ESR Essentials: imaging in fibrotic lung diseases-practice recommendations by the European Society of Thoracic Imaging

Fibrotic lung diseases (FLDs) represent a subgroup of interstitial lung diseases (ILDs), which can progress over time and carry a poor prognosis. Imaging has increased diagnostic discrimination in the evaluation of FLDs. International guidelines have stated the role of radiologists in the diagnosis and management of FLDs, in the context of the interdisciplinary discussion. Chest computed tomography (CT) with high-resolution technique is recommended to correctly recognise signs, patterns, and distribution of individual FLDs. Radiologists may be the first to recognise the presence of previously unknown interstitial lung abnormalities (ILAs) in various settings. A systematic approach to CT images may lead to a non-invasive diagnosis of FLDs. Careful comparison of serial CT exams is crucial in determining either disease progression or supervening complications. This 'Essentials' aims to provide radiologists a concise and practical approach to FLDs, focusing on CT technical requirements, pattern recognition, and assessment of disease progression and complications. Hot topics such as ILAs and progressive pulmonary fibrosis (PPF) are also discussed. KEY POINTS: Chest CT with high-resolution technique is the recommended imaging modality to diagnose pulmonary fibrosis. CT pattern recognition is central for an accurate diagnosis of fibrotic lung diseases (FLDs) by interdisciplinary discussion. Radiologists are to evaluate disease behaviour by accurately comparing serial CT scans

Diagnostic performance of radiologists in distinguishing post-COVID-19 residual abnormalities from interstitial lung abnormalities

OBJECTIVE Distinguishing post-COVID-19 residual abnormalities from interstitial lung abnormalities (ILA) on CT can be challenging if clinical information is limited. This study aimed to evaluate the diagnostic performance of radiologists in distinguishing post-COVID-19 residual abnormalities from ILA. METHODS This multi-reader, multi-case study included 60 age- and sex-matched subjects with chest CT scans. There were 40 cases of ILA (20 fibrotic and 20 non-fibrotic) and 20 cases of post-COVID-19 residual abnormalities. Fifteen radiologists from multiple nations with varying levels of experience independently rated suspicion scores on a 5-point scale to distinguish post-COVID-19 residual abnormalities from fibrotic ILA or non-fibrotic ILA. Interobserver agreement was assessed using the weighted κ value, and the scores of individual readers were compared with the consensus of all readers. Receiver operating characteristic curve analysis was conducted to evaluate the diagnostic performance of suspicion scores for distinguishing post-COVID-19 residual abnormalities from ILA and for differentiating post-COVID-19 residual abnormalities from both fibrotic and non-fibrotic ILA. RESULTS Radiologists' diagnostic performance for distinguishing post-COVID-19 residual abnormalities from ILA was good (area under the receiver operating characteristic curve (AUC) range, 0.67-0.92; median AUC, 0.85) with moderate agreement (κ = 0.56). The diagnostic performance for distinguishing post-COVID-19 residual abnormalities from non-fibrotic ILA was lower than that from fibrotic ILA (median AUC = 0.89 vs. AUC = 0.80, p = 0.003). CONCLUSION Radiologists demonstrated good diagnostic performance and moderate agreement in distinguishing post-COVID-19 residual abnormalities from ILA, but careful attention is needed to avoid misdiagnosing them as non-fibrotic ILA. KEY POINTS Question How good are radiologists at differentiating interstitial lung abnormalities (ILA) from changes related to COVID-19 infection? Findings Radiologists had a median AUC of 0.85 in distinguishing post-COVID-19 abnormalities from ILA with moderate agreement (κ = 0.56). Clinical relevance Radiologists showed good diagnostic performance and moderate agreement in distinguishing post-COVID-19 residual abnormalities from ILA; nonetheless, caution is needed in distinguishing residual abnormalities from non-fibrotic ILA

Hormonal and biochemical normalization and tumor shrinkage induced by anti-parathyroid hormone immunotherapy in a patient with metastatic parathyroid carcinoma.

Parathyroid carcinoma is a rare cause of primary hyperparathyroidism, and the efficacy of medical therapy and chemo- and radiotherapy is poor in recurrent or metastatic disease. We report the first case of PTH immunization in which tumor shrinkage accompanied hormonal, biochemical, and clinical improvements in a patient with metastatic parathyroid carcinoma.A 50-yr-old woman with refractory parathyroid carcinoma and pulmonary metastases was immunized eight times between February 2001 and December 2003 with bovine and modified human PTH fragments and intact human PTH, mixed with Freund's adjuvant. Total and ionized calcium and PTH levels were assayed weekly for 6 months and regularly thereafter. Thoracic computed tomography scans were performed regularly.Antibodies to all PTH fragments were detected after two immunizations. Baseline PTH and total calcium were 213.0 ng/liter and 13.96 mg/dl, respectively, and remained elevated during the first three immunizations. From the fourth immunization onward, PTH and calcium decreased, and the patient's clinical condition improved markedly. PTH and calcium levels have remained controlled for more than 24 months, and the sizes (surface area) of pulmonary metastases decreased from baseline by 39-71%.This is the first evidence that PTH immunization not only can improve clinical, hormonal, and biochemical measures in parathyroid carcinoma but also has an antitumor effect

CT of blunt diaphragmatic rupture

The diagnosis of blunt diaphragmatic rupture (BDR) is difficult and often missed, leaving many patients with this traumatic injury at risk for life-threatening complications. The potential diagnostic pitfalls are numerous and include anatomic variants and congenital and acquired abnormalities. Chest radiography, despite its known limitations, may still be helpful in the early assessment of severe thoracoabdominal trauma and for detecting initially overlooked BDR or late complications of BDR. However, since the development of helical and multidetector scanners, computed tomography (CT) has become the reference standard; thus, knowledge of the CT signs suggestive of BDR is important for recognition of this injury pattern. A large number of CT signs of BDR have been described elsewhere, many of them individually, but the use of various appellations for the same sign can make previously published reports confusing. The systematic description and classification of CT signs provided in this article may help clarify matters and provide clues for diagnosing BDR. The authors describe 19 distinct CT signs grouped in three categories: direct signs of rupture, indirect signs that are consequences of rupture, and signs that are of uncertain origin. Since no single CT sign can be considered a marker leading to a correct diagnosis in every case of BDR, accurate diagnosis depends on the analysis of all signs present

Multiple-detector CT venography in: MDCT of the chest

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