How the innate and adaptive host immune system miscommunicate to worsen COVID-19 immunopathology has not been fully elucidated. Here, we perform single-cell deep-immune profiling of bronchoalveolar ...lavage (BAL) samples from 5 patients with mild and 26 with critical COVID-19 in comparison to BALs from non-COVID-19 pneumonia and normal lung. We use pseudotime inference to build T-cell and monocyte-to-macrophage trajectories and model gene expression changes along them. In mild COVID-19, CD8
resident-memory (T
) and CD4
T-helper-17 (T
) cells undergo active (presumably antigen-driven) expansion towards the end of the trajectory, and are characterized by good effector functions, while in critical COVID-19 they remain more naïve. Vice versa, CD4
T-cells with T-helper-1 characteristics (T
-like) and CD8
T-cells expressing exhaustion markers (T
-like) are enriched halfway their trajectories in mild COVID-19, where they also exhibit good effector functions, while in critical COVID-19 they show evidence of inflammation-associated stress at the end of their trajectories. Monocyte-to-macrophage trajectories show that chronic hyperinflammatory monocytes are enriched in critical COVID-19, while alveolar macrophages, otherwise characterized by anti-inflammatory and antigen-presenting characteristics, are depleted. In critical COVID-19, monocytes contribute to an ATP-purinergic signaling-inflammasome footprint that could enable COVID-19 associated fibrosis and worsen disease-severity. Finally, viral RNA-tracking reveals infected lung epithelial cells, and a significant proportion of neutrophils and macrophages that are involved in viral clearance.
Radial endobronchial ultrasonography miniprobe (rEBUS-MP) is a technique that has increased the diagnostic yield of bronchoscopic occult pulmonary lesions. The purpose of this study was to identify ...computed tomography (CT) characteristics affecting the success rate of rEBUS-MP in the evaluation of these pulmonary lesions.
Our study encompassed a retrospective review of all consecutive patients who underwent a rEBUS-MP examination between January 2011 and December 2013. CT characteristics including lesion size, lesion location, and bronchus sign were analyzed against two defined outcomes (visualization yield and diagnostic yield). Univariate analysis was employed to examine the individual effects of each CT parameter on visualization yield and diagnostic yield. Multivariate logistic regression was performed to identify significant predictors of diagnostic yield.
Seven hundred and sixty lesions (760 patients) were included. The mean ± SD longest lesion diameter was 43 ± 2 mm. rEBUS-MP could visualize 83% and a definitive diagnosis was established in 62%. In a multivariate analysis, longest lesion diameter greater than 20 mm (odds ratio OR: 1.97 and p = 0.036), distance lesion to secondary or tertiary carina greater than 40 mm (OR: 0.60 and p=0.016), and lobar segment (1, 3, or 6, respectively) were determined to be significant factors predicting diagnostic yield. Bronchus sign was the only parameter that indirectly influenced the diagnostic yield through enhancing visualization yield (p < 0.001).
Multivariate analysis revealed that lesion size, distance to carina, and segment were predictors of diagnostic yield. The presence of a bronchus sign substantially increased the diagnostic yield through the visualization yield.
Background
Although most guidelines suggest performing a positron emission tomography/computed tomography (PET/CT) with somatostatin receptor (SSTR) ligands for staging of pulmonary carcinoid tumours ...(PC), only a limited number of studies have evaluated the role of this imaging tool in this specific patient population. The preoperative differentiation between typical carcinoid (TC) and atypical carcinoid (AC) and the extent of dissemination (N/M status) are crucial factors for treatment allocation and prognosis of these patients. Therefore, we performed a pathology-based retrospective analysis of the value of SSTR PET/CT in tumour grading and detection of nodal and metastatic involvement of PC and compared this with the previous literature and with
18
FFDG PET/CT in a subgroup of patients.
Methods
SSTR PET/CT scans performed between January 2007 and May 2020 in the context of PC were included. If available,
18
FFDG PET/CT images were also evaluated. The maximum standardized uptake (SUV
max
) values of the primary tumour, of the pathologically examined hilar and mediastinal lymph node stations, as well as of the distant metastases, were recorded. Tumoural SUV
max
values were related to the tumour type (TC versus AC) for both SSTR and
18
FFDG PET/CT in diagnosing and differentiating both tumour types. Nodal SUV
max
values were compared to the pathological status (N
+
versus N
−
) to evaluate the diagnostic accuracy of SSTR PET/CT in detecting lymph node involvement. Finally, a mixed model analysis of all pathologically proven distant metastatic lesions was performed.
