Developing radiology diagnostic tools for pulmonary fibrosis using machine learning methods

BACKGROUND

Accurate and prompt diagnosis of the different patterns for pulmonary fibrosis is essential for patient management. However, accurate diagnosis of the specific pattern is challenging due to overlapping radiographic characteristics.

MATERIALS AND METHODS

We conducted a retrospective chart review utilizing two machine learning methods, classification and regression tree and Bayesian additive regression tree, to select the most important radiographic features for diagnosing the three most common fibrosis patterns and created an online diagnostic app for convenient implementation.

RESULTS

Four hundred patients (median age of 67 with inter quartile range 58-73; 200 males) were included in the study. Peripheral distribution, homogeneity, lower lobe predominance and mosaic attenuation of fibrosis are the four most important features identified. Bayesian additive regression tree demonstrates better performance than classification and regression tree in diagnosis prediction and provides the predicted probability of each diagnosis with uncertainty intervals for each combination of features.

CONCLUSION

The model and app built with Bayesian additive regression tree can be used as an effective tool in assisting radiologists in the diagnostic process of pulmonary fibrosis pattern recognition.

Peripheral blood BDNF and soluble CAM proteins as possible markers of prolonged disorders of consciousness: a pilot study

Although clinical examination still represents the gold standard for the differential diagnosis of prolonged disorders of consciousness (pDoC), the introduction of innovative markers is essential for diagnosis and prognosis, due to the problem of covert cognition. We evaluated the brain-derived neurotrophic factor protein (BDNF) and the soluble cell adhesion molecules proteins (CAMs) in a cohort of prolonged disorders of consciousness patients to identify a possible application in the clinical context. Furthermore, peripheral blood determinations were correlated with imaging parameters such as white matter hyperintensities (WMH), cranial standardized uptake value (cSUV), electroencephalography (EEG) data and clinical setting. Our results, although preliminary, identify BDNF as a possible blood marker for the diagnosis of pDoC (p value 0.001), the soluble CAMs proteins CD44, Vcam-1, E-selectin (p value < 0.01) and Icam-3 (p value < 0.05) showed a higher peripheral blood value in pDoC compared with control. Finally, soluble Ncam protein could find useful applications in the clinical evolution of the pDoC, showing high levels in the MCS and EMCS subgroups (p value < 0. 001) compared to VS/UWS.

Breast stiffness, a risk factor for cancer and the role of radiology for diagnosis

Over the last five decades, breast density has been associated with increased risk of developing breast cancer. Mammographically dense breasts are considered those belonging to the heterogeneously dense breasts, and extremely dense breasts subgroups according to the American College of Radiology's Breast Imaging Reporting and Data System (BI-RADS). There is a statistically significant correlation between the increased mammographic density and the presence of more glandular tissue alone. However, the strength of this correlation is weak. Although the mechanisms driving breast density-related tumor initiation and progression are still unknown, there is evidence suggesting that certain molecular pathways participating in epithelial-stromal interactions may play a pivotal role in the deposition of fibrillar collagen, increased matrix stiffness, and cell migration that favor breast density and carcinogenesis. This article describes these molecular mechanisms as potential "landscapers" for breast density-related cancer. We also introduce the term "Breast Compactness" to reflect collagen density of breast tissue on chest CT scan and the use of breast stiffness measurements as imaging biomarkers for breast cancer screening and risk stratification.

Analogies between the periphery of cancer and the leading edge of pulmonary fibrosis

The periphery of malignant tumors and the leading edge of fibrotic tissue have analogous metabolic pathways. Both use glycolysis as the primary source of energy to produce biomass with consequential acidification of the microenvironment. A low PH has been shown to increase the ability of cancer cells to invade the surrounding tissue in both in vitro and in vivo studies. The pH-dependent activation of TGF-B leading to myofibroblast activation is an important step in the initiation and progression of fibrosis. Markers of accelerated cell proliferation have also been reported in the periphery of malignant tumors and the leading edge of fibrosis. Understanding the shared molecular and metabolic characteristics of these conditions may explain the increased prevalence of cancer among patients with fibrosis.

Is pulmonary fibrosis a precancerous disease?

Idiopathic pulmonary fibrosis (IPF) is the most common type of interstitial lung disease (ILD) characterized by a histopathological pattern of usual interstitial pneumonia with progressive fibrosis of the pulmonary epithelium. The incidence of IPF is increasing worldwide as the population ages and with that, there is a concomitant increase in the incidence of lung cancer in these patients who are living longer with the disease. The average length of time for lung cancer development following an IPF diagnosis is 3 years. Given the high prevalence of lung cancer among patients with pulmonary fibrosis, we wondered if pulmonary fibrosis could be classified as a precancerous disease. We provided support from the Pubmed published literature to investigate whether pulmonary fibrosis meets the five criteria of the National Cancer Institute's definition of premalignant conditions for classification as a precancerous disease. We found out pulmonary fibrosis meets the five criteria of the National Cancer Institute's definition of a premalignant condition and can be considered a precancerous disease. To identify early lung cancer in patients with pulmonary fibrosis, regular screening with HRCT and PET-CT scans is highly recommended for these patients.

