in our study highlights the importance of evaluation for lung disease in patients with variants in FLNA. FLNA sequencing in suspected cases with ILD may obviate the need for a lung biopsy, prompt surveillance for progressive lung disease, and evaluation for associated clinical features.

ANCA-negative microscopic polyangiitis with diffuse alveolar hemorrhage masquerading as congestive heart failure

BackgroundMicroscopic polyangiitis (MPA) is a subtype of anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV), involving small and medium sized vessels, often affecting the kidneys and lungs. Anti-neutrophil cytoplasmic antibody (ANCA) is detected in up to 90% of cases of MPA and its detection helps guide diagnosis, however cases of ANCA-negative MPA have been reported, hence definitive diagnosis relies on tissue biopsy.Case reportA 23-year-old man was evaluated for dyspnea and pleuritic chest pain, and found to have bilateral intra-alveolar opacities and hilar adenopathy. Diagnostic work up revealed positive anti-nuclear antibodies (ANA) and negative ANCA, which in the setting of a non-classical presentation, delayed diagnosis and appropriate treatment. Due to persistent symptoms and a high suspicion for autoimmune disease with pulmonary-renal syndrome, he underwent lung biopsy which revealed intra-alveolar hemorrhage and capillaritis indicative of microscopic polyangiitis (MPA). Surprisingly, kidney biopsy was not typical of classic MPA, but revealed less common features. Due to therapeutic noncompliance he was readmitted multiple times thereafter with rare complications of MPA such as acute pancreatitis and hemorrhagic pericardial effusion with tamponade.ConclusionThis case serves as an important clinical reminder to consider AAV even in those with negative ANCA serologies and a high suspicion for pulmonary-renal syndrome. It also demonstrates the high morbidity in cases of diagnostic delay and inadequate treatment.

Etiological profile and main imaging findings in patients with granulomatous diseases who underwent lung biopsy

BackgroundGranulomatous Lung Diseases (GLD) encompasses a wide range of infectious and non-infectious conditions characterized by chronic inflammatory response. However, different GLD may share similar imaging findings. In this context, the purpose of this study was to outline the etiological profile and their imaging features in patients with GLD who underwent lung biopsy. MethodsPatients with granulomatous lesions in lung biopsies and previous chest CT performed from 2014 to 2017 at our institution had imaging data reviewed by three blinded radiologists. The imaging features were analyzed according to the Fleischner Society glossary. Categorical data were represented by absolute (n) and relative (%) frequency. The contingency matrices were analyzed by Pearson's Chi-square test. Interreader agreement was assessed by calculating the intraclass correlation coefficient, using kappa (κ) statistic. ResultsThirty-eight of 75 (50.7%) patients were women with a mean age of 59 ± 39 years. Infection was the most common cause of GLD (47/75, 62.7%) and Histoplasma capsulatum (27/75, 36%) was the most prevalent etiology. Nodular pattern was the most common imaging feature in histoplasmosis cases (25/27, 92.6%), whereas it occurred in half of cases (24/48) of GLD of other causes (p < 0.05). Among patients with tuberculosis, the second etiology of GLD in our study population, the most common imaging pattern was centrilobular micronodules (3/7, 42.9%), significantly more frequent than in other causes of GLD (6/68, 8.8%). Interreader agreement in detecting imaging features was almost perfect (κ = 0.88-1.00), except the nodular pattern, which had substantial agreement (κ = 0.73). ConclusionsIn our study population, the main etiologies found in patients with granulomatous disease who underwent lung biopsy were fungal or mycobacterial disease, specially histoplasmosis and tuberculosis, and nodular pattern with focal distribution was the most common imaging finding which was detected with substantial interreader agreement.

Lung biopsy in the diagnosis of pediatric ANCA-associated vasculitis.

To investigate pulmonary histopathologic features in a cohort of pediatric patients with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) who underwent a lung biopsy as part of their evaluation. We report the safety and the findings of lung biopsies in this population. After IRB approval, we performed a retrospective chart review of all patients <18 years of age presenting to our institution with a diagnosis of pediatric AAV (pAAV) who underwent lung biopsy. We reviewed histopathologic features, serologies, the timing of biopsy, and complications. Fourteenpatients met inclusion criteria, nine patients with microscopic polyangiitis (MPA), and five patients with granulomatosis with polyangiitis (GPA). All patients had positive ANCA serology. 13/14 patients required admission on initial presentation for respiratory symptoms; 11/13 required respiratory support. The indication for biopsy was confirmation of diagnosis before initiating therapy in 11 patients (78%), part of the infectious evaluation in two (14%), and part of interstitial lung disease evaluation in one (7%). 11/14 (78%) biopsies had findings consistent with AAV diagnosis: 6/9 (67%) of the MPA patients compared with 5/5 (100%) of the GPA patients. The most common findings on histopathology were vascular inflammation and signs of alveolar hemorrhage. The only reported complication after lung biopsy was pneumothorax in four patients (28%). Lung biopsy had a higher diagnostic yield in GPA compared with MPA patients. In our cohort, a diagnosis of AAV could be made with clinical features and positive serology but was confirmed by lung histopathology in the majority of cases. Obtaining a lung biopsy for diagnostic purposes in pAAV should be reserved for uncertain cases where the diagnosis cannot be confirmed clinically and with serology.

