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1.  Improving CT-guided transthoracic biopsy of mediastinal lesions by diffusion-weighted magnetic resonance imaging 
Clinics  2014;69(11):787-791.
OBJECTIVES:
To evaluate the preliminary results obtained using diffusion-weighted magnetic resonance imaging and the apparent diffusion coefficient for planning computed tomography-guided biopsies of selected mediastinal lesions.
METHODS:
Eight patients with mediastinal lesions suspicious for malignancy were referred for computed tomography-guided biopsy. Diffusion-weighted magnetic resonance imaging and apparent diffusion coefficient measurement were performed to assist in biopsy planning with diffusion/computed tomography fused images. We selected mediastinal lesions that could provide discordant diagnoses depending on the biopsy site, including large heterogeneous masses, lesions associated with lung atelectasis or consolidation, lesions involving large mediastinal vessels and lesions for which the results of biopsy using other methods and histopathological examination were divergent from the clinical and radiological suspicion.
RESULTS:
In all cases, the biopsy needle was successfully directed to areas of higher signal intensity on diffusion-weighted sequences and the lowest apparent diffusion coefficient within the lesion (mean, 0.8 [range, 0.6–1.1]×10-3 mm2/s), suggesting high cellularity. All biopsies provided adequate material for specific histopathological diagnoses of four lymphomas, two sarcomas and two thymomas.
CONCLUSION:
Functional imaging tools, such as diffusion-weighted imaging and the apparent diffusion coefficient, are promising for implementation in noninvasive and imaging-guided procedures. However, additional studies are needed to confirm that mediastinal biopsy can be improved with these techniques.
doi:10.6061/clinics/2014(11)13
PMCID: PMC4255081  PMID: 25518038
MRI-Guided Biopsy; DWI-Guided Biopsy; Mediastinal Lesion; Diagnosis; Malignancy; Tomography
2.  Thoracic textilomas: CT findings*  
Jornal Brasileiro de Pneumologia  2014;40(5):535-542.
OBJECTIVE:
The aim of this study was to analyze chest CT scans of patients with thoracic textiloma.
METHODS:
This was a retrospective study of 16 patients (11 men and 5 women) with surgically confirmed thoracic textiloma. The chest CT scans of those patients were evaluated by two independent observers, and discordant results were resolved by consensus.
RESULTS:
The majority (62.5%) of the textilomas were caused by previous heart surgery. The most common symptoms were chest pain (in 68.75%) and cough (in 56.25%). In all cases, the main tomographic finding was a mass with regular contours and borders that were well-defined or partially defined. Half of the textilomas occurred in the right hemithorax and half occurred in the left. The majority (56.25%) were located in the lower third of the lung. The diameter of the mass was ≤ 10 cm in 10 cases (62.5%) and > 10 cm in the remaining 6 cases (37.5%). Most (81.25%) of the textilomas were heterogeneous in density, with signs of calcification, gas, radiopaque marker, or sponge-like material. Peripheral expansion of the mass was observed in 12 (92.3%) of the 13 patients in whom a contrast agent was used. Intraoperatively, pleural involvement was observed in 14 cases (87.5%) and pericardial involvement was observed in 2 (12.5%).
CONCLUSIONS:
It is important to recognize the main tomographic aspects of thoracic textilomas in order to include this possibility in the differential diagnosis of chest pain and cough in patients with a history of heart or thoracic surgery, thus promoting the early identification and treatment of this postoperative complication.
doi:10.1590/S1806-37132014000500010
PMCID: PMC4263335  PMID: 25410842
Foreign-body reaction; Tomography; spiral computed; Thoracic surgery
4.  Is DWI/ADC a Useful Tool in the Characterization of Focal Hepatic Lesions Suspected of Malignancy? 
PLoS ONE  2014;9(7):e101944.
Objective
Apparent diffusion coefficient (ADC) values calculated through magnetic resonance imaging have been proposed as a useful tool to distinguish benign from malignant liver lesions. Most studies however included simple cysts in their analysis. Liver cysts are easy to diagnose, have very high ADC values and their inclusion facilitates differentiation in the ADC values between benign and malignant liver lesions groups. We prospectively evaluated the ability of ADC values to differentiate metastatic liver lesions from all benign or only solid benign liver lesions.
