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Background To evaluate the chest CT appearance of patients with a clinicopathologic diagnosis of hypersensitivity pneumonia. Methods IRB approval was obtained for a retrospective review of patients with a preoperative CT scan, a surgical pathology report from a transbronchial biopsy or wedge resection consistent with hypersensitivity pneumonitis, and a pulmonary consultation, which also supported the diagnosis. The pathology report was evaluated for granulomas, airway-centered fibrosis, microscopic honeycombing, and fibroblast foci. The medical records were reviewed for any known antigen exposure. Patients were separated into two groups; those with and without a known antigen exposure. The CT scans were assessed for distribution of fibrosis: upper lobe or lower lobe predominance, airway-centered versus peripheral distribution, three-density pattern, and honeycombing. Results 264 pathology reports included the term chronic hypersensitivity pneumonitis (CHP). Thirty-eight of the patients had a pulmonologist who gave the patient a working diagnosis of CHP. The average age of these patients was 64 years, and 21/38 were women. Seventeen of the 38 patients had at least one antigen exposure described in the medical records. All the patients had fibrosis along the airways on chest CT. Both known antigen exposure and no known antigen patients had upper and lower lung-predominant fibrosis. There were more patients with hiatal hernias in the unknown antigen group. Honeycombing was an uncommon finding. Conclusion Airway-centered fibrosis was present on chest CT in all 38 patients with CHP (100%), with or without known antigen exposure.

BACKGROUND Chest CT scans are routinely obtained to monitor disease progression in pulmonary fibrosis. However, radiologists do not employ a standardized system for quantitative description of the severity of the disease. Development and validation of a grading system offers potential for enhancing the information that radiologists provide clinicians. STUDY DESIGN AND METHODS Our retrospective review analyzed 100 sequential patients with usual interstitial pneumonitis (UIP) on HRCT scans from 2018 and 2019. A radiologic scoring system evaluated the percent of normal lung on the basis of a 0-5 point scale per lobe (findings for the right middle lobe were included in the right upper lobe score), yielding an overall additive numerical score on a scale of 20 (completely normal lung) to 0 (no normal lung). Two radiologists quantified the percentage of normal lung by consensus agreement. Percent DLCO as well as demographic data were obtained from the medical record. Statistical analysis was performed using Spearman correlation to assess correlation between grade and percent DLCO. RESULTS 96 patients met the inclusion criteria; average age was 71, 68% were male. Score on CT scan ranged from 18 to 4; average 10.9, SD 3.58. The single-breath diffusing capacity (percent DLCO) ranged from 88% to 17%; mean 44.5%, SD 14.3%. Spearman's correlation for CT score and percent DLCO was 0.622, P

Background Thrombotic complications of COVID-19 infection have become increasingly apparent as the disease has infected a growing number of individuals. Although less common than upper respiratory symptoms, thrombotic complications are not infrequent and may result in severe and long-term sequelae. Common thrombotic complications include pulmonary embolism, cerebral infarction, or venous thromboembolism; less commonly seen are acute myocardial injury, renal artery thrombosis, and mesenteric ischemia. Several case reports and case series have described acute myocardial injury in patients with COVID-19 characterized by elevations in serum biomarkers. Case report Here, we report the first case to our knowledge of a patient with acute coronary syndrome confirmed on catheter angiography and cardiac MRI. This patient was found to additionally have a left ventricular thrombus and ultimately suffered an acute cerebral infarction. Recognition of thrombotic complications in the setting of COVID-19 infection is essential for initiating appropriate therapy. Conclusions In acute myocardial injury, given the different treatment strategies for myocarditis versus acute myocardial infarction secondary to coronary artery thrombus, imaging can play a key role in clinical decision making for patients., Highlights • COVID-19 is known to cause thrombotic complications; here we present a rare case of ACS secondary to COVID-19 infection. • COVID-19 may cause coronary artery thrombosis or myocarditis and imaging studies can play a key role in differentiation. • Both COVID-19 infection and thrombotic complications can have serious long-term effects.