CANNOT B UIP

The American Thoracic Society provides guidelines for the confident radiographic diagnosis of UIP. In addition, the guidelines identify findings on CT scans that should suggest an alternative diagnosis to UIP. These findings include consolidation, air trapping, nodules, ground glass opacities, cysts, and upper lung and bronchovascular distribution. We present a mnemonic to help the reader remember the list of findings that are inconsistent with UIP and provide imaging examples for completeness. The mnemonic is "CANNOT B" UIP.

COVID-19 on Chest CT: Translating Known Microscopic Findings to Imaging Observations

Purpose: To describe the imaging findings of COVID-19 and correlate them with their known pathology observations. Methods: This is an IRB-approved retrospective study performed at Columbia University Irving Medical Center (IRB # AAAS9652) that included symptomatic adult patients (21 years or older) who presented to our emergency room and tested positive for COVID-19 and were either admitted or discharged with at least one chest CT from 11 March 2020 through 1 July 2020. CT scans were ordered by the physicians caring for the patients; our COVID-19 care protocols did not specify the timing for chest CT scans. A scoring system was used to document the extent of pulmonary involvement. The total CT grade was the sum of the individual lobar grades and ranged from 0 (no involvement) to 16 (maximum involvement). The distribution of lung abnormalities was described as peripheral (involving the outer one-third of the lung), central (inner two-thirds of the lung), or both. Additional CT findings, including the presence of pleural fluid, atelectasis, fibrosis, cysts, and pneumothorax, were recorded. Contrast-enhanced CT scans were evaluated for the presence of a pulmonary embolism, while non-contrast chest CT scans were evaluated for hyperdense vessels. Results: 209 patients with 232 CT scans met the inclusion criteria. The average age was 61 years (range 23–97 years), and 56% of the patients were male. The average score reflecting the extent of the disease on the CT was 10.2 (out of a potential grade of 16). Further, 73% of the patients received contrast, which allowed the identification of a pulmonary embolism in 21%. Of those without contrast, 33% had hyperdense vessels, which might suggest a chronic pulmonary embolism. Further, 47% had peripheral opacities and 9% had a Hampton’s hump, and 78% of the patients had central consolidation, while 28% had round consolidations. Atelectasis was, overall, infrequent at 5%. Fibrosis was observed in 11% of those studied, with 6% having cysts and 3% pneumothorax. Conclusions: The CT manifestations of COVID-19 can be divided into findings related to endothelial and epithelial injury, as were seen on prior post-mortem reports. Endothelial injury may benefit from treatments to stabilize the endothelium. Epithelial injury is more prone to developing pulmonary fibrotic changes.

The Role of Radiology in Progressive Fibrosing Interstitial Lung Disease

In this article, we describe the role of radiology for diagnosis and follow-up of progressive fibrosing interstitial lung disease (PF-ILD). Patients with PF-ILD are at increased risk for early death without treatment. Clinical diagnosis of PF-ILD has been described in the literature. This manuscript reviews the radiographic diagnosis of PF-ILD and the unique CT characteristics associated with specific types of fibrosis. Ultimately, we believe that radiology has the potential to recognize progression early and thus make an important contribution to the multidisciplinary discussion for this important diagnosis.

Patterns of repeated diagnostic testing for COVID-19 in relation to patient characteristics and outcomes

BACKGROUND

Whilst the COVID-19 diagnostic test has a high false-negative rate, not everyone initially negative is re-tested. Michigan Medicine, a primary regional centre, provided an ideal setting for studying testing patterns during the first wave of the pandemic.

OBJECTIVES

To identify the characteristics of patients who underwent repeated testing for COVID-19 and determine if repeated testing was associated with downstream outcomes amongst positive cases.

METHODS

Characteristics, test results, and health outcomes for patients presenting for a COVID-19 diagnostic test were collected. We examined whether patient characteristics differed with repeated testing and estimated a false-negative rate for the test. We then studied repeated testing patterns in patients with severe COVID-19-related outcomes.

