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Imaging of Pulmonary Hypertension: Pictorial Essay. Chest 2019; 156:211-227. [PMID: 30981724 DOI: 10.1016/j.chest.2019.04.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 04/01/2019] [Indexed: 11/20/2022] Open
Abstract
Pulmonary hypertension (PH) is an end result of a diverse array of complex clinical conditions that invoke hemodynamic and pathophysiological changes in the pulmonary vasculature. Many patients' symptoms begin with dyspnea on exertion for which screening tests such as chest roentgenograms and more definitive noninvasive tests such as CT scans are ordered initially. It is imperative that clinicians are cognizant of subtle clues on these imaging modalities that alert them to the possibility of PH. These clues may serve as a stepping stone towards more advanced noninvasive (echocardiogram) and invasive (right heart catheterization) testing. On the CT scan, the signs are classified into mediastinal and lung parenchymal abnormalities. In addition to suspecting the diagnosis of PH, this paper provides a pictorial essay to guide health care professionals in identifying the etiology of PH. This paper also provides concrete definitions, wherever possible, of what constitutes abnormalities in PH, such as dilated pulmonary arteries, pruning of vessels, and increased thickness of free wall of the right ventricle. The sensitivities and specificities of each sign are enumerated. The common radiographic and clinical features of many different etiologies of PH are tabulated for the convenience of the readers. Some newer imaging modalities such as dual-energy CT of the chest that hold promise for the future are also described.
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Shweihat YR, Perry J, Etman Y, Gabi A, Hattab Y, Al-Ourani M, Santhanam P, Bartter T. Congestive Adenopathy: A Mediastinal Sequela of Volume Overload. J Bronchology Interv Pulmonol 2017; 23:298-302. [PMID: 27623420 DOI: 10.1097/lbr.0000000000000325] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Endosonography has improved our ability to reach thoracic lymph nodes and to diagnose pathologic conditions with nodal involvement and has lowered the threshold for biopsy. The purpose of this study was to avoid unnecessary procedures, it is important to recognize benign adenopathy. Congestive heart failure (CHF) is both common and a common cause of adenopathy. The purpose of this study was to study the association between CHF and adenopathy and to describe the typical presentation of congestive adenopathy. METHODS We performed a retrospective correlation of computed tomographic (CT) and laboratory findings for patients admitted to hospital with a diagnosis of CHF. RESULTS Of 500 patients admitted with a diagnosis of CHF, 215 appeared to have CT scans of the chest, and not to have a potentially confounding etiology of adenopathy. The incidence of adenopathy in this study group was 68%. Pulmonary edema on CT and pleural effusion were both significantly associated with adenopathy (P<0.01 for both). The pattern of congestive adenopathy was one of enlargement of several mediastinal nodes and less likely to involve hilar nodes and single stations in isolation. CONCLUSION Congestive adenopathy is common in patients with evidence for acute volume overload. The pattern of presentation should allow clinicians to recognize congestive adenopathy and to separate it from other adenopathy for which biopsy might be appropriate.
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Affiliation(s)
- Yousef R Shweihat
- *Department of Internal Medicine, Division of Pulmonary and Critical Care †Department of Internal Medicine, Marshall University, Huntington, WV ‡Department of Internal Medicine, Pulmonary and Critical Care, Interventional Pulmonary, University of Arkansas for Medical Sciences, Little Rock, AR
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Nin CS, de Souza VVS, do Amaral RH, Schuhmacher Neto R, Alves GRT, Marchiori E, Irion KL, Balbinot F, Meirelles GDSP, Santana P, Gomes ACP, Hochhegger B. Thoracic lymphadenopathy in benign diseases: A state of the art review. Respir Med 2016; 112:10-7. [PMID: 26860219 DOI: 10.1016/j.rmed.2016.01.021] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 11/14/2015] [Accepted: 01/28/2016] [Indexed: 12/27/2022]
Abstract
Lymphadenopathy is a common radiological finding in many thoracic diseases and may be caused by a variety of infectious, inflammatory, and neoplastic conditions. This review aims to describe the patterns of mediastinal and hilar lymphadenopathy found in benign diseases in immunocompetent patients. Computed tomography is the method of choice for the evaluation of lymphadenopathy, as it is able to demonstrate increased size of individual nodes, abnormalities of the interface between the mediastinum and lung, invasion of surrounding fat, coalescence of adjacent nodes, obliteration of the mediastinal fat, and hypo- and hyperdensity in lymph nodes. Intravenous contrast enhancement may be needed to help distinguish nodes from vessels. The most frequent infections resulting in this finding are tuberculosis and fungal disease (particularly histoplasmosis and coccidioidomycosis). Sarcoidosis is a relatively frequent cause of lymphadenopathy in young adults, and can be distinguished from other diseases - especially when enlarged lymph nodes are found to be multiple and symmetrical. Other conditions discussed in this review are silicosis, drug reactions, amyloidosis, heart failure, Castleman's disease, viral infections, and chronic obstructive pulmonary disease.