Results
A total of 86 SSTR PET/CT scans performed in 86 patients with PC were retrospectively analysed.
18
FFDG PET/CT was available in 46 patients. Analysis of the SUV
max
values in the primary tumour showed significantly higher SSTR uptake in TC compared with AC (median SUV
max
18.4 vs 3.8;
p
= 0.003) and significantly higher
18
FFDG uptake in AC compared to TC (median SUV
max
5.4 vs 3.5;
p
= 0.038). Receiver operating characteristic (ROC) curve analysis resulted in an area under the curve (AUC) of 0.78 for the detection of TC on SSTR PET/CT and of 0.73 for the detection of AC on
18
FFDG PET/CT. A total of 267 pathologically evaluated hilar and mediastinal lymph node stations were analysed. ROC analysis of paired SSTR/
18
FFDG SUV
max
values for the detection of metastasis of TC in 83 lymph node stations revealed an AUC of 0.91 for SSTR PET/CT and of 0.74 for
18
FFDG PET/CT (difference 0.17; 95% confidence interval − 0.03 to 0.38;
p
= 0.10). In a sub-cohort of 10 patients with 12 distant lesions that were pathologically examined due to a suspicious aspect on SSTR PET/CT, a positive predictive value (PPV) of 100% was observed.
Conclusion
Our findings confirm the higher SSTR ligand uptake in TC compared to AC and vice versa for
18
FFDG uptake. More importantly, we found a good diagnostic performance of SSTR PET/CT for the detection of hilar and mediastinal lymph node metastases of TC. Finally, a PPV of 100% for SSTR PET/CT was found in a small sub-cohort of patients with pathologically investigated distant metastatic lesions. Taken together, SSTR PET/CT has a very high diagnostic value in the TNM assessment of pulmonary carcinoids, particularly in TC, which underscores its position in European guidelines.
The Clinical Techniques, Imaging and Endoscopy Assembly is involved in the diagnosis and treatment of several pulmonary diseases, as demonstrated at the 2023 European Respiratory Society (ERS) ...International Congress in Milan, Italy. From interventional pulmonology, the congress included several exciting results for the use of bronchoscopy in lung cancer, including augmented fluoroscopy, robotic-assisted bronchoscopy and cryobiopsies. In obstructive lung disease, the latest results on bronchoscopic treatment of emphysema with hyperinflation and chronic bronchitis were presented. Research on using cryobiopsies to diagnose interstitial lung disease was further explored, with the aims of elevating diagnostic yield and minimising risk. For imaging, the latest updates in using artificial intelligence to overcome the increased workload of radiologists were of great interest. Novel imaging in sarcoidosis explored the use of magnetic resonance imaging, photon-counting computed tomography and positron emission tomography/computed tomography in the diagnostic work-up. Lung cancer screening is still a hot topic and new results were presented regarding incorporation of biomarkers, identifying knowledge gaps and improving screening programmes. The use of ultrasound in respiratory medicine is an expanding field, which was demonstrated by the large variety in studies presented at the 2023 ERS Congress. Ultrasound of the diaphragm in patients with amyotrophic lateral sclerosis and myasthenia gravis was used to assess movements and predict respiratory fatigue. Furthermore, studies using ultrasound to diagnose or monitor pulmonary disease were presented. The congress also included studies regarding the training and assessment of competencies as an important part of implementing ultrasound in clinical practice.
Pulmonary embolism (PE) is a pathological entity characterised by venous thromboembolism in the pulmonary arteries. It is a common entity in daily clinical practice and is the third most common cause ...of cardiovascular death. Correct diagnostic work-up is pivotal to ensure timely institution of appropriate therapy. This requires recognition of the characteristic imaging findings and awareness of the role and peculiarities of the different imaging techniques involved in the diagnostic and therapeutic process. This review aims to showcase the most commonly encountered imaging findings associated with pulmonary thromboembolism for each imaging modality, outline their advantages and disadvantages, and define the specific role of these techniques in the clinical setting. The latest innovations concerning the diagnostic work-up of PE will be also briefly discussed, yielding a perspective on the future developments and challenges that the radiologist will have to face in the coming years.
Assembly 14 (clinical techniques, imaging and endoscopy) is the youngest assembly of the European Respiratory Society (ERS). Because the increasing role of interventional pulmonology in diagnosis and ...treatment, and the role of imaging as key element in the diagnosis of many diseases, these two groups were growing, and the moment came that they became a new assembly. Assembly 14 accommodates the following groups.