RESULTS

Patient age, sex, body mass index, neighbourhood poverty levels, pre-existing type 2 diabetes, circulatory, kidney, and liver diseases, and cough, fever/chills, and pain symptoms 14 days prior to a first test were associated with repeated testing. Amongst patients with a positive result, age (OR: 1.17; 95% CI: (1.05, 1.34)) and pre-existing kidney diseases (OR: 2.26; 95% CI: (1.41, 3.68)) remained significant. Hospitalization (OR: 7.88; 95% CI: (5.15, 12.26)) and ICU-level care (OR: 6.93; 95% CI: (4.44, 10.92)) were associated with repeated testing. The estimated false-negative rate was 23.8% (95% CI: (19.5%, 28.5%)).

CONCLUSIONS

Whilst most patients were tested once and received a negative result, a meaningful subset underwent multiple rounds of testing. These results shed light on testing patterns and have important implications for understanding the variation of repeated testing results within and between patients.

PET/MRI for staging patients with Hodgkin lymphoma: equivalent results with PET/CT in a prospective trial

To compare FDG-PET/unenhanced MRI and FDG-PET/diagnostic CT in detecting infiltration in patients with newly diagnosed Hodgkin lymphoma (HL). The endpoint was equivalence between PET/MRI and PET/CT in correctly defining the revised Ann Arbor staging system. Seventy consecutive patients with classical-HL were prospectively investigated for nodal and extra-nodal involvement during pretreatment staging with same-day PET/CT and PET/MRI. Findings indicative of malignancy with the imaging procedures were regarded as lymphoma infiltration; in case of discrepancy, positive-biopsy and/or response to treatment were evidenced as lymphoma. Sixty of the 70 (86%) patients were evaluable having completed the staging program. Disease staging based on either PET/MRI or PET/CT was correct for 54 of the 60 patients (90% vs. 90%), with difference between proportions of 0.0 (95% CI, -9 to 9%; P=0.034 for the equivalence test). As compared with reference standard, invasion of lymph nodes was identified with PET/MRI in 100% and with PET/CT in 100%, of the spleen with PET/MRI in 66% and PET/CT in 55%, of the lung with PET/MRI in 60% and PET/CT in 100%, of the liver with PET/MRI in 67% and PET/CT in 100%, and of the bone with PET/MRI in 100% and PET/CT in 50%. The only statistically significant difference between PET/MRI and PET/CT was observed in bony infiltration detection rates. For PET/CT, iodinate contrast medium infusions' average was 86 mL, and exposure to ionizing radiation was estimated to be 4-fold higher than PET/MRI. PET/MRI is a promising safe new alternative in the care of patients with HL.

Forty Postmortem Examinations in COVID-19 Patients

OBJECTIVES

Although 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.

METHODS

A 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.

RESULTS

Three 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.

CONCLUSIONS

Two 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.

Integrated analysis of DNA methylation profile in HLA-G gene and imaging in coronary heart disease

Aims

Immune endothelial inflammation, underlie coronary heart disease (CHD) related phenotypes, could provide new insight into the pathobiology of the disease. We investigated DNA methylation level of the unique CpG island of HLA-G gene in CHD patients and evaluated the correlation with cardiac computed tomography angiography (CCTA) features.

Methods

Thirty-two patients that underwent CCTA for suspected CHD were enrolled for this study. Obstructive CHD group included fourteen patients, in which there was a stenosis greater than or equal to 50% in one or more of the major coronary arteries detected; whereas subjects with Calcium (Ca) Score=0, uninjured coronaries and with no obstructive CHD were considered as control subjects (Ctrls) (n=18). For both groups, DNA methylation profile of the whole 5'UTR-CpG island of HLA-G was measured. The plasma soluble HLA-G (sHLA-G) levels were detected in all subjects by specific ELISA assay. Statistical analysis was performed using R software.

Results

For the first time, our study reported that 1) a significant hypomethylation characterized three specific fragments (B, C and F) of the 5'UTR-CpG island (p=0.05) of HLA-G gene in CHD patients compared to Ctrl group; 2) hypomethylation level of one specific fragment positively correlated with coronary Ca score, a relevant parameter of CCTA (p&lt;0.05) between two groups.

Conclusions

Our results showed that reduced levels of circulating HLA-G molecules could derive from epigenetic marks inducing hypomethylation of specific regions into 5'UTR-CpG island of HLA-G gene in CHD patients with obstructive coronary stenosis vs non critical stenosis group.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Italian Minister of Health

The right upper lobe bronchus angle: A tool for differentiating fibrotic and non-fibrotic sarcoidosis

Purpose:

To evaluate the Right Upper Lobe Bronchus Angle (RUL-BA) on chest CT in patients with Stage 4 sarcoidosis and compare to others with non-fibrotic sarcoidosis.