Rationale: The computed tomography (CT) pattern of definite or probable usual interstitial pneumonia (UIP) can be diagnostic of idiopathic pulmonary fibrosis and may obviate the need for invasive surgical biopsy. Few machine-learning studies have investigated the classification of interstitial lung disease (ILD) on CT imaging, but none have used histopathology as a reference standard. Objectives: To predict histopathologic UIP using deep learning of high-resolution computed tomography (HRCT). Methods: Institutional databases were retrospectively searched for consecutive patients with ILD, HRCT, and diagnostic histopathology from 2011 to 2014 (training cohort) and from 2016 to 2017 (testing cohort). A blinded expert radiologist and pulmonologist reviewed all training HRCT scans in consensus and classified HRCT scans based on the 2018 American Thoracic Society/European Respriatory Society/Japanese Respiratory Society/Latin American Thoracic Association diagnostic criteria for idiopathic pulmonary fibrosis. A convolutional neural network (CNN) was built accepting 4 × 4 × 2 cm virtual wedges of peripheral lung on HRCT as input and outputting the UIP histopathologic pattern. The CNN was trained and evaluated on the training cohort using fivefold cross validation and was then tested on the hold-out testing cohort. CNN and human performance were compared in the training cohort. Logistic regression and survival analyses were performed. Results: The CNN was trained on 221 patients (median age 60 yr; interquartile range [IQR], 53–66), including 71 patients (32%) with UIP or probable UIP histopathologic patterns. The CNN was tested on a separate hold-out cohort of 80 patients (median age 66 yr; IQR, 58–69), including 22 patients (27%) with UIP or probable UIP histopathologic patterns. An average of 516 wedges were generated per patient. The percentage of wedges with CNN-predicted UIP yielded a cross validation area under the curve of 74% for histopathological UIP pattern per patient. The optimal cutoff point for classifying patients on the training cohort was 16.5% of virtual lung wedges with CNN-predicted UIP and resulted in sensitivity and specificity of 74% and 58%, respectively, in the testing cohort. CNN-predicted UIP was associated with an increased risk of death or lung transplantation during cross validation (hazard ratio, 1.5; 95% confidence interval, 1.1–2.2; P = 0.03). Conclusions: Virtual lung wedge resection in patients with ILD can be used as an input to a CNN for predicting the histopathologic UIP pattern and transplant-free survival.

Purpose The purpose of our research is to evaluate the usefulness of chest X-ray for triaging patients with suspected COVID-19 infection. Methods IRB approval was obtained to allow a retrospective review of adult patients who presented to the Emergency Department with a complaint of fever, cough, dyspnea or hypoxia and had a chest X-ray between 12 March 2020 and 26 March 2020. The initial chest X-ray was graded on a scale of 0–3 with grade 0 representing no alveolar opacities, grade 1: 2/3 alveolar opacities of the lung. Past medical history of diabetes and hypertension, initial oxygen saturation, COVID-19 testing results, intubation, and outcome were also collected. Results Four hundred ten patient chest X-rays were reviewed. Oxygen saturation and X-ray grade were both significantly associated with the length of stay in hospital, the hazard ratio (HR) of discharge was 1.05 (95% CI [1.01, 1.09], p = 0.017) and 0.61 (95% CI [0.51, 0.73], p

Background: COVID-19 commonly presents with upper respiratory symptoms; however, studies have shown that SARS-CoV-2 infection affects multiple organ systems. Here, we review the pathophysiology and imaging characteristics of SARS-CoV-2 infection in organ systems throughout the body and explore commonalities. Objective: Familiarity with the underlying pathophysiology and imaging characteristics is essential for the radiologist to recognize these findings in patients with COVID-19 infection. Though pulmonary findings are the most prevalent presentation, COVID-19 may have multiple manifestations and recognition of the extrapulmonary manifestations is especially important because of the potential serious and long-term effects of COVID-19 on multiple organ systems.

Objective To evaluate diaphragmatic excursion as a quantitative metric for change in lung volume between inspiratory and expiratory chest computed tomography (CT) images. Methods A 12-month retrospective review identified 226 chest CT exams with inspiratory and expiratory phase imaging, 63 in individuals referred with diagnosis of asthma by ICD9/10 code. Exams acquired in the supine position at 1.25 mm slice thickness in each phase were included (n = 30, mean age = 62, M = 15, F = 15). Diaphragmatic excursion was calculated as the difference between axial slices through the lungs on inspiration and expiration, using the lung apex as the cranial bound, and the hemidiaphragm caudally. Inspiratory and expiratory lung and tracheal volumes were calculated through volumetric segmentation. Tracheal morphology was assessed at 1 cm above the level of the aortic arch, and 1 cm above the carina. Results Inspiratory and expiratory lung volumes were higher in men (mean I = 5 + 1.6 L, E = 3.1 + 1.2 L) than women (mean I = 3.6 + 0.8 L, E = 2.4 + 0.7 L), p = .005 and p = .047, respectively. Average inspiratory and expiratory tracheal volumes were higher in men (I = 61 + 17 mL, E = 43 + 14) than women (I = 44 + 14, E = 30 + 8), p = .006 and p = .005. Average change in lung and tracheal volume between inspiratory and expiratory scans did not significantly differ between men and women. Average diaphragmatic excursion was 2.5 cm between inspiratory and expiratory scans (2.7 cm in men, 2.3 cm in women; p = .5). There was a strong positive correlation between diaphragmatic excursion and change in lung (r = .84) and tracheal volume (r = .79). A moderate correlation was also found between change in tracheal volume and change in lung volume (r = 0.67). Change in tracheal morphology between inspiratory and expiratory imaging was associated with change in tracheal volume at both 1 cm above the aortic arch (p = .04) and 1 cm above the carina (p = .008); there was no association with diaphragmatic excursion or lung volume. Conclusions Diaphragmatic excursion is a quantitative measure of expiratory effort as validated by both lung and tracheal volumes in asthma patients, and may be more accurate than qualitative assessment based on tracheal morphology.

