Can you diagnose this case of a 27-year-old female who presented 1-week post-partum with an incidental finding of intrathoracic masses and probable hilar lymphadenopathy? https://bit.ly/3S3ejVK.

Methods: We evaluated a deep learning algorithm (DL), for classifying HRCT based on ATS/ERS/JRS/ALAT IPF guideline criteria (SOFIA), among an international group of radiologists and pulmonologists. Participants evaluated HRCTs from 203 suspected IPF patients, assigning a likelihood score for each of the guideline-based HRCT categories (each 0-100%, summing to 100%). SOFIA scores were then provided, and participants were given the opportunity to revise their scores. Agreement on (weighted kappa) and prognostic accuracy (Cox regression and C-index) of 1) UIP scores, 2) guideline-based diagnosis and 3) INBUILD categorisation (UIP/probable UIP vs indeterminate/alternative diagnosis – i.e., trial screening mode) were evaluated. Results: 116 participants completed the study, including 20 ILD trained radiologists. The majority opinion of ILD radiologists on each HRCT was used as a diagnostic reference standard. SOFIA improved agreement for UIP probability scores among all participants, excluding the ILD radiologists, (0.67 [IQR 0.57-0.73] vs 0.71 [IQR, 0.65-0.76], p=2.1x10-5) and guideline-based diagnoses (0.50 [IQR 0.43-0.54] vs 0.61 [IQR, 0.56-0.66], p=2.8x10-16) and INBUILD categorisation (0.42 [IQR 0.35-0.47] vs 0.56 [IQR, 0.49-0.62], p=7.1x10-19). Prognostic accuracy for UIP probability scores (mortality) were good for radiologist scoring (n=116, C-index=0.60 [IQR 0.58-0.62]), and these improved with the addition of SOFIA (C-index=0.63 [IQR 0.61-0.65], p=3.6x10-12). Conclusion: In pulmonary fibrosis, DL support may improve accuracy of HRCT diagnoses, provide prognostic information and faciliate screening in clinical trials.

Background: ‘Tree in bud’ refers to a radiological abnormality that is not an uncommon finding on computed tomography (CT) of the chest and is thought to represent inflammation in the small non-cartilaginous airways or bronchioles. Aetiology and outcomes in adults are not well characterised.Methods: We retrospectively analysed a cohort of 99 individuals with bronchiolitis, of whom 72 had the tree in bud abnormality on CT. Demographics, co-morbidities, radiological and spirometry results and respiratory microbiology results were collected. Follow-up was at 3 months.Results: Respiratory microbiology was consistent with infective exacerbations of established airway disease, particularly bronchiectasis, as the most frequent cause. Gastro-oesophageal reflux (GORD) was a common cofactor (38%), but non-tuberculous mycobacteria infection was rare (6%). Treatment commonly included azithromycin, in combination with a proton pump inhibitor in those with GORD. Two thirds of patients had a follow-up CT at three months and 60% these demonstrated significant improvement or resolution.Discussion: Tree in bud bronchiolitis is a common inflammatory condition most frequently seen in infective exacerbations of airways disease. Acid reflux appears to be a frequent cofactor. We propose a management algorithm for individuals with this condition, encompassing investigation, treatment and follow-up. Patients should be screened for GORD. A prolonged course of a macrolide antibiotic is suggested, with therapeutic trial of high dose PPI if GORD is present. Outcome is generally favourable however.

The urachus is a fibrous tube extending from the umbilicus to the anterosuperior bladder dome that usually obliterates at week 12 of gestation, becoming the median umbilical ligament. Urachal pathology occurs when there is incomplete obliteration of this channel during foetal development, resulting in the formation of a urachal cyst, patent urachus, urachal sinus or urachal diverticulum. Patients with persistent urachal remnants may be asymptomatic or present with lower abdominal or urinary tract symptoms and can develop complications. The purpose of this review is to describe imaging features of urachal remnant pathology and potential benign and malignant complications on ultrasound, CT, positron emission tomography CT and MRI.

A 67-year-old woman was referred for respiratory assessment with a history of chronic cough. There were no other associated symptoms and spirometry was normal. The initial chest radiograph was unremarkable, and a decision was made to further investigate with high-resolution CT of the chest. A

Endobronchial metastasis from extrapulmonary malignancies are rare and include malignant melanoma. Cases that are complicated by central airway obstruction should follow a patient-centred approach, guided by patient and tumour characteristics. http://bit.ly/32baZvo.

Background and objectiveHiatal hernias (HH) are associated with gastro-oesophageal reflux and may contribute to lung disease severity. We aimed to evaluate the prevalence of HH among stable non-cystic fibrosis bronchiectasis (NCFB) patients and determine associations with disease severity.MethodsA retrospective cross-sectional cohort study of 100 consecutive NCFB patients in our institution was performed. Data were collected on baseline variables, microbiology, lung function and radiology, according to the modified Bhalla score. Disease severity was assessed using the Bronchiectasis Severity Index (BSI) and FACED severity scores.ResultsFollowing expert radiological review, 81 patients were deemed suitable for study inclusion (mean age (SD) 62.6 (12.4), females 55 (67.9%), body mass index (BMI) 26.9 (5.7)); 29 (35.8%) were HH positive (HH+). HH+ patients had a trend towards higher BMI (P=0.07), and a significantly higher proportion had reflux symptoms (HH+ 62.1% vs HH- 28.8%, P<0.01). The presence of HH+ was associated with cystic bronchiectasis (HH+ 30.1%, HH- 11.5%; P=0.03), increased number of lobes involved (HH+ 2.62 (1.54), HH- 2.17 (1.42); P=0.03), increased extent of bronchiectasis, (HH+ 6.2 (4.7), HH- 4.5 (3.1); P=0.04), decreased parenchymal attenuation (HH+ 1.0 (1.8), HH- 0.2 (0.5); P=0.03) and reduced percent predicted forced expiratory volume in 1s (HH+ 75.4% (24.5), HH- 90.4% (25.5); P=0.02). There was no lobar predilection. HH+ was associated with increased disease severity scores: BSI (HH+ 4.93 (1.65), HH- 3.25 (2.13); P<0.001) and FACED (HH+ 2.21 (1.52), HH- 1.35 (1.43); P<0.01).ConclusionsHH+ was associated with worse disease severity in NCFB patients, characterized by decreased lung function, increased extent and severity of radiological disease, and increased composite disease severity scores.This is the first study to evaluate the role of hiatal hernias in bronchiectasis. The presence of a hiatal hernia was associated with worse disease severity, characterized by decreased lung function, increased extent and severity of radiological disease, and increased composite disease severity scores.