Methods:

IRB approval was obtained for review of all chest CT scans performed from January 2015 through December 2017 that contained the word sarcoidosis using the computer program Montage. The most recent CT scans of 633 people were reviewed. The patients’ age and sex at the time of their most recent CT scan were recorded. The radiographic diagnosis and the Right Upper Lobe Bronchus Angle (RUL-BA) were determined by a chest radiologist with 20 years of experience.

Results:

The RUL-BA increased with Stage 4 sarcoidosis, measuring on average 104 degrees, compared to the average angle of 88 degrees for those without fibrotic sarcoid. More often men’s CT scans exhibited the earlier stages of sarcoidosis, and a higher number of women’s scans showed fibrotic sarcoidosis. As would be expected, scans with advanced disease were typically from older patients; however, there was no correlation between age and degree of fibrosis as measured by increasing RUL-BA.

Conclusion:

The RUL-BA assists radiologists in differentiating fibrotic sarcoidosis from non-fibrotic sarcoidosis. Further research will determine if the RUL-BA measurement can help differentiate fibrotic sarcoid from other fibrotic lung diseases and if the angle can be used to follow disease progression. (Sarcoidosis Vasc Diffuse Lung Dis 2020; 37 (2): 99-103)

In vivo imaging of CNS microglial activation/macrophage infiltration with combined [18F]DPA-714-PET and SPIO-MRI in a mouse model of relapsing remitting experimental autoimmune encephalomyelitis

Purpose

To evaluate the feasibility and sensitivity of multimodality PET/CT and MRI imaging for non-invasive characterization of brain microglial/macrophage activation occurring during the acute phase in a mouse model of relapsing remitting multiple sclerosis (RR-MS) using [¹⁸F]DPA-714, a selective radioligand for the 18-kDa translocator protein (TSPO), superparamagnetic iron oxide particles (SPIO), and ex vivo immunohistochemistry.

Methods

Experimental autoimmune encephalomyelitis (EAE) was induced in female SJL/J mice by immunization with PLP_139–151. Seven symptomatic EAE mice and five controls underwent both PET/CT and MRI studies between 11 and 14 days post-immunization. SPIO was injected i.v. in the same animals immediately after [¹⁸F]DPA-714 and MRI acquisition was performed after 24 h. Regional brain volumes were defined according to a mouse brain atlas on co-registered PET and SPIO-MRI images. [¹⁸F]DPA-714 standardized uptake value (SUV) ratios (SUVR), with unaffected neocortex as reference, and SPIO fractional volumes (SPIO-Vol) were generated. Both SUVR and SPIO-Vol values were correlated with the clinical score (CS) and among them. Five EAE and four control mice underwent immunohistochemical analysis with the aim of identifying activated microglia/macrophage and TSPO expressions.

Results

SUVR and SPIO-Vol values were significantly increased in EAE compared with controls in the hippocampus (p < 0.01; p < 0.02, respectively), thalamus (p < 0.02; p < 0.05, respectively), and cerebellum and brainstem (p < 0.02), while only SPIO-Vol was significantly increased in the caudate/putamen (p < 0.05). Both SUVR and SPIO-Vol values were positively significantly correlated with CS and among them in the same regions. TSPO/Iba1 and F4/80/Prussian blue staining immunohistochemistry suggests that increased activated microglia/macrophages underlay TSPO expression and SPIO uptake in symptomatic EAE mice.

Conclusions

These preliminary results suggest that both activated microglia and infiltrated macrophages are present in vulnerable brain regions during the acute phase of PLP-EAE and contribute to disease severity. Both [¹⁸F]DPA-714-PET and SPIO-MRI appear suitable modalities for preclinical study of neuroinflammation in MS mice models.

2-deoxy-2[F-18] fluoro-D-glucose positron emission tomography Deauville scale and core-needle biopsy to determine successful management after six doxorubicin, bleomycin, vinblastine and dacarbazine cycles in advanced-stage Hodgkin lymphoma

BACKGROUND

The clinical impact of the positivity of the Deauville scale (DS) of positron emission tomography (PET) performed at the end of doxorubicin, bleomycin, vinblastine and dacarbazine (ABVD) in patients with advanced Hodgkin lymphoma (HL), in terms of providing rationale to shift poor responders onto a more intensive regimen, remain to be validated by histopathology.

PATIENTS AND METHODS

This prospective trial involved patients with stage IIB/IV HL who after six ABVD cycles underwent PET (PET6) and core-needle cutting biopsy (CNCB) of 2-deoxy-2[F-18] fluoro-d-glucose (FDG)-avid lymph nodes. Patients received high-dose chemotherapy/autologous haematopoietic stem cell rescue (HDCT/AHSCR) if CNCB was positive for HL, alternatively, if CNCB or PET was negative, received observation or consolidation radiotherapy (cRT) on residual nodal masses, as initially planned. The end-point was 5-year progression-free survival (PFS).