Purpose Chronic Obstructive Pulmonary Disease (COPD) includes chronic bronchitis, small airways disease, and emphysema. Diagnosis of COPD requires spirometric evidence and may be normal even when small airways disease or emphysema is present. Emphysema increases the risk of exacerbations, and is associated with all-cause mortality and increased risk of lung cancer. We evaluated the prevalence of emphysema in participants with and without a prior history of COPD. Methods We reviewed a prospective cohort of 52,726 subjects who underwent baseline low dose CT screening for lung cancer from 2003 to 2016 in the International Early Lung Cancer Action Program. Results Of 52,726 participants, 23.8%(12,542) had CT evidence of emphysema. Of these 12,542 participants with emphysema, 76.5%(9595/12,542) had no prior COPD diagnosis even though 23.6% (2258/9595) had moderate or severe emphysema. Among 12,542 participants, significant predictors of no prior COPD diagnosis were: male (OR = 1.47, p Conclusion Emphysema was identified in 23.8% participants undergoing LDCT and was unsuspected in 76.5%. LDCT provides an opportunity to identify emphysema, and recommend smoking cessation.

ObjectivesAlthough diffuse alveolar damage, a subtype of acute lung injury (ALI), is the most common microscopic pattern in coronavirus disease 2019 (COVID-19), other pathologic patterns have been described. The aim of the study was to review autopsies from COVID-19 decedents to evaluate the spectrum of pathology and correlate the results with clinical, laboratory, and radiologic findings.MethodsA comprehensive and quantitative review from 40 postmortem examinations was performed. The microscopic patterns were categorized as follows: “major” when present in more than 50% of cases and “novel” if rarely or not previously described and unexpected clinically.ResultsThree major pulmonary patterns were identified: ALI in 29 (73%) of 40, intravascular fibrin or platelet-rich aggregates (IFPAs) in 36 (90%) of 40, and vascular congestion and hemangiomatosis-like change (VCHL) in 20 (50%) of 40. The absence of ALI (non-ALI) was novel and seen in 11 (27%) of 40. Compared with ALI decedents, those with non-ALI had a shorter hospitalization course (P = .02), chest radiographs with no or minimal consolidation (P = .01), and no pathologically confirmed cause of death (9/11). All non-ALI had VCHL and IFPAs, and clinically most had cardiac arrest.ConclusionsTwo distinct pulmonary phenotypic patterns—ALI and non-ALI—were noted. Non-ALI represents a rarely described phenotype. The cause of death in non-ALI is most likely COVID-19 related but requires additional corroboration.

Purpose To assess the feasibility of using CT to correct specific uptake values (SUVs) for fluorodeoxyglucose (FDG) in patients with nonsolid nodules. Methods Patients with FDG-PET/CT and thin-section CT were included in this pilot study. Thirty-five adenocarcinomas manifesting as nonsolid nodules were classified into two groups; 90–100% and 1–89% lepidic component. SUVmax was corrected based on the CT determination of the proportion of soft tissue component within the cancer (SUVatt). Results Both SUVmax and SUVatt increased as the percentage of the lepidic component decreased. SUVmax and SUVatt were significantly different between the groups. Conclusion Extent of invasiveness of nonsolid cancers (as a marker of aggressiveness) can potentially be quantified by PET/CT using a correction method that accounts for the proportion of soft tissue within the tumor.

Objective To assess causative factors, associated imaging findings, and CT course of round atelectasis (RA). Materials and methods We retrospectively reviewed CT reports for “round” or “rounded atelectasis” over a 5-year time frame. Patients with at least 2 CT scans a minimum of 6 months apart were included. Electronic medical records and clinical and imaging follow-up was reviewed for all cases. Results Study population included 50 individuals with mean age of 63 years, and 59 unique instances of RA. The most commonly associated etiologies were hepatic hydrothorax (26%, n = 13) and asbestos exposure (26%), followed by post-infectious pleural inflammation (22%), congestive heart failure (12%), and end stage renal disease (8%). RA was found in the right lower lobe in over half of cases (n = 30). Association with one or more pleural abnormality was identified in all cases, including thickening (88%), fluid (60%), or calcification (40%). Nearly one third (n = 19) demonstrated intra-lesional calcification. In those who underwent PET/CT (20%), lesions demonstrated an average SUV of 2.2 (range 0–7.8). CT course over mean follow up of 32 months (range 6–126 months), demonstrated RA to remain stable (n = 26) or decrease (n = 26) in size in the majority (88%) of cases. Conclusion Round atelectasis may arise from diverse etiologies beyond asbestos, and will most often decrease or remain stable in size over serial exams. Accurate identification may obviate the need for added diagnostic interventions.