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Affiliation(s)
- Carlos Schüler Nin
- Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil.
| | | | | | | | | | - Edson Marchiori
- Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
| | | | - Fernanda Balbinot
- Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil.
| | | | - Pablo Santana
- Hospital São Joaquim Beneficência Portuguesa, São Paulo-SP, Brazil
| | | | - Bruno Hochhegger
- Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil.
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Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a disease with high mortality and few treatment options. This article reviews the epidemiology of CTEPH and identifies risk factors for its development. The pathobiology and the progression from thromboembolic events to chronically increased right-sided pressures are discussed. The diagnosis and assessment of CTEPH requires several modalities and the role of these is detailed. The pre-operative evaluation assesses peri-operative risk and determines the likelihood of benefit from PTE. Pulmonary thromboendarterectomy (PTE) remains the treatment of choice in appropriate patients. Nonsurgical therapies for CTEPH may provide benefit in patients who cannot be offered surgery.
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Affiliation(s)
- Peter S Marshall
- Yale University School of Medicine, Section of Pulmonary, Critical Care & Sleep Medicine, 15 York Street, LCI 101, New Haven, CT 06510, USA.
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Moua T, Levin DL, Carmona EM, Ryu JH. Frequency of mediastinal lymphadenopathy in patients with idiopathic pulmonary arterial hypertension. Chest 2013; 143:344-348. [PMID: 22922444 DOI: 10.1378/chest.12-0663] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE The objective of this study was to assess the frequency of mediastinal lymphadenopathy in patients with idiopathic pulmonary arterial hypertension (IPAH) and describe the correlative clinical features. METHODS We conducted a retrospective review of patients with IPAH who underwent right-sided heart catheterization (RHC) and chest CT scan within 3 months of each other. Patients were from a single tertiary institution. CT scans were reviewed for the presence of mediastinal lymphadenopathy (MLAD) with correlating demographic and clinical data, including lymph node size and location, right atrial pressure (RAP), mean pulmonary arterial pressure (mPAP), and the presence of pleural and pericardial effusion. RESULTS The study population included 85 patients with a mean age of 48 17.3 years; 70 (82%) were women. Fifteen patients (18%) had MLAD on chest CT scan. The mean short-axis diameter of the largest lymph node in these patients was 13.6 mm (range, 11-20 mm). The enlarged lymph nodes were located predominantly in the lower paratracheal and subcarinal stations. There was no association of MLAD with age, sex, RAP, or mPAP. MLAD was associated with presence of pleural effusion ( P , .02) but not pericardial effusion. Mean left ventricular ejection fraction for those with lymphadenopathy was 63% (range, 45%-76%). CONCLUSIONS MLAD without other identifiable causes is seen in approximately one in fi ve patients with IPAH and is associated with pleural effusion but not mPAP, RAP, or left ventricular function.
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Affiliation(s)
- Teng Moua
- Division of Pulmonary and Critical Care, Mayo Clinic Rochester, Rochester, MN.
| | - David L Levin
- Department of Radiology, Mayo Clinic Rochester, Rochester, MN
| | - Eva M Carmona
- Division of Pulmonary and Critical Care, Mayo Clinic Rochester, Rochester, MN
| | - Jay H Ryu
- Division of Pulmonary and Critical Care, Mayo Clinic Rochester, Rochester, MN
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Coche E. Advances and perspectives in lung cancer imaging using multidetector row computed tomography. Expert Rev Anticancer Ther 2013; 12:1313-26. [PMID: 23176619 DOI: 10.1586/era.12.112] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The introduction of multidetector row computed tomography (CT) into clinical practice has revolutionized many aspects of the clinical work-up. Lung cancer imaging has benefited from various breakthroughs in computing technology, with advances in the field of lung cancer detection, tissue characterization, lung cancer staging and response to therapy. Our paper discusses the problems of radiation, image visualization and CT examination comparison. It also reviews the most significant advances in lung cancer imaging and highlights the emerging clinical applications that use state of the art CT technology in the field of lung cancer diagnosis and follow-up.