RESULTS

In all, 43 of the 169 (25%) evaluable patients were PET6 positive (DS 4, 32; DS 5, 11). Among them, histology showed malignancy (HL) in 100% of DS 5 scores and in 12.5% of DS 4 scores. Fifteen patients with positive biopsy received HDCT/AHSCR, whereas 28 patients with negative biopsy, as well as 126 patients with negative PET6, continued the original plan (cRT, 78 patients; observation, 76 patients). The 5-year PFS in the negative PET6 group, negative biopsy group and positive biopsy group was 95.4%, 100% and 52.5%, respectively.

CONCLUSION

DS positivity of end-of-ABVD PET in advanced HL carried a certain number of CNCB-proven non-malignant FDG-uptakes. The DS 4 scores which were found to have negative histology appeared to benefit from continuing the original non-intensive therapeutic plane as indicated by the successful outcome in more than 95% of them by obtaining similar 5-year PFS to the PET6-negative group. By contrast, the DS 5 score had consistently positive histology and was associated with unsuccessful conventional therapy, promptly requiring treatment intensification or innovative therapeutic approaches.

The Undiagnosed Diseases Network International: Five years and more!

Undiagnosed rare diseases (URDs) account for a significant portion of the overall rare disease burden, depending upon the country. Hence, URDs represent an unmet medical need. A specific challenge posed by the ensemble of the URD patient cohort is the heterogeneity of its composition; the group, indeed, includes very rare, still unidentified conditions as well as clinical variants of recognized rare diseases. Exact disease recognition requires new approaches that cut across national and institutional boundaries, may need the implementation of methods new to diagnostics, and embrace clinical care and research. To address these issues, the Undiagnosed Diseases Network International (UDNI) was established in 2014, with the major aims of providing diagnoses to patients, implementing additional diagnostic tools, and fostering research on novel diseases, their mechanisms, and their pathways. The UDNI involves centres with internationally recognized expertise, and its scientific resources and know-how aim to fill the knowledge gaps that impede diagnosis, in particularly for ultra-rare diseases. Consequently, the UDNI fosters the translation of research into medical practice, aided by active patient involvement. The goals of the UDNI are to work collaboratively and at an international scale to: 1) provide diagnoses for individuals who have conditions that have eluded diagnosis by clinical experts; 2) gain insights into the etiology and pathogenesis of novel diseases; 3) contribute to standards of diagnosing unsolved patients; and 4) share the results of UDNI research in a timely manner and as broadly as possible.

Non-Gaussian models of diffusion weighted imaging for detection and characterization of prostate cancer: a systematic review and meta-analysis

The importance of Diffusion Weighted Imaging (DWI) in prostate cancer (PCa) diagnosis have been widely handled in literature. In the last decade, due to the mono-exponential model limitations, several studies investigated non-Gaussian DWI models and their utility in PCa diagnosis. Since their results were often inconsistent and conflicting, we performed a systematic review of studies from 2012 examining the most commonly used Non-Gaussian DWI models for PCa detection and characterization. A meta-analysis was conducted to assess the ability of each Non-Gaussian model to detect PCa lesions and distinguish between low and intermediate/high grade lesions. Weighted mean differences and 95% confidence intervals were calculated and the heterogeneity was estimated using the I² statistic. 29 studies were selected for the systematic review, whose results showed inconsistence and an unclear idea about the actual usefulness and the added value of the Non-Gaussian model parameters. 12 studies were considered in the meta-analyses, which showed statistical significance for several non-Gaussian parameters for PCa detection, and to a lesser extent for PCa characterization. Our findings showed that Non-Gaussian model parameters may potentially play a role in the detection and characterization of PCa but further studies are required to identify a standardized DWI acquisition protocol for PCa diagnosis.

P6431Association of circulating miR-765, miR-93-5p and miR-433-3p with obstructive coronary heart disease evaluated by cardiac computed tomography

Background

Although advances in diagnosis, treatment and prognosis, coronary heart disease (CHD) is still the most prevalent cause of mortality and morbidity worldwide. Thus, there is still the need to identify both novel diagnostic and prognostic biomarkers to improve the clinical decision-making and help to stratify patients for early preventive treatment. Epigenetic-sensitive mechanisms may be related both to pathogenesis and prognosis of CHD. Among the epigenetic hallmarks, microRNAs (miRNAs), acting as flexible modulators of gene expression, could represent attractive candidate biomarkers useful in clinical practice.