The interstitial lung disease spectrum under a uniform diagnostic algorithm: a retrospective study of 1,945 individuals.

BackgroundReported data on the disease spectrum of interstitial lung diseases (ILDs) of China are sparse and varied. We aimed to investigate the spectrum of ILDs and the distribution of diagnostic methods under a uniform diagnosis.MethodsThis retrospective study enrolled ILDs cases from Guangzhou Institute of Respiratory Health (GIRH). All cases were classified into specific subgroups of ILDs according to updated guidelines.ResultsA total of 1,945 subjects were enrolled from January 2012 to December 2017. The mean age was 57.9 years, and 1,080 (55.5%) patients were male. The most common subtype of ILDs was idiopathic pulmonary fibrosis (IPF, 20.3%), followed by interstitial pneumonia with autoimmune features (IPAF, 17.9%), connective tissue disease associated ILD (CTD-ILD, 18.3%) and unclassifiable idiopathic interstitial pneumonia (UIIP, 14.7%). A total of 818 (42.1%) patients underwent lung biopsy in order to obtain a histological diagnose. TBLB was performed in 565 (29.0%) patients, eleven of whom underwent SLB because TBLB failed to obtain lung samples. SLB was performed in 213 (11.0%) patients and TBCB was performed in 51 (2.6%) patients. Among them, histological results were considered clinically helpful in 722 (88.3%) cases, and provided definitive histopathological diagnoses in 368 cases. Surgical lung biopsy (SLB) was performed in 213 (10.9%) subjects, while 115 (54.0%) cases were performed among the idiopathic interstitial pneumonia (IIP). Among SLB cases in IIP, the highest rate of SLB was desquamative interstitial pneumonia/respiratory bronchiolitis-interstitial lung disease (DIP/RB-ILD, 10/10), lymphoid interstitial pneumonia (LIP, 9/9), followed by cryptogenic organizing (COP, 18/26), nonspecific interstitial pneumonia (NSIP, 22/53), IPF (43/395), UIIP (13/285).ConclusionsIPF was the most common ILDs in our ILD center, followed by IPAF, CTD-ILD and UIIP. Histological information may help to establish diagnostic algorithm in ILD.

Hybrid Scheme for Automated Classification of Pulmonary Nodules Using PET/CT Images and Patient Information

The classification of pulmonary nodules using computed tomography (CT) and positron emission tomography (PET)/CT is often a hard task for physicians. To this end, in our previous study, we developed an automated classification method using PET/CT images. In actual clinical practice, in addition to images, patient information (e.g., laboratory test results) is available and may be useful for automated classification. Here, we developed a hybrid scheme for automated classification of pulmonary nodules using these images and patient information. We collected 36 conventional CT images and PET/CT images of patients who underwent lung biopsy following bronchoscopy. Patient information was also collected. For classification, 25 shape and functional features were first extracted from the images. Benign and malignant nodules were identified using machine learning algorithms along with the images’ features and 17 patient-information-related features. In the leave-one-out cross-validation of our hybrid scheme, 94.4% of malignant nodules were identified correctly, and 77.7% of benign nodules were diagnosed correctly. The hybrid scheme performed better than that of our previous method that used only image features. These results indicate that the proposed hybrid scheme may improve the accuracy of malignancy analysis.

The yield of immediate post lung biopsy CT in predicting iatrogenic pneumothorax

BackgroundThe most prevalent complication of percutaneous lung biopsy is pneumothorax (PNX). A routine immediate post-procedure CT scan (ICT) to spot PNX is done in many centers. However, the diagnostic yield of this practice has not been studied broadly. We sought to evaluate whether an ICT could replace the routine follow-up chest X-ray (CXR) in detecting procedure related PNX.MethodsWe examined case-records of 453 patients who underwent lung biopsy at our medical center. We analyzed findings from CXR performed 2-h after biopsy and from CT images at the site of biopsy acquired immediately after the procedure (ICT). Multivariate analysis was used to identify the risk factors for PNX, and we examined the concordance between ICT and CXR-2-h post-procedure.ResultsA total of 87 patients (19%) were diagnosed with PNX on CXR-2-h post-procedure. ICT detected 80.5% of diagnosed PNX (p < 0.01). However, ICT demonstrated a negative predictive value of only 94%, meaning 17 patients (6%) with a negative ICT did eventually develop PNX seen on CXR. Furthermore, bleeding surrounding the puncture area spotted on ICT negatively predicted the development of PNX (OR = 0.4 95% CI; 0.2–0.7).ConclusionsWe conclude that a CT scan performed immediately after percutaneous lung biopsy cannot replace the routine follow-up CXR in predicting iatrogenic PNX. Bleeding in the needle’s tract may lower the risk for procedure-related PNX.

