Biomedical subjects
D M Hansell
Publications and source records attributed to D M Hansell.
Spontaneous regression of large-cell carcinoma of the lung--a rare observation in clinical practice.
Spontaneous regression of non-small-cell lung carcinoma is extremely rare and there are few documented cases. We report a 59-year-old man with a right upper lobe tumour which showed progressive regression while hilar adenopathy appeared 2 months after the initial tumour detection. At operation, only scar tissue was found in the lung but a hilar lymph node contained large-cell undifferentiated carcinoma. This report indicates that a decrease in size of a pulmonary mass does not exclude the diagnosis of carcinoma and that metastatic disease can occur even if the primary tumour regresses.
Visual quantitation and observer variation of signs of small airways disease at inspiratory and expiratory CT.
Areas of decreased pulmonary attenuation representing small airways disease can be identified on computed tomography (CT). The objective was to quantify differences between inspiratory and expiratory CT for the detection of signs of small airways disease by four observers. Observer variation and the superiority of a fine versus a coarse grading system were also evaluated. Inspiratory and expiratory CT scans of 106 patients with conditions characterized by small airways disease and 19 healthy individuals were assessed by four observers. The extent of decreased attenuation was scored on a fine scale to the nearest 5% and also semiquantitatively on a coarser 5-point scale. Decreased attenuation was more extensive on expiratory CT (median. 6.7%; 0-76.7%) than on inspiratory CT (median, 3.8%; 0-81.7%). The fine scoring system had unacceptable interobserver variation (coefficient of variation, 80% for inspiratory CT, 70% for expiratory CT). The semiquantitative system had acceptable interobserver agreement (inspiratory CT k(w) = 0.64; expiratory CT, k(w) = 0.69) and good intra-observer agreement (inspiratory CT, k(w) = 0.80; expiratory CT, k(w) = 0.64). The major CT sign of small airways disease is more confidently quantified on expiratory CT. A fine scoring system is associated with unacceptable observer variation, and a coarse semiquantitative system is more suitable for quantitative studies of small airways disease.
Clinical significance of respiratory bronchiolitis on open lung biopsy and its relationship to smoking related interstitial lung disease.
BACKGROUND: Respiratory bronchiolitis-associated interstitial lung disease (RBILD) is a rare form of interstitial lung disease which may present in similar fashion to other types of chronic interstitial pneumonia. The purpose of this study was to undertake a clinicopathological review of 10 patients with RBILD and to examine the clinical and imaging data related to its histopathological pattern, in particular the relationship of RBILD to smoking. METHODS: Thirteen out of 168 retrospectively reviewed patients, from whom biopsy specimens were taken for suspected diffuse lung disease, were identified with a histopathological pattern of RBILD. Three cases were rejected as follow up data were unavailable. The 10 remaining cases constituted the study group and both clinical and imaging data were collected from patients' notes and referring physicians. RESULTS: Histopathologically, four cases of RBILD overlapped with the pattern of desquamative interstitial pneumonitis (DIP) and nine also had microscopic evidence of centrilobular emphysema. Nine patients were smokers, ranging from 3 to 80 pack years. The one non-smoker had an occupational exposure to the fumes of solder flux. The sex distribution was equal with an age range of 32-65 years. Two patients were clubbed. Lung function tests showed both restrictive and obstructive patterns together with severe reductions in carbon monoxide transfer factor in seven patients. Chest radiographs showed reticular or reticulonodular infiltrates in five patients and a ground glass pattern in two. CT scans were consistent with either DIP or RBILD in six of eight patients. Although seven patients remained stable or improved, either with or without treatment, three patients deteriorated. CONCLUSIONS: This study adds weight to the hypothesis that smoking can cause clinically significant interstitial lung disease, with deterioration in pulmonary function despite treatment. Given the overlapping histopathological patterns of RBILD and DIP and their strong association with smoking, the term "smoking related interstitial lung disease" is suggested for those patients who are smokers.
Acute respiratory distress syndrome: CT abnormalities at long-term follow-up.