Material and Methods
Sixty-seven adult cancer patients with 188 liver lesions were evaluated. Lesions were categorized as metastatic or benign throughout imaging and clinical evaluation. One hundred and five (105) metastatic lesions and 83 benign lesions including hemangiomas (37), cysts (42), adenomas (2) and focal nodular hyperplasias (2) were evaluated. ADC values were calculated for each lesion utilizing two b values (0 and 600 sec/mm2).
Results
The average ADC value for cysts was 2.4×10−3 mm2/sec (CI: 2.1–2.6), for solid benign lesions was 1.4×10−3 mm2/sec (CI: 1.1–1.7) and for metastases was 1.0×10−3 mm2/sec (CI: 0.8–1.3). There was a difference between the ADC values of metastases and benign solid lesions (p<0.0001). With the ADC value of 1.5×10−3 mm2/sec as a cut off it is possible to distinguish metastatic from benign liver lesions, including cysts, with an accuracy of 78%. But to distinguish metastatic from benign solid liver lesions the best ADC cut off value was 1.2×10−3 mm2/sec and the accuracy drops to 71%.
Conclusions
ADC values proved to be helpful in the distinction between metastasis and benign solid hepatic lesions. But the exclusion of cysts in the analysis point out to a lower cut off value and lower accuracy than previously reported.
doi:10.1371/journal.pone.0101944
PMCID: PMC4099077  PMID: 25025151
5.  Functional imaging with diffusion-weighted MRI for lung biopsy planning: initial experience 
Background
The purpose of this study was to evaluate the usefulness of diffusion-weighted magnetic resonance imaging (DW-MRI) and positron emission tomography/computed tomography (PET/CT) in planning transthoracic CT-guided biopsies of lung lesions.
Methods
Thirteen patients with lung lesions suspicious for malignancy underwent CT-guided biopsy. Chest DW-MRI and apparent diffusion coefficient (ADC) calculation were performed to aid biopsy planning with fused images. MRI was indicated due to large heterogeneous masses, association with lung atelectasis/consolidation/necrosis, and/or divergent results of other biopsy type and histopathology versus clinical/radiological suspicion. Eight patients underwent PET/CT to identify appropriate areas for biopsy.
Results
Mean patient (n = 9 males) age was 59 (range, 30 to 78) years. Based on DW-MRI results, biopsies targeted the most suspicious areas within lesions. All biopsied areas showed higher DW signal intensity and lower ADCs (mean, 0.79 (range, 0.54 to 1.2) × 10−3 mm2/s), suggesting high cellularity. In patients who underwent PET/CT, areas with higher 18-fluorodeoxyglucose concentrations (standard uptake value mean, 7.7 (range, 3.6 to 13.7)) corresponded to areas of higher DW signal intensity and lower ADCs. All biopsies yielded adequate material for histopathological diagnosis.
Conclusions
Functional imaging is useful for lung biopsy planning. DW-MRI and PET/CT increase overall performance and enable the collection of adequate material for specific diagnosis.
doi:10.1186/1477-7819-12-203
PMCID: PMC4101714  PMID: 25012544
Functional imaging; MRI-guided biopsy; DWI; Transthoracic biopsy; Lung lesion; PET/CT-guided biopsy
8.  Lung in Dengue: Computed Tomography Findings 
PLoS ONE  2014;9(5):e96313.
Background
Dengue is the most important mosquito-borne viral disease in the world. Dengue virus infection may be asymptomatic or lead to undifferentiated fever, dengue fever with or without warning signs, or severe dengue. Lower respiratory symptoms are unusual and lung-imaging data in patients with dengue are scarce.
Methodology/Principal Findings
To evaluate lung changes associated with dengue infection, we retrospectively analyzed 2,020 confirmed cases of dengue. Twenty-nine of these patients (11 females and 18 males aged 16–90 years) underwent chest computed tomography (CT), which yielded abnormal findings in 17 patients: 16 patients had pleural effusion (the sole finding in six patients) and 11 patients had pulmonary abnormalities. Lung parenchyma involvement ranged from subtle to moderate unilateral and bilateral abnormalities. The most common finding was ground-glass opacity in eight patients, followed by consolidation in six patients. Less common findings were airspace nodules (two patients), interlobular septal thickening (two patients), and peribronchovascular interstitial thickening (one patient). Lung histopathological findings in four fatal cases showed thickening of the alveolar septa, hemorrhage, and interstitial edema.