A 52-year-old female patient with a background history of malignant melanoma was referred to the interventional pulmonology unit at Galway University Hospital for the investigation of possible intrathoracic recurrence. A CT of the thorax (CT thorax) demonstrated mediastinal lymphadenopathy at position 4R, right paratracheal region. An endobronchial ultrasound (EBUS) revealed multiple enlarged lymph nodes at station 4R. The nodes were heterogeneous with solid and cystic elements. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) obtained a black material consistent with malignant melanoma. Multiple TBNA samples were obtained and the diagnosis was confirmed pathologically by the presence of multiple epithelioid pigmented cells on cell block analysis. This case report emphasises the value of EBUS in the assessment of metastatic disease and, in particular, how the gross appearance of the sample can be suggestive of the diagnosis.

BACKGROUND:Middle-lobe predominant bronchiectasis affecting the right middle-lobe and/or lingula (RMLP) is classically described in asthenic, elderly females with skeletal abnormalities or associated nontuberculous mycobacterial (NTM) infection.OBJECTIVES:We aimed to evaluate the frequency and clinical characteristics of patients with an RMLP phenotype in a cohort of newly diagnosed bronchiectasis patients and determine associations with disease severity.METHODS:A retrospective observational cross-sectional cohort study of consecutive bronchiectasis patients in our institution was performed. Data were collected on baseline variables, microbiology status, lung function, and radiology according to the modified Bhalla score. Disease severity was assessed using bronchiectasis severity index (BSI) and FACED severity scores.RESULTS:Of 81 patients (mean age [SD] 62.6 [12.4], females 55 [67.9%], BMI 26.9 [5.7%]), 20 (24.7%) had RMLP disease. These patients were significantly younger, female, and with lower BMIs than patients with the classical bronchiectasis phenotype (p = 0.03, 0.01, and p <0.01, respectively). Fewer symptoms of cough and daily sputum (p = 0.01 and <0.01), prior exacerbation frequency (p = 0.03), and higher baseline forced expiratory volume (p = 0.04) were noted. A higher incidence of NTM at diagnosis was demonstrated (p = 0.01). BSI and FACED severity scores in RMLP patients were significantly lower than their counterparts (both p < 0.001).CONCLUSIONS:The RMLP phenotype is associated with younger patients than classically described in the literature. An increased rate of NTM infection in this phenotype was noted, particularly in females, but much lower than previously described. Lung function and disease severity scores in this patient group are relatively normal, suggesting a milder phenotype in patients with this form of the disease.

Solid pseudopapillary neoplasms (SPNs) are rare entities accounting for between 0.13 and 2.7 per cent of pancreatic tumours. This neoplasm has a predilection for females under the age of 35. The authors report this case of a SPN incidentally discovered when a 59-year-old female underwent a chest x-ray to investigate a wheeze. A subsequent CT abdomen revealed a 10 cm well-circumscribed mass adjacent to the tail of the pancreas. This mass was successfully resected. Immunohistochemical markers established the diagnosis of a SPN. The wheeze associated with the presentation of this case was unrelated to the tumour which was an incidental finding. These neoplasms are largely asymptomatic and indolent reaching a large size before detection. Diagnosis is confirmed on histology and in this case surgical resection was curative and there was no metastasis at presentation.

A 50-year-old woman presented with rapidly progressive shortness of breath. Five months earlier, she had received a diagnosis of invasive breast carcinoma, at a tumor-node-metastasis (TNM) clinical stage of T2N1M0, and had undergone mastectomy. She received four cycles of cyclophosphamide and doxorubicin, followed by one cycle of paclitaxel with prednisolone. Her fifth cycle of chemotherapy was completed 10 days before presentation. She reported no cough, fever, or chest pain.

A pleural effusion is excess fluid that collects in the pleural cavity, the fluid-filled space that surrounds the lungs. Surplus amounts of such fluid can impair breathing by limiting the expansion of the lungs during inhalation. Measuring the fluid volume is indicative of the effectiveness of any treatment but, due to the similarity to surround regions, fragments of collapsed lung present and topological changes; accurate quantification of the effusion volume is a difficult imaging problem. A novel code is presented which performs conditional region growth to accurately segment the effusion shape across a dataset. We demonstrate the applicability of our technique in the segmentation of pleural effusion and pulmonary masses.

A pleural effusion is excess fluid that collects in the pleural cavity, the fluid-filled space that surrounds the lungs. Surplus amounts of such fluid can impair breathing by limiting the expansion of the lungs during inhalation. Measuring the fluid volume is indicative of the effectiveness of any treatment but, due to the similarity to surround regions, fragments of collapsed lung present and topological changes; accurate quantification of the effusion volume is a difficult imaging problem. A novel slice-by-slice code is presented which performs conditional region growth to accurately segment the effusion shape. We demonstrate the applicability of our technique in the segmentation of pleural effusion and pulmonary masses.