PURPOSE: To document abnormalities at computed tomography (CT) in adult survivors of acute respiratory distress syndrome (ARDS), to determine the relationships between CT patients during the acute phase and at follow-up, and to assess the effects of mechanical ventilation on the development of CT abnormalities. MATERIALS AND METHODS: Thin-section CT scans were obtained during the acute illness and at follow-up in 27 patients with ARDS. The extent and distribution of individual CT patterns were independently analyzed. RESULTS: At follow-up CT, a reticular pattern was the most prevalent (23 patients [85%]) and extensive CT abnormality, with a striking anterior distribution (more anterior distribution than posterior distribution, P < .001). A reticular pattern at follow-up was inversely correlated with the extent of intense parenchymal opacification on scans obtained during the acute illness (Spearman r = -0.26; P < .001). The extent of a reticular pattern at follow-up CT was independently related to the total duration of mechanical ventilation (P = .02) but was most strongly related to the duration of pressure-controlled inverse-ratio ventilation (P < .001). CONCLUSION: A reticular pattern, with a striking anterior distribution, is a frequent finding of follow-up CT in ARDS survivors and is most strongly related to the duration of pressure-controlled inverse-ratio ventilation.
Follicular bronchiolitis: thin-section CT and histologic findings.
PURPOSE: To evaluate the thin-section computed tomographic (CT) findings of follicular bronchiolitis and compare them with the histologic findings. MATERIALS AND METHODS: Thin-section CT scans obtained in 12 patients (age range, 24-77 years; mean age, 47 years) with follicular bronchiolitis proved at open lung biopsy were reviewed by two observers. Underlying conditions included rheumatoid arthritis (n = 8), mixed collagen vascular disorders (n = 2), autoimmune disorder (n = 1), and acquired immunodeficiency syndrome (n = 1). All patients had thin-section CT scans (1.0-1.5-mm collimation, 11 patients; 3.0-mm collimation, one patient; high-spatial-frequency reconstruction algorithm) obtained at 10-mm intervals through the chest. RESULTS: The main CT findings included bilateral centrilobular (n = 12) and peribronchial (n = 5) nodules. All 12 patients had nodules smaller than 3 mm in diameter; six patients also had nodules 3-12 mm in diameter. Areas of ground-glass opacity were present in nine (75%) patients. Histologically, all patients had lymphoid hyperplasia along the bronchioles; eight had peribronchiolar lymphocytic infiltration. CONCLUSION: The cardinal CT feature of follicular bronchiolitis consists of small centrilobular nodules variably associated with peribronchial nodules and areas of ground-glass opacity.
Mechanism of mosaic attenuation of the lungs on computed tomography in induced bronchospasm.
The purpose of this study was to investigate whether hypoxic pulmonary vasoconstriction is the major determinant of the computed tomography (CT) pattern of mosaic attenuation in asthmatic patients with induced bronchoconstriction. Thin-section CT was performed at suspended full inspiration immediately and 30 min after methacholine bronchoprovocation in 22 asthmatic subjects, who were randomly assigned to breathe room air (group A, n = 8), oxygen via nasal prongs at 5 l/min (group B, n = 8), and oxygen via face mask at 12 l/min (group C, n = 6). CT changes were quantified in terms of global lung density and density in hypodense and hyperdense areas. Lung parenchymal density increases were greatest in group C and greater in group B than in group A, globally (P = 0.03) and in hypodense regions (P = 0.01). On bivariate analysis, the only change in cross-sectional area was related to change in global density. In hypodense regions, density change was related both to reduction in cross-sectional area (P < 0.0005) and to oxygen administration (P = 0.01). After correction for changes in global lung density, only oxygen was independently related to density increase in hypodense areas (P = 0.02). In induced bronchoconstriction, the CT appearance of mosaic attenuation can be largely ascribed to hypoxic vasoconstriction rather than to changes in lung inflation.
A histologic pattern of nonspecific interstitial pneumonia is associated with a better prognosis than usual interstitial pneumonia in patients with cryptogenic fibrosing alveolitis.
This study aimed to investigate whether there was a difference in outcome related to histologic pattern in cryptogenic fibrosing alveolitis (CFA) and to see whether there were correlations between clinical and radiologic findings and histology. One hundred thirteen lung biopsies from consecutive patients taken for the diagnosis of diffuse lung disease were reviewed and reclassified using the Katzenstein and Myers criteria for interstitial pneumonias. Patients lacking full investigational data at presentation and those with conditions predisposing to lung fibrosis were excluded, leaving 15 patients diagnosed with nonspecific interstitial pneumonia (NSIP) and 15 with usual interstitial pneumonia (UIP). Clinical and radiologic findings at presentation and serial lung function information and survival status in November 1998 were compared for the two groups. Survival was found to be significantly greater in the NSIP group compared with the UIP group (p < 0.001). This could not be explained by differences in treatment. Patients with UIP showed a progressive deterioration in lung function whereas those with NSIP remained stable. CT scans of patients with UIP showed more fibrosis than those of patients with NSIP (p < 0.011). A histologic diagnosis of NSIP is associated with a better prognosis than UIP. This subclassification of CFA is clinically useful.