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Affiliation(s)
- Emmanuel Coche
- Department of Medical Imaging, Cliniques Universitaires St-Luc, Université Catholique de Louvain, Avenue Hippocrate, 10, 1200 Brussels, Belgium.
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Pastis NJ, Van Bakel AB, Brand TM, Ravenel JG, Gilbert GE, Silvestri GA, Judson MA. Mediastinal lymphadenopathy in patients undergoing cardiac transplant evaluation. Chest 2010; 139:1451-1457. [PMID: 20966040 DOI: 10.1378/chest.10-1386] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND We evaluated the association between hemodynamic parameters of chronic congestive heart failure (CHF) and mediastinal lymphadenopathy (MLA) in heart transplantation (HT) candidates and the effect of HT on MLA. We also described the results of lymph node (LN) biopsies of MLA in the patients. METHODS Patients who underwent HT evaluation over an 8-year period and had chest CT scans were evaluated retrospectively. Data collected included LN sizes pre-HT and post-HT, echocardiographic measurements, radionuclide-derived ejection fraction, and right-sided heart catheterization hemodynamics. MLA was defined as LNs > 1 cm in smallest dimension. RESULTS Of 118 patients, 53 patients had MLA. MLA had weak statistically significant correlations with elevated mean pulmonary artery pressure (MPAP), mitral regurgitation (MR), tricuspid regurgitation (TR), right atrial pressure (RAP), and pulmonary capillary wedge pressure (PCWP). Thirty-six patients with MLA underwent HT, and nine of the 36 had post-HT chest CT scans. All nine patients showed a decrease in LN size post-HT (mean LN diameter pre-HT = 1.16 ± 0.137 cm, post-HT = 0.75 ± 0.32 cm). Seven of 53 patients with MLA underwent biopsies. Four had benign LNs, one had sarcoidosis, and two had lung cancer. CONCLUSIONS MPAP, MR, TR, RAP, and PCWP had weak statistically significant correlations with MLA. HT led to regression of MLA in patients who underwent CT scans post-HT, implying that MLA is related to CHF. However, we also identified clinically important causes of MLA; therefore, biopsy should be considered if enlarged LNs fail to regress after maximal medical management of CHF.
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Affiliation(s)
- Nicholas J Pastis
- Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, SC.
| | - Adrian B Van Bakel
- Division of Cardiology, Medical University of South Carolina, Charleston, SC
| | - Timothy M Brand
- College of Medicine, Medical University of South Carolina, Charleston, SC
| | - James G Ravenel
- Department of Radiology and Radiological Sciences, Medical University of South Carolina, Charleston, SC
| | - Gregory E Gilbert
- Centers for Disease Prevention and Health Inventions for Diverse Interventions, Charleston, SC
| | - Gerard A Silvestri
- Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, SC
| | - Marc A Judson
- Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, SC
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Coche E, Lonneux M, Geets X. Lung cancer: Morphological and functional approach to screening, staging and treatment planning. Future Oncol 2010; 6:367-80. [PMID: 20222794 DOI: 10.2217/fon.10.7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Lung cancer is a major problem in public health and constitutes the leading cause of cancer-related mortality in the world. Lung cancer screening with low-dose computed tomography is promising but needs to overcome many difficulties, such as the large number of incidentally discovered nodules, the radiation dose delivered to the patient during a whole screening program and its cost. The ultimate target point represented by the reduction of lung cancer-related mortality needs to be proved in large, well-designed, randomized, multicenter, prospective trials. Lung cancer staging by morphological tools seems to be limited owing to the presence of metastases in normal-sized lymph nodes. In this context, multidetector computed tomography cannot be used alone but is useful in conjunction with molecular imaging and MRI. Today, flurodeoxglucose PET-CT appears to be the most accurate method for lung cancer staging and may prevent unnecessary thoracotomies. For treatment planning, flurodeoxglucose PET-CT is playing an increasing role in radiotherapy planning at the target selection and definition steps.
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Affiliation(s)
- Emmanuel Coche
- Department of Medical Imaging, Université Catholique de Louvain, Cliniques Universitaires St-Luc, Brussels, Belgium.
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Reversible Locoregional Lymph Node Enlargement After Radiofrequency Ablation of Lung Tumors. AJR Am J Roentgenol 2010; 194:1250-6. [DOI: 10.2214/ajr.09.3206] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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