Objective To determine the prevalence of osteophyte induced lung fibrosis (OIF) and its relationship to osteophyte size, location, and surrounding fat. Methods 94 CT scans of the chest were reviewed, size of the largest osteophyte and the presence of fibrosis were recorded. Results Presence of fibrosis was higher among patient with large (> 10 mm) osteophytes compared to those with small (1–10 mm) osteophytes. Age and presence of periosteophyte fat were significantly associated with presence of fibrosis. Conclusions As the size of an osteophyte increases, there is a greater likelihood of lung fibrosis. Subpleural fat protects the lung from OIF.

Background Early recognition of patients with interstitial lung disease (ILD) who have an increased risk of developing acute exacerbation (AE) or preclinical AE may be clinically useful, since AE is associated with poor outcome and preventive measures would be of interest to ILD researchers. This study evaluated the relationship between elevated serum D-dimer level (≥0.4 mcg/mL) and subsequent AE or preclinical AE in patients with ILD. Methods This single-center, retrospective study was performed from October 2009 through September 2015 in patients with ILD who were ≥18 years old and had idiopathic pulmonary fibrosis, other idiopathic interstitial pneumonias, chronic hypersensitivity pneumonitis, ILD related to collagen tissue disease, or combined pulmonary fibrosis/emphysema. The primary outcome measure was AE development within three months from each D-dimer measurement. The secondary outcome measures were respiratory-related hospitalization, all-cause hospitalization, venous thromboembolism (VTE), and all-cause mortality within three months. Results A total of 263 patients (mean age, 64.1 years) with 374 D-dimer measurements (median, 0.44 mcg/mL) were included. The risk of developing AE was significantly higher in patients with elevated serum D-dimer level (adjusted odds ratio: 10.46; 95% CI: 1.24–88.11; p = 0.03). Patients with elevated serum D-dimer level had increased risk for respiratory-related hospitalization, all-cause hospitalization, VTE, and all-cause mortality. The other factors predictive for AE were home oxygen therapy, increased serum lactate dehydrogenase, decreased FVC, and decreased FEV1.0. Conclusions Elevated serum D-dimer is associated with the risk of developing AE. Serum D-dimer may be used as a prognostic marker to predict AE or recognize preclinical AE.

The benefits of early diagnosis and treatment of breast cancer are well established. Thoracic CT which is performed with increased frequency for lung cancer screening can diagnose breast cancer earlier then might be possible clinically. The imaged and radiation exposed breasts must be included in their entirety on images which are reviewed by the radiologist. Because of concerns about how altering the field of view might affect image quality, we advocate for inclusion of the entire breast on the soft tissue series, which can be viewed on mediastinal window settings and expose the patient to no additional radiation.

Introduction: Idiopathic pulmonary fibrosis (IPF) is a relentless form of fibrotic lung disease with a median survival of approximately 3 years after diagnosis and a mortality rate that surpasses that of many types of cancer. The pathophysiology of IPF is complex as there are likely different stages of disease occurring simultaneously in the lung. Areas covered: Some scientists consider IPF as primarily an epithelial driven disease in which dysfunctional surfactant-producing cells take an etiological precedent. Others focus on the augmented deposition of collagen within the interstitium as the primary inciting event causing fibrosis. An increase in collagen deposition augmenting the tensile strength of the pulmonary interstitium fits with the well-known restrictive nature of fibrotic lung diseases; however, it fails to explain the creation of cystic 'honeycombing' lesions and the preference of such lesions for the peripheral and basilar lung parenchyma. Expert opinion: In this paper, we will review both ideas and propose incorporating them into a single pathophysiological chain-of-events that could account for all the features that characterize IPF, allowing us to envision new therapeutic approaches to improve patient outcomes.

Purpose To determine patterns of progression of probable Usual Interstitial Pneumonitis (UIP). Methods This HIPPA compliant, IRB-approved study draws patients from our Fibrosis Registry. All patients with a consensus diagnosis of Idiopathic Pulmonary Fibrosis (IPF) were included. Most recent CT scans and all earlier CT scans were reviewed to determine the fibrosis grade in each lobe based on probable UIP (pUIP) findings of ground glass opacities, traction bronchiolectasis and reticulations or UIP findings of subpleural basilar predominant fibrosis with honeycombing (HC) and absence of features that would suggest an alternative diagnosis. Results 103 patients with a working diagnosis of IPF are the focus of this report. Among the 68 with pUIP on the initial CT, 32 (47%) progressed; median time to progression was 51 months. The risk of HC progression, adjusted for gender, of patients with emphysema was 2.53 times higher than patients without emphysema (HR = 2.53, 95% CI: 1.06–6.02). Among the 35 with HC on the initial CT scan, 20 (57%) progressed to more advanced HC; median time to progression was 31 months. Increased pulmonary artery size was significantly associated with an elevated risk for more advanced HC progression (HR = 1.16, 95% CI: 1.04–1.31). Conclusion Ground glass opacities, traction bronchiolectasis and reticulations, a “Probable UIP Pattern” by ATS criteria progressed to UIP in 47% of patients on follow-up imaging.