Imaging of patients with severe emphysema considered for lung volume reduction surgery.
Lung volume reduction surgery has recently been reintroduced as a palliative treatment for patients with severe emphysema. Selection criteria vary between centres and imaging is extensively used, but the exact role of individual techniques in the selection process is still emerging.
Pericardial thickening or effusion in patients with pulmonary artery hypertension: a CT study.
OBJECTIVE: The aim of the study was to determine the prevalence of pericardial thickening or effusion revealed by CT in patients with pulmonary artery hypertension. MATERIALS AND METHODS: Forty-five patients underwent pulmonary artery catheterization and CT of the thorax. On CT, we measured the maximum pericardial thickness, total pericardial score (the sum of four measures of pericardial thickness), and thickness of the anterior pericardial recess. Patients were grouped according to mean pulmonary artery pressure: group 1, less than 21 mm Hg (n = 15); group 2, 21-35 mm Hg (n = 15); and group 3, greater than 35 mm Hg (n = 15). RESULTS: The prevalence of an increased pericardial score and increased maximum pericardial thickening was higher in group 3 than in group 1 or group 2 (p = .02 and < .001, respectively). Anterior pericardial recess thickening was markedly increased in group 3 (p < .0001). For all patients, significant correlations (Spearman's rank correlation coefficient = .44-.56, p < .005-.0001) were found between mean pulmonary artery pressure and all pericardial measures. CONCLUSION: On CT, pericardial thickening or effusion is a frequent finding in patients with severe pulmonary hypertension.
Accuracy of CT in the diagnosis of allergic bronchopulmonary aspergillosis in asthmatic patients.
OBJECTIVE: The purpose of this study was to assess the accuracy of high-resolution CT in the diagnosis of allergic bronchopulmonary aspergillosis in asthmatic patients. MATERIALS AND METHODS: The high-resolution CT scans of 44 asthmatic patients with allergic bronchopulmonary aspergillosis and 38 asthmatic patients without allergic bronchopulmonary aspergillosis were analyzed retrospectively and randomly by two independent observers for these features: bronchial wall thickening, bronchiectasis, centrilobular nodules, mucoid impaction, mosaic perfusion, atelectasis, and consolidation. Each observer made a final diagnosis with a stated degree of confidence. The results are expressed as the average number of observations by the two observers. RESULTS: Findings seen more commonly in patients with allergic bronchopulmonary aspergillosis than in patients with asthma alone included bronchiectasis, centrilobular nodules, and mucoid impaction (p < .01, chi-square test). Bronchiectasis was present in 42 (95%) of 44 patients with allergic bronchopulmonary aspergillosis, centrilobular nodules in 41 (93%), and mucoid impaction in 29.5 (67%) (average of two observers). In the asthmatic control group, bronchiectasis was detected in 11 (29%) of 38 patients, centrilobular nodules in 10.5 (28%), and mucoid impaction in 4%. Bronchiectasis was seen in 184 (70%) of 264 lobes of patients with allergic bronchopulmonary aspergillosis compared with 19.5 (9%) of 228 lobes in asthmatic controls (p < .001, chi-square test). CONCLUSION: In asthmatic patients, bronchiectasis affecting three or more lobes, centrilobular nodules, and mucoid impaction are findings on high-resolution CT that are highly suggestive of allergic bronchopulmonary aspergillosis.
Imaging pulmonary embolism. A new look with spiral computed tomography.
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The significance of bronchial dilatation on CT in patients with adult respiratory distress syndrome.
AIMS: Irreversible bronchial dilatation on computed tomography (CT) is seen in patients with interstitial pulmonary fibrosis whereas reversible dilatation of the bronchi is a feature of many conditions. The aim of this study was to determine whether airways dilatation, which is a frequent finding in adult respiratory distress syndrome (ARDS), is reversible and to establish whether persistent airways dilatation is accompanied by other CT signs of established interstitial fibrosis. METHOD: Thin section CT scans of 16 patients with ARDS were analysed at a lobar level in the acute phase of the disease and at follow-up (median interval 6.3 months) for the presence and extent of a ground-glass pattern, reticular or linear opacities and the presence or absence of bronchial dilatation. RESULTS: 95 out of 96 (99%) lobes on the initial CT scan showed ground-glass pattern. Airway dilatation was present in 65 of 95 (68%) of these lobes. On follow-up CT the airways remained dilated in 60 of 65 (92%) lobes and, in the majority of these, 53 of 60 (88%), a reticular and linear pattern with associated distortion had developed. A coexisting ground-glass pattern was present in 12 of 60 (20%) lobes on follow-up CT, but was the sole residual abnormality in only one lobe. CONCLUSION: In patients with ARDS, dilatation of the airways within areas of ground-glass pattern is a frequent observation in the acute phase of the condition and tends to persist at follow-up, usually accompanied by the CT features of supervening pulmonary fibrosis.