Meet @EuroRespSoc Assembly 14: clinical techniques, imaging and endoscopy
http://bit.ly/2oAf65R
Fast diagnosis of Coronavirus Disease 2019 (COVID-19), and the detection of high-risk patients are crucial but challenging in the pandemic outbreak. The aim of this study was to evaluate if deep ...learning-based software correlates well with the generally accepted visual-based scoring for quantification of the lung injury to help radiologist in triage and monitoring of COVID-19 patients.
In this retrospective study, the lobar analysis of lung opacities (% opacities) by means of a prototype deep learning artificial intelligence (AI)-based software was compared to visual scoring. The visual scoring system used five categories (0: 0%, 1: 0-5%, 2: 5-25%, 3: 25-50%, 4: 50-75% and 5: >75% involvement). The total visual lung injury was obtained by the sum of the estimated grade of involvement of each lobe and divided by five.
The dataset consisted of 182 consecutive confirmed COVID-19 positive patients with a median age of 65 ± 16 years, including 110 (60%) men and 72 (40%) women. There was a correlation coefficient of 0.89 (
< 0.001) between the visual and the AI-based estimates of the severity of lung injury.
The study indicates a very good correlation between the visual scoring and AI-based estimates of lung injury in COVID-19.
To evaluate the diagnostic accuracy of the visual assessment of malignant pleural mesothelioma (MPM) on magnetic resonance (MR) images by using two known visual markers (mediastinal pleural thickness ...and shrinking of the lung) and a newly introduced one (pleural pointillism).
With the approval of the local ethics committee, 100 consecutive patients (mean age, 61.4 years; age range, 18-87 years; 75 men, 25 women) suspected of having MPM pleural abnormalities underwent positron emission tomography/computed tomography and MR imaging, including diffusion-weighted (DW) MR imaging, followed by explorative thoracoscopy or guided biopsy with histopathologic confirmation. Because visual assessment is still the preferred method of image interpretation, the diagnostic accuracy of mediastinal pleural thickening, shrinking lung (hemithorax volume decrease due to fibrosis), and pleural pointillism were examined. Pleural pointillism was denoted by the presence of multiple, hyperintense pleural spots on high-b-value DW images. Histopathologic findings in the surgical specimen served as the reference standard. McNemar tests with Bonferroni correction were used to assess differences in accuracy among the three examined markers.
Of 100 patients, 33 had benign pleural alterations, and 67 had malignant pleural diseases (MPDs); 57 of 67 had MPM. A total of 78 patients received a correct diagnosis (benign vs malignant) on the basis of mediastinal pleural thickening (sensitivity, 81%; specificity, 73%; accuracy, 78%); and 66 patients, on the basis of shrinking lung (sensitivity, 60%; specificity, 79%; accuracy, 66%). The correct diagnosis was indicated on the basis of pleural pointillism in 88 patients (sensitivity, 93%; specificity, 79%; accuracy, 88%).
Visual assessment of pleural pointillism on high-b-value DW images is useful to differentiate MPD from benign alterations, performing substantially better than mediastinal pleural thickness and shrinking lung, and might obviate unnecessary invasive procedures for MPM.
Chronic lung allograft dysfunction (CLAD) is the main factor limiting long-term survival after lung transplantation. Besides bronchiolitis obliterans syndrome, a restrictive phenotype of CLAD (rCLAD) ...exists, which is associated with poor prognosis after diagnosis. However, survival determinants for rCLAD remain to be elucidated. Our aim in this study was to establish parameters predicting survival in patients with rCLAD.
All patients diagnosed with rCLAD in 2 lung transplant centers were assessed in a retrospective manner. Various clinical parameters demography, pulmonary function, bronchoalveolar lavage (BAL), histopathology, radiology and blood differentials at rCLAD diagnosis were correlated with graft survival using unadjusted and adjusted analysis.
A total of 53 patients with rCLAD were included with a median graft survival after diagnosis of 1.1 years. Univariate analysis demonstrated that lower-lobe-dominant or diffuse infiltrates on chest computed tomography, presence of an identifiable trigger before rCLAD onset, lymphocytic bronchiolitis, increased BAL neutrophilia, increased BAL eosinophilia and increased blood eosinophils were associated with inferior graft survival after rCLAD diagnosis. Multivariate analysis confirmed the association of location of infiltrates and blood eosinophilia on graft survival.
In this study we have identified parameters associated with graft survival after rCLAD diagnosis that may be useful to predict prognosis.
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