Purpose

We prospectively investigated the expression pattern of circulating miRNAs in patients undergoing Cardiac Computed Tomography (CCT) for suspected CHD (n=95) with the aim to integrate molecular findings with morphological and clinical parameters derived by CCT.

Methods

CCT was performed with a third-generation dual source multidetector computed tomography scanner. Peripheral venous blood samples were collected into EDTA after a 12 h fasting in the same day of CCT, before imaging execution and the levels of 42 selected plasmatic miRNAs were analyzed by qRT-PCR.

Results

Let-7c-5p, miR-765, miR-483-5p, miR-31-5p and miR-206 were upregulated in CHD patients (n=66) vs healthy subjects HS (n=29) as well as let-7c-5p, miR-765, miR- 483-5p showed higher expression in obstructive CHD (n=36) compared to no obstructive CHD patients (n=66). In addition, miR-93-5p and miR-433-3p showed an upregulation in patients with critical coronary stenosis. Multivariate regression analysis demonstrated that miR-765, miR-31-5p and miR-206 were independently associated with CHD also in combination with Framingham risk score. Relevantly, miR-765, miR-93-5p and miR-433-3p were obstructive CHD predictors. ROC curve analysis also revealed a good performance for miR-765, miR-93-5p and miR-433-3p on predicting CHD severity.

Circulating microRNA expression

Conclusions

Our study represents a combined epigenetic/imaging approach useful to support the diagnosis and prediction of CHD.

Acknowledgement/Funding

Italian Ministry of Health grants: “Giovani Ricercatori 2011-12” (project code GR-2011-02349436) and “Ricerca Corrente 2018”

Interstitial Lung Abnormalities and Lung Cancer Risk in the National Lung Screening Trial

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.

Progression of probable UIP and UIP on HRCT

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.

Sentinel Lymph Node Detection by Lymphoscintigraphy in Malignant Melanoma

Aims and Background

Sentinel lymph node (SLN) detection is currently employed in patients with malignant melanoma (MM) to spare them unnecessary lymph node dissection.

Methods and Study Design

We investigated 241 patients (130 men and 111 women, median age, 50 years (range, 14-92)) with MM (192 before and 51 after surgical biopsy); two of them had more than one melanoma lesion. In each patient approx. 10 MBq of 99mTc Nanocoll in 0.1 mL (Nycomed Amersham Sorin; particle size range, 3-80 nm) was injected intradermally around the MM lesion or surgical scar. Dynamic acquisition was performed for 20 minutes (20 frames/min) and the study was concluded within four hours of injection. Using an external radioactive marker, the skin over the SLN was marked with China ink.

Results

294 SLNs were scintigraphically identified: 117 in the inguinal region, 147 in the axillae, four in the submandibular region, three in the laterocervical region and 23 at other sites. In two patients no drainage was detected. In 43 patients more than one sentinel node was identified. In 13 patients with lesions located in the trunk the tracer drained towards multiple lymph node stations or unexpected lymph nodes (nine cases). Histology and immunohistochemistry diagnosed MM in 25 SLNs; 19 were positive for metastasis with hematoxylin-eosin staining, five with Hmb45 and one with CD68 immunostaining. All 25 detected lymphatic basins were excised. In nine of these basins there was metastatic involvement of at least one other lymph node besides the SLN. During follow-up, which ranged from six to 86 months, metastatic disease was found in only one patient with a histologically negative SLN six months after surgery.

Conclusions

This study confirms the utility of scintigraphic SLN detection in patients with MM. In most of the cases the procedure led the surgeon to evaluate the drainage area, which is unpredictable for lesions in the trunk and may be difficult to delineate using only patent blue dye. Furthermore, in approximately 10% of cases we observed dual drainage from individual lesions, mainly those located on the trunk. We will proceed to compare the results obtained during follow-up with those of an investigational group of patients with melanoma who were not subjected to lymphoscintigraphy for SLN detection in order to obtain well-founded information on the prognostic value of this technique.

Epirubicin in Combination Chemotherapy in the Treatment of Advanced Stage Non-Hodgkin's Lymphomas

From April 1981 to May 1984, 23 patients with advanced non-Hodgkin's lymphomas were treated with CEOP (cyclophosphamide, epirubicin, vincristine, and prednisone) or OEPP (vincristine, epirubicin, procarbazine, and prednisone) combination chemotherapy. CR was achieved in 58 % and PR in 31 % of the patients, giving an overall response rate of 89 %. Nine of 15 (60 %) previously untreated patients with unfavorable histology obtained a CR and 5 a PR. Median relapse-free survival was 33 months; median overall survival has not yet been reached, and the probability of survival for CRs was 91 % after 54 months of follow-up. Acute toxicity was quite acceptable, and chronic cardiac toxicity was detected in 6 patients only. In conclusion, epirubicin used in combination chemotherapies induced durable remissions and prolonged survivals in advanced non-Hodgkin's lymphomas.