Background Some interstitial lung diseases are associated with lung cancer. However, it is unclear whether asymptomatic interstitial lung abnormalities convey an independent risk. Objectives The goal of this study was to assess whether interstitial lung abnormalities are associated with an increased risk of lung cancer. Methods Data from all participants in the National Lung Cancer Trial were analyzed, except for subjects with preexisting interstitial lung disease or prevalent lung cancers. The primary analysis included those who underwent low-dose CT imaging; those undergoing chest radiography were included in a confirmatory analysis. Participants with evidence of reticular/reticulonodular opacities, honeycombing, fibrosis, or scarring were classified as having interstitial lung abnormalities. Lung cancer incidence and mortality in participants with and without interstitial lung abnormalities were compared by using Poisson and Cox regression, respectively. Results Of the 25,041 participants undergoing low-dose CT imaging included in the primary analysis, 20.2% had interstitial lung abnormalities. Participants with interstitial lung abnormalities had a higher incidence of lung cancer (incidence rate ratio, 1.61; 95% CI, 1.30-1.99). Interstitial lung abnormalities were associated with higher lung cancer incidence on adjusted analyses (incidence rate ratio, 1.33; 95% CI, 1.07-1.65). Lung cancer-specific mortality was also greater in participants with interstitial lung abnormalities. Similar findings were obtained in the analysis of participants undergoing chest radiography. Conclusions Asymptomatic interstitial lung abnormalities are an independent risk factor for lung cancer that can be incorporated into risk score models.

Background. We encounter interstitial lung disease (ILD) patients with psoriasis. The aim of this case series was to examine clinical and radiographic characteristics of patients with concomitant psoriasis and ILD. Methods. This is a retrospective review of our institutional experience of ILD concomitant with psoriasis, from the database in the Advanced Lung/Interstitial Lung Disease Program at the Mount Sinai Hospital. Out of 447 ILD patients, we identified 21 (4.7%) with antecedent or concomitant diagnosis of psoriasis. Clinical, radiographic, pathological, and outcome data were abstracted from our medical records. Results. Median age was 66 years (range, 46–86) and 14 (66.7%) were male. Thirteen (61.9%) had not previously or concomitantly been exposed to immunosuppressive therapy directed against psoriasis. Two (9.5%) ultimately died. Clinical diagnosis of ILD included idiopathic pulmonary fibrosis, 11 (52.4%); nonspecific interstitial pneumonia (NSIP), 2 (9.5%); cryptogenic organizing pneumonia, 2 (9.5%); chronic hypersensitivity pneumonitis, 2 (9.5%); and the others, while radiographic diagnosis included usual interstitial pneumonia pattern, 9 (42.9%); NSIP pattern, 6 (28.6%); organizing pneumonia pattern, 4 (19.0%); hypersensitivity pneumonitis pattern, 2 (9.5%); and the others. Conclusions. We report 21 ILD cases with antecedent or concomitant diagnosis of psoriasis. Further prospective studies are required to determine the association between ILD and psoriasis.

The purpose of this study was to assess the frequencies of identifying participants with part-solid nodules, of diagnostic pursuit, of diagnoses of lung cancer, and long-term lung cancer survival in baseline and annual repeat rounds of CT screening in the International Early Lung Cancer Action Project.Screenings were performed under a common protocol. Participants with solid, nonsolid, and part-solid nodules and the diagnoses of lung cancer were documented.Part-solid nodules were identified in 2892 of 57,496 (5.0%) baseline screening studies; 567 (19.6%) of these nodules resolved or decreased in size. Diagnostic pursuit led to the diagnosis of adenocarcinoma in 79 cases, all clinical stage I. At resection, one nodule (12-mm solid component) had a single N2 metastasis. A new part-solid nodule was identified in 541 of 64,677 (0.8%) annual repeat screenings; 377 (69.7%) of these nodules resolved or decreased in size. In eight cases among the 541, the diagnosis of adenocarcinoma manifesting as a part solid nodule was made; on retrospective review the nodule originally had been a nonsolid nodule. In another 20 cases, the cancer originally had manifested as a nonsolid nodule but had progressed to become part-solid at annual repeat screening before any diagnosis was pursued. These 28 annual repeat cases of lung cancer were all pathologic stage IA. Of the 107 cases of lung cancer (79 baseline cases and 28 annual repeat cases), 106 were surgically resected, and one baseline case was followed up with imaging for 4 years. The lung cancer survival rate was 100% with a median follow-up period from diagnosis of 89 months (interquartile range, 52-134 months).Lung cancers manifesting as part-solid nodules at repeat screening studies all started as nonsolid nodules. Among 107 cases of adenocarcinoma manifesting as a part-solid nodule, a single lymph node metastasis was found in a single case (solid component, 12 mm).