Infective patterns of cryptococcosis in patients with connective tissue disease: a retrospective study.

To explore the clinical features and associated factors of cryptococcosis in patients with connective tissue disease (CTD) from Southern China. Demographic and clinical data were collected between 2007 and 2018. Associated factors were analyzed by logistic regression analysis. A total of 6809 inpatients with CTD were included. Cryptococcosis was diagnosed in 30 patients (prevalence, 0.4%). Cryptococcosis was predominant in patients with ANCA-associated vasculitis (AAV) (prevalence, 6/530, 1.1%). Lung was commonly involved (18/30, 60.0%), followed by meninges (6/30, 20.0%), blood stream (5/30, 16.7%), and disseminated cryptococcosis (involved blood stream and meninges) (1/30, 3.3%). Infiltrates (10/18, 55.6%) and small nodules (8/18, 44.4%) were the main radiographic manifestation of pulmonary cryptococcosis (PC). The positive rate of serum cryptococcal antigen (CrAg) in patients with PC was 88.2%. Cryptococcus spp. were found in 75% (3/4) patients who underwent lung biopsy. Most of the patients with cryptococcal meningitis (CM) had elevated cerebrospinal fluid (CSF) opening pressure (6/7, 85.7%) and decreased CSF glucose level (5/7, 71.4%). Positive blood culture confirmed the diagnosis of cryptococcal sepsis (CS). Three patients died (10.0%), including one with CM and two with PC. Multivariate logistic regression analysis showed that accumulated dose of glucocorticoid (GC) [odds ratio (OR) = 1.42, 95% confidence interval (CI) 1.04-1.93, P = 0.03] was associated with cryptococcosis in patients with CTD. Cryptococcosis develops in various organs. Typical radiological manifestation accompanied with positive serum CrAg provides helpful clues for the diagnosis. Lumbar puncture is a critical diagnostic method to distinguish CM. The accumulated dose of GC is associated with cryptococcosis in patients with CTD. Key Points • Pulmonary cryptococcosis is suspected if pulmonary nodules adjacent to the pleura are present, with serum CrAg positive. • Cryptococcal meningitis has insidious onset and the diagnosis mainly depends on lumber puncture. • Cryptococcal sepsis is not rare and needs timely blood culture in suspected patients.

Lung biopsy in children's interstitial and diffuse lung disease: Does it alter management?

Pediatric patients with acute life-threatening consequences of interstitial and diffuse lung disease are often treated with empiric systemic corticosteroids, immune modulators, and/or broad antibiotic therapy. Histological evaluation of lung tissue represents the final necessary step in diagnosis-however, a definitive diagnosis may still remain elusive and medical therapies may not be changed following biopsy. We hypothesized that lung biopsy from pediatric patients with children's interstitial and diffuse lung disease (chILD) without a defined lesion on computed tomography (CT) imaging would guide diagnosis, but not substantially alter clinical management. After IRB approval, patients who underwent a lung biopsy at a single large children's hospital between 2013 and 2018 were retrospectively reviewed. Patients without a defined lesion were included. Demographics, length of stay, oxygen-requirements, steroid, unique number of immune modulators, and antibiotics prebiopsy and postbiopsy were reviewed. Nonparametric data were compared by the Mann Whitney U and Kruskal Wallace tests and expressed as median with interquartile range. Decision tree alterations were analyzed by t test. P < .05 was significant. Sixty-four patients underwent lung biopsy during the period. Nineteen (30%) did not have a defined lesion on CT scan, and were included. A significant difference was seen between prebiopsy, 2 weeks, and 2 months postbiopsy prednisone dosing (P = .03), whilethe number of unique immune modulators, antibiotics, type of oxygen support and FiO2 were not significantly different before or after obtaining biopsy results. Pathology results provided additional information in 12 of 19 (63%) patients which resulted in management changes. Lung biopsy in chILD may guide clinical management, especially influencing the management of steroid dosing. Although on aggregate the number of antibiotics, immune modulators, mode of oxygen support and FiO2 did not differ significantly before and after biopsy, the pathologic evaluation provided diagnostic information that led to a variety of changes in therapeutic management in greater than half of the population.