Conclusions/Significance
In this largest series involving the use of chest CT to evaluate lung involvement in patients with dengue, CT findings of lower respiratory tract involvement were uncommon. When abnormalities were present, pleural effusion was the most frequent finding and lung involvement was often mild or moderate and bilateral. Extensive lung abnormalities are infrequent even in severe disease and when present should lead physicians to consider other diagnostic possibilities.
doi:10.1371/journal.pone.0096313
PMCID: PMC4023925  PMID: 24836605
9.  CT-guided biopsy of lung lesions: defining the best needle option for a specific diagnosis 
Clinics  2014;69(5):335-340.
OBJECTIVES:
To evaluate the performance of fine and cutting needles in computed tomography guided-biopsy of lung lesions suspicious for malignancy and to determine which technique is the best option for a specific diagnosis.
METHODS:
This retrospective study reviewed the data from 362 (71.6%) patients who underwent fine-needle aspiration biopsy and from 97 (19.7%) patients who underwent cutting-needle biopsy between January 2006 and December 2011. The data concerning demographic and lesion characteristics, procedures, biopsy sample adequacy, specific diagnoses, and complications were collected. The success and complication rates of both biopsy techniques were calculated.
RESULTS:
Cutting-needle biopsy yielded significantly higher percentages of adequate biopsy samples and specific diagnoses than did fine-needle aspiration biopsy (p<0.05). The sensitivity, specificity, and accuracy of cutting-needle biopsy were 93.8%, 97.3%, and 95.2%, respectively; those of fine-needle aspiration biopsy were 82.6%, 81.3%, and 81.8%, respectively (all p<0.05). The incidence of pneumothorax was higher for fine-needle aspiration biopsy, and that of hematoma was higher for cutting-needle biopsy (both p<0.05).
CONCLUSIONS:
Our experience using these two techniques for computed tomography-guided percutaneous biopsy showed that cutting-needle biopsy yielded better results than did fine-needle aspiration biopsy and that there was no significant increase in complication rates to indicate the best option for specific diagnoses.
doi:10.6061/clinics/2014(05)07
PMCID: PMC4012240  PMID: 24838899
Computed Tomography-Guided Biopsy; Lung Lesion; Neoplasm; Diagnosis; Malignancy; Tomography
10.  Imaging acute complications in cancer patients: what should be evaluated in the emergency setting? 
Cancer Imaging  2014;14(1):18.
Increased incidence world-wide of cancer and increased survival has also resulted in physicians seeing more complications in patients with cancer. In many cases, complications are the first manifestations of the disease. They may be insidious and develop over a period of months, or acute and manifest within minutes to days. Imaging examinations play an essential role in evaluating cancer and its complications. Plain radiography and ultrasonography (US) are generally performed initially in an urgent situation due to their wide availability, low cost, and minimal or no radiation exposure. However, depending on a patient’s symptoms, evaluation with cross-sectional imaging methods such as computed tomography (CT) and magnetic resonance imaging (MRI) is often necessary. In this review article, we discuss some of the most important acute noninfectious oncological complications for which imaging methods play an essential role in diagnosis.
doi:10.1186/1470-7330-14-18
PMCID: PMC4331823  PMID: 25609051
13.  Barium swallow study in routine clinical practice: a prospective study in patients with chronic cough*,** 
OBJECTIVE:
To assess the routine use of barium swallow study in patients with chronic cough.
METHODS:
Between October of 2011 and March of 2012, 95 consecutive patients submitted to chest X-ray due to chronic cough (duration > 8 weeks) were included in the study. For study purposes, additional images were obtained immediately after the oral administration of 5 mL of a 5% barium sulfate suspension. Two radiologists systematically evaluated all of the images in order to identify any pathological changes. Fisher's exact test and the chi-square test for categorical data were used in the comparisons.
RESULTS:
The images taken immediately after barium swallow revealed significant pathological conditions that were potentially related to chronic cough in 12 (12.6%) of the 95 patients. These conditions, which included diaphragmatic hiatal hernia, esophageal neoplasm, achalasia, esophageal diverticulum, and abnormal esophageal dilatation, were not detected on the images taken without contrast. After appropriate treatment, the symptoms disappeared in 11 (91.6%) of the patients, whereas the treatment was ineffective in 1 (8.4%). We observed no complications related to barium swallow, such as contrast aspiration.