This study sought to determine if breast arterial calcification (BAC) on digital mammography predicts coronary artery calcification (CAC).BAC is frequently noted but the quantitative relationships to CAC and risk factors are unknown.A total of 292 women with digital mammography and nongated computed tomography was evaluated. BAC was quantitatively evaluated (0 to 12) and CAC was measured on computed tomography using a 0 to 12 score; they were correlated with each other and the Framingham Risk Score (FRS) and the 2013 Cholesterol Guidelines Pooled Cohort Equations (PCE).BAC was noted in 42.5% and was associated with increasing age (p0.0001), hypertension (p = 0.0007), and chronic kidney disease (p0.0001). The sensitivity, specificity, positive and negative predictive values, and accuracy of BAC0 for CAC0 were 63%, 76%, 70%, 69%, and 70%, respectively. All BAC variables were predictive of the CAC score (p0.0001). The multivariable odds ratio for CAC0 was 3.2 for BAC 4 to 12, 2.0 for age, and 2.2 for hypertension. The agreements of FRS risk categories with CAC and BAC risk categories were 57% for CAC and 55% for BAC; the agreement was 47% for PCE risk categories for CAC and 54% by BAC. BAC0 had area under the curve of 0.73 for identification of women with CAC0, equivalent to both FRS (0.72) and PCE (0.71). BAC0 increased the area under the curve curves for FRS (0.72 to 0.77; p = 0.15) and PCE (0.71 to 0.76; p = 0.11) for the identification of high-risk (4 to 12) CAC. With the inclusion of 33 women with established CAD, BAC0 was significantly additive to both FRS (p = 0.02) and PCE (p = 0.04) for high-risk CAC.There is a strong quantitative association of BAC with CAC. BAC is superior to standard cardiovascular risk factors. BAC is equivalent to both the FRS and PCE for the identification of high-risk women and is additive when women with established CAD are included.

The purposes of this study were to determine the prevalence of interstitial lung disease (ILD) in a cohort undergoing low-dose CT screening for lung cancer, to identify the CT patterns of fibrosis, and to determine prognostic factors of disease progression.The study drew from a database of 951 participants in a lung cancer screening program between 2010 and 2014. Three thoracic radiologists reviewed CT scans to identify the ILD findings, defined as traction bronchiectasis, ground-glass opacities with traction bronchiectasis, reticulations with traction bronchiectasis, and honeycombing. Evidence of ILD was considered present if at least two of three reviewing radiologists agreed. Age, smoking history, and CT evidence of emphysema were also documented.Of the 951 participants, 63 (6.6%) had CT evidence of ILD, and 16 of the 63 (1.7% of the total cohort) had honeycombing. Significant univariate predictors of ILD were male sex (p = 0.003), older age (p0.0001), higher number of pack-years of cigarette smoking (p = 0.0003), and greater severity of emphysema (p = 0.004), but only age and male sex remained significant in the multivariate analysis. The most common pattern of ILD was peripheral fibrosis without honeycombing involving multiple lobes. The presence of honeycombing was significantly associated with progression of fibrosis score (p = 0.0001) and extent of fibrosis (p = 0.005).A potential added benefit of CT screening is earlier diagnosis of ILD in older smokers, who are at increased risk. Radiologists should recognize the earliest findings of ILD and understand the importance of early recognition.

To determine long-term survival of visceral pleural invasion (VPI) and parenchymal invasion (PAI) (angiolymphatic and/or vascular) on survival of NSCLCs less than 30 mm in maximum diameter.Kaplan-Meier survivals for NSCLCs, with and without VPI and/or PAI, were determined for a prospective cohort of screening participants stratified by pathologic tumor size (≤10 mm, 11-20 mm, and 21-30 mm) and nodule consistency. Log-rank test statistics were calculated.The frequency of PAI versus VPI was significantly lower in patients with subsolid nodules than in those with solid nodules (4.9% versus 27.7% [p0.0001]), and correspondingly, Kaplan-Meier lung cancer survival was significantly higher among patients with subsolid nodules (99.1% versus 91.3% [p = 0.0009]). Multivariable Cox regression found that only tumor diameter (adjusted hazard ratio [HR] =1.07, 95% confidence interval [CI]: 1.01-1.14, p = 0.02) and PAI (adjusted HR = 3.15, 95% CI: 1.25-7.90, p = 0.01) remained significant, whereas VPI was not significant (p = 0.15). When clinical and computed tomography findings were included with the pathologic findings, Cox regression showed that the risk of dying of lung cancer increased 10-fold (HR = 10.06, 95% CI: 1.35-75.30) for NSCLCs in patients with solid nodules and more than twofold (by a factor of 2.27) in patients with moderate to severe emphysema (HR = 2.27, 95% CI: 1.01-5.11), as well as with increasing tumor diameter (HR = 1.06, 95% CI: 1.01-1.13), whereas PAI was no longer significant (p = 0.19).Nodule consistency on computed tomography was a more significant prognostic indicator than either PAI or VPI. We propose that patients with NSCLC with VPI and a maximum tumor diameter of 30 mm or less not be upstaged to T2 without further large, multicenter studies of NSCLCs, stratified by the new T status and that classification be considered separately for patients with subsolid or solid nodules.