Malignant Melanoma of the Nipple: A Case Studied with Radiolabeled Monoclonal Antibody

We describe a case of histologically confirmed malignant melanoma of the nipple. The rare occurrence of these lesions accounts for the relative lack of criteria for standard surgical treatment. After a conventional workup including mammography, chest X ray, bone scan, liver ultrasonography and cytologic smear of the lesion, we used specific radiolabeled monoclonal antibody and external photoscanning to differentiate melanoma from Paget's disease. The patient underwent wide local excision of the lesion and axillary node dissection, and tumor control is optimal since she has no evidence of disease after 5 years of follow-up.

A multiparametric and multiscale approach to automated segmentation of brain veins

Cerebral vein analysis provides a fundamental tool to study brain diseases such as neurodegenerative disorders or traumatic brain injuries. In order to assess the vascular anatomy, manual segmentation approaches can be used but are observer-dependent and time-consuming. In the present work, a fully automated cerebral vein segmentation method is proposed, based on a multiscale and multiparametric approach. The combined investigation of the R2(*)- and a Vesselness probability-map was used to obtain a fast and highly reliable classification of venous voxels. A semiquantitative analysis showed that our approach outperformed the previous state-of-the-art algorithm both in sensitivity and specificity. Inclusion of this tool within a parametric brain framework may therefore pave the way for a quantitative study of the intracranial venous system.

Anti-CEA and Other Antibodies in the Study of Gastrointestinal Tumors

Localization of gastrointestinal tumors by means of labeled monoclonal antibodies is a new, sensitive and suitable technique currently used in several centers. Encouraging results have been documented with several monoclonal antibodies by different authors. This article reviews our experience with radioimmunoscintigraphy in 59 patients with colorectal cancer in follow-up, using 131I and 111In labeled B72.3, and in 16 patients with primary gastrointestinal tumors using 99mTc anti-CEA monoclonal antibody (type F023C5). The sensitivity of both B72.3 and anti-CEA was greater than 70% either for primary tumors and abdominal recurrences or distant metastases except hepatic ones. A significant gradient in antibody uptake was measured on surgical biopsies between tumors and normal tissues allowing a good in vivo contrast for gamma detection. We have defined the impact of some factors affecting in vivo tumor targeting. In fact, pharmacodynamics of MAbs, percentage of injected dose bound to tissues were measured, and in particular antigenic content in tumor nodules was quantified. Furthermore, the results of RIS were compared to those obtained by CT and other imaging modalities.

Correction to: Baseline and annual repeat rounds of screening: implications for optimal regimens of screening

The original version of this article unfortunately contained a mistake. The conflict of interest was incorrect.

The SubCons webserver: A user friendly web interface for state-of-the-art subcellular localization prediction

SubCons is a recently developed method that predicts the subcellular localization of a protein. It combines predictions from four predictors using a Random Forest classifier. Here, we present the user-friendly web-interface implementation of SubCons. Starting from a protein sequence, the server rapidly predicts the subcellular localizations of an individual protein. In addition, the server accepts the submission of sets of proteins either by uploading the files or programmatically by using command line WSDL API scripts. This makes SubCons ideal for proteome wide analyses allowing the user to scan a whole proteome in few days. From the web page, it is also possible to download precalculated predictions for several eukaryotic organisms. To evaluate the performance of SubCons we present a benchmark of LocTree3 and SubCons using two recent mass-spectrometry based datasets of mouse and drosophila proteins. The server is available at http://subcons.bioinfo.se/.

OPO Strategies to Prevent Unintended Use of Kidneys Exported for High PRA (>98% cPRA) Recipients

Since the advent of the Kidney Allocation System (KAS), matched candidates with high (>98%) panel reactive antibody (hPRA) are given priority over local candidates with lower PRA. This often leads to exporting of kidneys. Data for these kidneys are not detailed on routine reports. Twenty-two organ procurement organizations prospectively submitted data from August 2015 to July 2016, describing allocation practices of kidneys to hPRA patients and outcomes of these kidneys. Five hundred twenty out of 6924 procured kidneys were exported for hPRA recipients. Of these, 402 (77.3%) were transplanted into the intended recipient (IR); 100 (19.2%) were transplanted into unintended recipients (UR), and 18 (3.5%) were discarded. The most common reason for use in an UR was a positive crossmatch (XM) (63%). The most common reasons for discard were donor quality (44%) and ischemic time (39%). Prior to kidney export, when tissue crossmatching was done, 96.2% of the kidneys went to the IR, versus 80.7% following virtual CM, versus 56.7% when no crossmatching was performed (p < 0.0001). A significant number of kidneys exported for hPRA patients are not being used in the IR or are being discarded. The most common reason for this is positive tissue XM. We report that unintended use of the kidney was minimized when tissue was shipped and XM results were known prior to exporting the kidney.