Lymphocytic disorders of the chest: pathology and imaging.
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Imaging the 'dirty lung'--has high resolution computed tomography cleared the smoke?
The histopathological abnormalities that characterize cigarette smokers' lung damage have been widely studied, but these microscopic changes do not fully explain the radiographic features that have been loosely termed the 'dirty lung'. High resolution computed tomography is not only more sensitive for the detection of early emphysema, it has also provided the imaging correlates of subtle parenchymal changes of smokers, for example, respiratory bronchiolitis - interstitial lung disease. Nevertheless, some aspects of the radiographic 'dirty lung' remain enigmatic.
Bronchiectasis.
Imaging has a key role in the identification of bronchiectasis. Over the years, imaging tests have become increasingly accurate in depicting the features of early bronchiectasis. This article covers the clinical, pathologic, and functional features of bronchiectasis; high-resolution CT scan technique; the signs of bronchiectasis on chest radiography and high-resolution CT scan; and the causes of misdiagnosis of bronchiectasis.
Pulmonary sarcoidosis: morphologic associations of airflow obstruction at thin-section CT.
PURPOSE: To identify relationships between the obstructive defects of pulmonary sarcoidosis and the computed tomographic (CT) patterns of disease. MATERIAL AND METHODS: CT scans obtained in 45 patients were scored semiquantitatively for extent of five CT patterns, and the functional importance of each pattern was evaluated. RESULTS: The most prevalent CT patterns were decreased attenuation (n = 40), a reticular pattern (n = 37), and a nodular pattern (n = 36). At univariate and multivariate analyses, a reticular pattern was the main determinant of functional impairment, particularly airflow obstruction. The extent of a reticular pattern was independently associated with airflow obstruction, as shown by the inverse relationships with the forced expiratory volume in 1 second (FEV1) (P < .001), FEV1-forced vital capacity ratio (P < .01), maximum expiratory flow at 25% above residual volume (P < .001), and maximum expiratory flow at 50% above residual volume (P < .001) and the positive relationship with the residual volume-total lung capacity ratio (P < .001). CONCLUSION: In sarcoidosis, CT features compatible with small airways disease are common but contribute little to airflow obstruction, particularly in more advanced disease, which is characterized by an extensive reticular pattern. A reticular pattern at CT is the major morphologic association of airflow obstruction.
Bronchoalveolar lavage cellularity: lone cryptogenic fibrosing alveolitis compared with the fibrosing alveolitis of systemic sclerosis.
Lone cryptogenic fibrosing alveolitis (CFA) is histologically identical to fibrosing alveolitis associated with systemic sclerosis (FASSc), but it has a much worse prognosis after matching for disease severity at presentation. The aims of this study were to gain insights into possible pathogenetic mechanisms contributing to this prognostic difference, by comparing bronchoalveolar lavage (BAL) cellularity in the two diseases, and to evaluate the relationships between BAL findings and the regional and global extent of disease, quantified by thin-section computed tomography (CT) and lung function indices. Patients with CFA were distinguished by more extensive fibrosing alveolitis on CT (p < 0.02) and by higher counts of neutrophils (total per ml, p < 0.02; percentage p < 0.03) and eosinophils (total per ml, p < 0.002; percentages, p < 0.02) in BAL fluid. After adjustment for functional and morphologic measures of disease extent, eosinophil percentages and total counts were increased in CFA (p < 0.05 in all 12 multivariate models), but they were not independently related to regional or global disease severity. Neutrophil percentages and total counts were virtually identical in CFA and FASSc in disease of comparable severity, and they increased with increasingly extensive lobar disease and global disease, as judged by CT, p < 0.0005 in all analyses. Neutrophil levels were more closely linked to the extent of disease on CT than to the severity of functional impairment, on univariate and multivariate analysis. The higher BAL eosinophil levels seen in CFA, compared with those seen in FASSc, after adjustment for disease extent, indicate that an eosinophilic influx may be linked to the pathogenesis of fibrosing alveolitis. By contrast, BAL neutrophil levels increase with increasingly extensive disease on CT, but they do not differ independently between CFA and FASSc, suggesting that neutrophil degradation products are unlikely to account for the excess mortality in CFA, compared with that in FASSc.