Objectives The goal of this work is to determine the optimal projection to detect breast masses on Chest CT. Methods Institutional Review Board (HIPPA compliant) approval was obtained with a waiver of consent. 10 image pairs of Chest CT images containing breast masses were selected for review by 10 chest radiologists: the pairs consisted of axial, sagittal, coronal and axial MIP images (MIP images) with each projection compared to a MIP and with one another. For each pair, the image where the mass was most conspicuous was recorded. Results MIPs were preferred to any cross sectional projection 82% of the time; sagittal (63%) or coronal (63%) images were preferred to the axial projection. When sagittal and coronal images were compared there was no preference. Conclusions MIP images should be obtained and reviewed for breast pathology; sagittal or coronal projections may provide additional information.

There are three major pathologic patterns of pulmonary fibrosis; usual interstitial pneumonia (UIP), nonspecific interstitial pneumonia (NSIP) and airway-centered fibrosis (ACF). These pathologic patterns correspond with radiographic patterns of UIP, NSIP, and chronic hypersensitivity pneumonitis (CHP). Previous studies have demonstrated that the radiologic diagnosis is correct approximately 50% of the time for these fibrotic lung diseases. Understanding the microscopic pathologic patterns that are recapitulated at a macroscopic level in the high resolution CT scan is key to radiologists' ability to correctly diagnose pulmonary fibrosis and thus improve patient outcomes with early diagnosis and avoidance of biopsy. We investigate the similarities between the pathology and radiology features of UIP, NSIP, and ACF.

Purpose To assess the ability of chest CT to identify patients needing further evaluation of the breasts. Methods IRB approval was obtained with a waiver of consent. Women with chest CT and mammogram within 12 months formed the cohort. A breast assessment and recommendation CT score (BARCS) analogous to mammographic BI-RADS was created and compared to the mammogram BI-RADS. Results BARCS and mammographic BI-RADS management recommendations were concordant for 77.1%. 11 invasive cancers were detected; all by mammogram while CT missed 2. Conclusion BARCS score should be studied in prospective trials. Chest CT might be the earliest opportunity to detect breast cancer.

Differences in results of baseline and subsequent annual repeat rounds provide important information for optimising the regimen of screening. A prospective cohort study of 65,374 was reviewed to examine the frequency/percentages of the largest noncalcified nodule (NCN), lung cancer cell types and Kaplan–Meier (K-M) survival rates, separately for baseline and annual rounds. Of 65,374 baseline screenings, NCNs were identified in 28,279 (43.3%); lung cancer in 737 (1.1%). Of 74,482 annual repeat screenings, new NCNs were identified in 4959 (7%); lung cancer in 179 (0.24%). Only adenocarcinoma was diagnosed in subsolid NCNs. Percentages of lung cancers by cell type were significantly different (p < 0.0001) in the baseline round compared with annual rounds, reflecting length bias, as were the ratios, reflecting lead times. Long-term K-M survival rate was 100% for typical carcinoids and for adenocarcinomas manifesting as subsolid NCNs; 85% (95% CI 81–89%) for adenocarcinoma, 74% (95% CI 63–85%) for squamous cell, 48% (95% CI 34–62%) for small cell. The rank ordering by lead time was the same as the rank ordering by survival rates. The significant differences in the frequency of NCNs and frequency and aggressiveness of diagnosed cancers in baseline and annual repeat need to be recognised for an optimal regimen of screening. • Lung cancer aggressiveness varies considerably by cell type and nodule consistency. • Kaplan–Meier survival rates varied by cell type between 100% and 48%. • The percentages of lung cancers by cell type in screening rounds reflect screening biases. • Rank ordering by cell type survival is consistent with that by lead times. • Empirical evidence provides critical information for the regimen of screening.

To (a) perform a pilot study comparing radiologists' reading of breast density at computed tomography (CT) of the chest with breast density readings from mammography performed in the same patient and (b) compare a subset of these with computer-derived measurements of breast density at CT.The institutional review board waived informed consent for this HIPAA-compliant retrospective review of mammograms and chest CT scans from 206 women obtained within 1 year of each other. Two radiologists with expertise in interpreting mammographic and CT findings independently reviewed the mammograms and CT scans and classified each case into one of the four breast density types defined by the Breast Imaging Reporting and Data System of the American College of Radiology. Interreader agreements for the mammographic density types and CT density grades were determined by using the Cohen weighted κ statistic. The intrareader correlation coefficient was determined in a subset of CT images. In another subset of 40 cases, the agreement of the semiautomated computer-derived measurements of breast density with the consensus of the two radiologists was assessed.Interreader agreement was higher for the CT density grades than for the mammographic density types, with 0.79 (95% confidence interval [CI]: 0.73, 0.85) versus 0.62 (95% CI: 0.54, 0.70). The intrareader reliability of breast density grades on CT images was 0.88. The computer-derived breast density measurements agreed with those of the radiologists in 36 (90%) cases. When four cases were manually adjusted for the complex anatomy, there was agreement for all cases.Preliminary results suggest that on further validation, breast density readings at CT may provide important additional risk information on CT of the chest and that computer-derived measurements may be helpful in such assessment.