Elevated serum D-dimer level is associated with an increased risk of acute exacerbation in interstitial lung disease

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 FEV_1.0.

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.

Osteophyte induced lung fibrosis prevalence and osteophyte qualities predicting disease

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 (1-10mm) 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.

Acute myocardial infarction in a patient with unstable angina: A case report

A 58-year-old-man with unstable angina developed a violent retrosternal and interscapular pain during coronary angiography with no associated ECG abnormalities. The patient was immediately submitted to transesophageal echocardiography, which revealed an echo-free space behind the ascending aorta thought to be consistent with an aortic dissection. To confirm this finding the patient underwent contrast-enhanced helical CT, which ruled out a dissection but revealed a small hypoattenuating, ill-defined area within the lateral wall of the left ventricle, consistent with an acute myocardial infarction. The finding was first confirmed by bedside echocardiography and later validated by laboratory tests. Review of the left coronary angiogram showed the culprit lesion at the origin of a major acute marginal branch of the circumflex artery.

The importance of the regimen of screening in maximizing the benefit and minimizing the harms

BACKGROUND

In CT screening for lung cancer, the regimen of screening is critical in diagnosing lung cancer early while limiting unnecessary tests and invasive procedures. The International Early Lung Cancer Action Program (I-ELCAP) has developed a regimen based on evidence collected in the I-ELCAP cohort of more than 70,000 participants.

METHODS

Important in the development of the regimen is the recognition of the profound difference between the first, baseline round of screening and all subsequent rounds of repeat screening. For each person undergoing screening, the baseline round happens only once while repeat rounds will be performed annually for many years. This difference needs to be clearly recognized as it is these annual rounds which allow for identification of small, early, yet aggressive, lung cancers which have high cure rates despite their aggressiveness. The importance of nodule consistency and size are key factors in the regimen. The regimen needs to be continuously updated by incorporating advances in technology and knowledge.

RESULTS

The use of the I-ELCAP regimen reduces the workup of participants in the screening program to less than 10% in the baseline round and less than 6% in the annual repeat rounds. By use of this regimen, estimated cure rate of lung cancers diagnosed under screening is 80% or higher in both baseline and annual repeat rounds.

CONCLUSIONS

The I-ELCAP collaboration provides a new paradigm that answers the 2002 NCI call for multiple approaches to address relevant questions about screening and the Institute of Medicine (IOM) Roundtable on Evidence-based Medicine from the National Academy of Science's call for a "new clinical research paradigm that takes better advantage of data generated in the course of healthcare delivery would speed and improve the development of evidence for real-world decision making".

The use of isodose levels to interpret radiation induced lung injury: a quantitative analysis of computed tomography changes

BACKGROUND

Patients treated with stereotactic body radiation therapy (SBRT) for lung cancer are often found to have radiation-induced lung injury (RILI) surrounding the treated tumor. We investigated whether treatment isodose levels could predict RILI.

METHODS

Thirty-seven lung lesions in 32 patients were treated with SBRT and received post-treatment follow up (FU) computed tomography (CT). Each CT was fused with the original simulation CT and treatment isodose levels were overlaid. The RILI surrounding the treated lesion was contoured. The RILI extension index [fibrosis extension index (FEI)] was defined as the volume of RILI extending outside a given isodose level relative to the total volume of RILI and was expressed as a percentage.

RESULTS

Univariate analysis revealed that the planning target volume (PTV) was positively correlated with RILI volume at FU: correlation coefficient (CC) =0.628 and P<0.0001 at 1(st) FU; CE =0.401 and P=0.021 at 2(nd) FU; CE =0.265 and P=0.306 at 3(rd) FU. FEI -40 Gy at 1(st) FU was significantly positively correlated with FEI -40 Gy at subsequent FU's (CC =0.689 and P=6.5×10(-5) comparing 1(st) and 2(nd) FU; 0.901 and P=0.020 comparing 2(nd) and 3(rd) FU. Ninety-six percent of the RILI was found within the 20 Gy isodose line. Sixty-five percent of patients were found to have a decrease in RILI on the second 2(nd) CT.

CONCLUSIONS

We have shown that RILI evolves over time and 1(st) CT correlates well with subsequent CTs. Ninety-six percent of the RILI can be found to occur within the 20 Gy isodose lines, which may prove beneficial to radiologists attempting to distinguish recurrence vs. RILI.