CONCLUSIONS:
Barium swallow improved the detection of significant radiographic findings related to chronic cough in 11.5% of patients. These initial findings suggest that the routine use of barium swallow can significantly increase the sensitivity of chest X-rays in the detection of chronic cough-related etiologies.
doi:10.1590/S1806-37132013000600007
PMCID: PMC4075900  PMID: 24473762
Barium sulfate; Cough; Contrast media; Radiography, thoracic
14.  CT densitovolumetry in children with obliterative bronchiolitis: correlation with clinical scores and pulmonary function test results*,** 
OBJECTIVE:
To determine whether air trapping (expressed as the percentage of air trapping relative to total lung volume [AT%]) correlates with clinical and functional parameters in children with obliterative bronchiolitis (OB).
METHODS:
CT scans of 19 children with OB were post-processed for AT% quantification with the use of a fixed threshold of −950 HU (AT%950) and of thresholds selected with the aid of density masks (AT%DM). Patients were divided into three groups by AT% severity. We examined AT% correlations with oxygen saturation (SO2) at rest, six-minute walk distance (6MWD), minimum SO2 during the six-minute walk test (6MWT_SO2), FVC, FEV1, FEV1/FVC, and clinical parameters.
RESULTS:
The 6MWD was longer in the patients with larger normal lung volumes (r = 0.53). We found that AT%950 showed significant correlations (before and after the exclusion of outliers, respectively) with the clinical score (r = 0.72; 0.80), FVC (r = 0.24; 0.59), FEV1 (r = −0.58; −0.67), and FEV1/FVC (r = −0.53; r = −0.62), as did AT%DM with the clinical score (r = 0.58; r = 0.63), SO2 at rest (r = −0.40; r = −0.61), 6MWT_SO2 (r = −0.24; r = −0.55), FVC (r = −0.44; r = −0.80), FEV1 (r = −0.65; r = −0.71), and FEV1/FVC (r = −0.41; r = −0.52).
CONCLUSIONS:
Our results show that AT% correlates significantly with clinical scores and pulmonary function test results in children with OB.
doi:10.1590/S1806-37132013000600009
PMCID: PMC4075902  PMID: 24473764
Multidetector computed tomography; Respiratory function tests; Bronchiolitis obliterans
17.  Right and left ventricular function and myocardial scarring in adult patients with sickle cell disease: a comprehensive magnetic resonance assessment of hepatic and myocardial iron overload 
Background
Patients with Sickle cell disease (SCD) who receive regular transfusions are at risk for developing cardiac toxicity from iron overload. The aim of this study was to assess right and left cardiac volumes and function, late gadolinium enhancement (LGE) and iron deposits in patients with SCD using CMR, correlating these values with transfusion burden, ferritin and hemoglobin levels.
Methods
Thirty patients with SCD older than 20 years of age were studied in a 1.5 T scanner and compared to age- and sex-matched normal controls. Patients underwent analysis of biventricular volumes and function, LGE and T2* assessment of the liver and heart.
Results
When compared to controls, patients with SCD presented higher left ventricular (LV) volumes with decreased ejection fraction (EF) with an increase in stroke volume (SV) and LV hypertrophy. The right ventricle (RV) also presented with a decreased EF and hypertrophy, with an increased end-systolic volume. Although twenty-six patients had increased liver iron concentrations (median liver iron concentration value was 11.83 ± 9.66 mg/g), only one patient demonstrated an abnormal heart T2* < 20 msec. Only four patients (13%) LGE, with only one patient with an ischemic pattern.
Conclusions
Abnormal heart iron levels and myocardial scars are not a common finding in SCD despite increased liver iron overload. The significantly different ventricular function seen in SCD compared to normal suggests the changes in RV and LV function may not be due to the anemia alone. Future studies are necessary to confirm this association.
doi:10.1186/1532-429X-15-83
PMCID: PMC3848779  PMID: 24050721
18.  Diagnostic criteria and follow-up in neuroendocrine cell hyperplasia of infancy: a case series*  
OBJECTIVE:
Neuroendocrine cell hyperplasia of infancy (NEHI) is a form of childhood interstitial lung disease characterized by tachypnea, retractions, crackles, and hypoxia. The aim of this study was to report and discuss the clinical, imaging, and histopathological findings in a series of NEHI cases at a tertiary pediatric hospital, with an emphasis on diagnostic criteria and clinical outcomes.