The purpose of this study was to determine whether additional breast imaging is clinically valuable in the evaluation of patients with gynecomastia incidentally observed on CT of the chest.In a retrospective analysis, 62 men were identified who had a mammographic diagnosis of gynecomastia and had also undergone CT within 8 months (median, 2 months). We compared the imaging findings of both modalities and correlated them with the clinical outcome.Gynecomastia was statistically significantly larger on mammograms than on CT images; however, there was a high level of concordance in morphologic features and distribution of gynecomastia between mammography and CT. In only one case was gynecomastia evident on mammographic but not CT images, owing to cachexia. Two of the 62 men had ductal carcinoma, which was obscured by gynecomastia. Both of these patients had symptoms suggesting malignancy.The appearance of gynecomastia on CT scans and mammograms was highly correlated. Mammography performed within 8 months of CT is unlikely to reveal cancer unless there is a suspicious clinical finding or a breast mass eccentric to the nipple. Men with clinical symptoms of gynecomastia do not need additional imaging with mammography to confirm the diagnosis if they have undergone recent cross-sectional imaging.

A 59-YEAR-OLD MAN with severe aortic stenosis presented for valve replacement surgery. After uncomplicated induction of anesthesia, an introducer was placed into the left internal jugular vein, through which a pulmonary artery catheter (PAC) was easily directed into the pulmonary artery on the first attempt. The intraoperative course was uneventful. On postoperative day 1 in the intensive care unit, the following chest x-ray was obtained (Fig 1). What is the diagnosis?

To determine if general radiologists can accurately measure breast density on low-dose chest computed tomographic (CT) scans, two board-certified radiologists with expertise in mammography and CT scan interpretation, and seven general radiologists performed retrospective review of 100 women's low-dose chest CT scans. CT breast density grade based on Breast Imaging Reporting and Data System grades was independently assigned for each case. Kappa statistic was used to compare agreement between the expert consensus grading and those of the general radiologists. Kappa statistics were 0.61-0.88 for the seven radiologists, showing substantial to excellent agreement and leading to the conclusion that general radiologists can be trained to determine breast density on chest CT.

Rationale and Objectives The purpose of this study was to evaluate the accuracy of ultrasound (US)–guided fine-needle aspiration (FNA), with radiographic follow-up or surgical excision, in conjunction with on-site cytopathologic support in the management of nonpalpable breast lesions. Materials and Methods The findings of 266 consecutive mammographically or sonographically identified, nonpalpable lesions (228 patients) that underwent US–guided FNA were examined retrospectively. Clustered microcalcifications did not undergo biopsy with this method. Patients who underwent follow-up excisional biopsy or mammography with a duration of at least 24 months were included in the study. Results In all, 117 lesions met criteria for inclusion, of which 85 (73%) were diagnosed as benign at cytopathologic evaluation and underwent mammographic follow-up of at least 24 months (range, 24–67 months; mean, 36 months). Thirty-two lesions (27%) had either malignant or atypical cytopathologic findings, for which surgery was recommended. Eleven (9%) of the 32 had malignant cytopathologic findings from initial US–guided FNA, which were confirmed at surgical excision. The remaining 21 lesions (18%) were diagnosed as atypical on the basis of US–guided FNA results. Of these, 18 lesions underwent excisional biopsy: Two were diagnosed as carcinoma (not otherwise specified), and 16 were diagnosed with a variety of benign disorders. The remaining three patients with atypical lesions chose mammographic follow-up rather than surgical diagnosis, and their conditions have remained stable for more than 24 months. Of the 85 benign cases, one changed during follow-up (12 months) and underwent repeat biopsy, with malignancy noted. The sensitivity of US–guided FNA in identifying malignant lesions was 93% (13 of 14), and the specificity of a benign finding was 100% (102 of 102). The positive and negative predictive values of US–guided FNA supported by on-site cytopathologic evaluation were 100% (13 of 13) and 99% (102 of 103), respectively. Conclusion Supported by appropriately trained on-site cytopathologists and in conjunction with follow-up mammography, US–guided FNA appears to be efficacious in the management of patients with abnormal radiographic findings. It is quick, relatively inexpensive, and minimally invasive, and, in the presence of competent cytopathologists, should be the modality of choice.