METHODS:
Between 2003 and 2011, 12 full-term infants were diagnosed with NEHI, based on clinical and tomographic findings. Those infants were followed for 1-91 months. Four infants were biopsied, and the histopathological specimens were stained with bombesin antibody.
RESULTS:
In this case series, symptoms appeared at birth in 6 infants and by 3 months of age in the remaining 6. In all of the cases, NEHI was associated with acute respiratory infection. The most common initial chest HRCT findings were ground-glass opacities that were in the middle lobe/lingula in 12 patients and in other medullary areas in 10. Air trapping was the second most common finding, being observed in 7 patients. Follow-up HRCT scans (performed in 10 patients) revealed normal results in 1 patient and improvement in 9. The biopsy findings were nonspecific, and the staining was positive for bombesin in all samples. Confirmation of NEHI was primarily based on clinical and tomographic findings. Symptoms improved during the follow-up period (mean, 41 months). A clinical cure was achieved in 4 patients.
CONCLUSIONS:
In this sample of patients, the diagnosis of NEHI was made on the basis of the clinical and tomographic findings, independent of the lung biopsy results. Most of the patients showed clinical improvement and persistent tomographic changes during the follow-up period, regardless of the initial severity of the disease or type of treatment.
doi:10.1590/S1806-37132013000500007
PMCID: PMC4075883  PMID: 24310630
Lung diseases, interstitial/diagnosis; Lung diseases, interstitial/treatment; Tomography, X-ray computed
21.  Influenza A (H1N1) pneumonia: HRCT findings*  
OBJECTIVE:
To describe aspects found on HRCT scans of the chest in patients infected with the influenza A (H1N1) virus.
METHODS:
We retrospectively analyzed the HRCT scans of 71 patients (38 females and 33 males) with H1N1 infection, confirmed through laboratory tests, between July and September of 2009. The HRCT scans were interpreted by two thoracic radiologists independently, and in case of disagreement, the decisions were made by consensus.
RESULTS:
The most common HRCT findings were ground-glass opacities (85%), consolidation (64%), or a combination of ground-glass opacities and consolidation (58%). Other findings were airspace nodules (25%), bronchial wall thickening (25%), interlobular septal thickening (21%), crazy-paving pattern (15%), perilobular pattern (3%), and air trapping (3%). The findings were frequently bilateral (89%), with a random distribution (68%). Pleural effusion, when observed, was typically minimal. No lymphadenopathy was identified.
CONCLUSIONS:
The most common findings were ground-glass opacities and consolidations, or a combination of both. Involvement was commonly bilateral with no axial or craniocaudal predominance in the distribution. Although the major tomographic findings in H1N1 infection are nonspecific, it is important to recognize such findings in order to include infection with the H1N1 virus in the differential diagnosis of respiratory symptoms.
doi:10.1590/S1806-37132013000300009
PMCID: PMC4075839  PMID: 23857688
Pneumonia, viral; Tomography, X-ray computed; Influenza A virus, H1N1 subtype
22.  Lung cysts in chronic paracoccidioidomycosis*  
On HRCT scans, lung cysts are characterized by rounded areas of low attenuation in the lung parenchyma and a well-defined interface with the normal adjacent lung. The most common cystic lung diseases are lymphangioleiomyomatosis, Langerhans cell histiocytosis, and lymphocytic interstitial pneumonia. In a retrospective analysis of the HRCT findings in 50 patients diagnosed with chronic paracoccidioidomycosis, we found lung cysts in 5 cases (10%), indicating that patients with paracoccidioidomycosis can present with lung cysts on HRCT scans. Therefore, paracoccidioidomycosis should be included in the differential diagnosis of cystic lung diseases.
doi:10.1590/S1806-37132013000300015
PMCID: PMC4075841  PMID: 23857700
Paracoccidioidomycosis; Cysts; Multidetector computed tomography

Results 1-25 (60)