Tetsu Kanauchi

Saitama Cancer Center, Saitama, Saitama, Japan

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Publications (19)41.02 Total impact

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    ABSTRACT: To review patients with rheumatoid arthritis (RA) receiving biologic therapy following a diagnosis of nontuberculous mycobacterial (NTM) lung disease and to evaluate disease deterioration according to clinical and radiological features and anti-NTM therapy. We retrospectively analyzed medical records of 11 human immunodeficiency virus-negative patients with RA (median age, 64 years) receiving biologic therapy following diagnosis of NTM lung disease. NTM species included Mycobacterium avium complex in 9 patients (81.8%) and M. gordonae in 2 (18.2%). Underlying respiratory disease was present in 6 patients (54.5%), and most (81.8%) had radiographic features of nodular/bronchiectatic disease. Extent of NTM disease was 1-2 pulmonary lobes in 6 patients (54.5%), 3-4 lobes in 5 patients (45.5%), and 5-6 lobes in none. The results of radiological evaluations were unchanged or improved in 7 patients (63.6%) and worsened in 4 (36.4%). Radiological outcome was worse in patients with poor RA control despite their receiving biologic therapies for RA. Two of 3 patients receiving anti-NTM therapy as initial management for NTM improved, and 1 worsened. Three of 4 patients with worsened radiological outcome had high erythrocyte sedimentation rate (> 50 mm/h). Radiological deterioration was not observed in the majority of patients with RA receiving biologic therapy with NTM lung disease, and radiological outcome of pulmonary NTM was favorable in some patients undergoing anti-NTM therapy. Further studies focusing on disease deterioration according to biologic therapy received during NTM followup are warranted to determine appropriate treatment of RA patients with NTM lung disease.
    The Journal of Rheumatology 11/2013; · 3.26 Impact Factor
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    ABSTRACT: OBJECTIVE: The aims of our study were to retrospectively review patients with rheumatoid arthritis (RA) with nontuberculous mycobacterial (NTM) lung disease, to assess the prognostic factors, and to analyze the time to disease deterioration according to the antirheumatic drugs received during the NTM lung disease followup period. METHODS: We retrospectively analyzed medical records of 98 HIV-negative RA patients with NTM lung disease treated at our institution, and investigated potential risk factors of mortality with Cox regression analysis. Time to radiologic deterioration was evaluated if antirheumatic drugs were not changed during observational periods and computed tomography was performed once each year. RESULTS: Mean patient age was 67.6 years, and median followup period was 4.4 years. NTM species included Mycobacterium avium complex (83.7%), M. kansasii (6.1%), M. gordonae (6.1%), and others (4.1%). Radiographic features included nodular/bronchiectatic (NB) disease (57.1%), fibrocavitary (FC) disease (14.3%), FC+NB disease (16.3%), and other types (12.2%). Initial management included observation in 74 (75.5%) patients. Negative prognostic factors of mortality were C-reactive protein (CRP) ≥ 1.0 mg/dl and radiographic features of FC, FC+NB, or other disease types. Median time to radiologic deterioration was 3.6 years. Erythrocyte sedimentation rate (ESR) > 50 mm/h was a negative prognostic factor of radiologic deterioration. CONCLUSION: The most frequent NTM species was M. avium complex. CRP and radiographic features were prognostic factors for all-cause mortality, and ESR was a prognostic factor of radiologic deterioration. Further studies are warranted focusing on time to disease deterioration according to antirheumatic drug received during NTM followup.
    The Journal of Rheumatology 04/2013; · 3.26 Impact Factor
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    ABSTRACT: CT-diagnosed emphysema is associated with poor prognosis in chronic obstructive pulmonary disease (COPD). Its clinical impacts on prognoses of asthma with chronic airflow obstruction (CAO) are not well known. We sought to compare mortalities and prognostic factors in COPD and asthma with CAO by the presence or absence of CT-diagnosed emphysema. Retrospective cohort study. Referral centre hospital for respiratory disease. 1272 patients aged over 40 years with CAO (January 2000 to December 2011). CAO was defined as a forced expiratory volume in 1 s/forced vital capacity <0.7 after bronchodilator use throughout the observation period. Overall mortality served as the primary endpoint. We compared mortalities and prognostic factors of COPD and asthma subgroups with or without emphysema. Secondary endpoints were the prevalence of COPD and asthma in patients with CAO. Overall, diagnoses included COPD with emphysema in 517 (40.6%) patients, COPD without emphysema in 104 (8.2%) patients, asthma with emphysema in 178 (13.9%) patients, asthma without emphysema in 169 (13.3%) patients, other respiratory diseases (RD) with emphysema in 128 (10.1%) patients, and other RD without emphysema in 176 (13.8%) patients. Patients with asthma without emphysema had the best prognosis followed by those with asthma with emphysema, COPD without emphysema and COPD with emphysema. Each subgroup had distinct prognostic factors. Presence of emphysema was an independent risk factor for de novo lung cancer among patients with CAO. Patients with asthma with CAO have a better prognosis than patients with COPD. The presence of CT-diagnosed emphysema predicts poor prognosis in COPD and asthma with CAO.
    BMJ Open 01/2013; 3(11):e003541. · 1.58 Impact Factor
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    ABSTRACT: Objective The prognostic factors of chronic necrotizing pulmonary aspergillosis remain unclear. We assessed the prognostic factors of all-cause mortality in patients with chronic necrotizing pulmonary aspergillosis, focusing especially on underlying pulmonary disease, first-line treatment and host predisposition. Methods We retrospectively analyzed the medical records of 194 patients negative for HIV who had chronic necrotizing pulmonary aspergillosis treated at our institution in Saitama, Japan. Results The patients (median age, 68.5 years) were followed over a median follow-up time of 2.6 years. The underlying pulmonary diseases consisted of previous pulmonary tuberculosis in 59 (30.4%) patients, emphysema in 39 (20.1%) patients, interstitial lung disease in 32 (16.5%) patients, nontuberculous mycobacteriosis in 29 (14.9%) patients and other diseases in 35 (18%) patients. The first-line treatments included observation in 65 (33.5%) patients, itraconazole in 56 (28.9%) patients, micafungin in 46 (23.7%) patients, voriconazole in 22 (11.3%) patients and amphotericin B (including liposomal amphotericin B) in five (2.6%) patients. The overall cumulative mortality rate was 50.2% at five years and 67.4% at 10 years. Multivariate Cox proportional hazard modeling found an older age, the presence of systemic comorbidities, baseline corticosteroid use, a body mass index of <18.5 kg/m(2) and a C-reactive protein level of ≥5.0 mg/dL to be negative prognostic factors for all-cause mortality. Conclusion The 5-year mortality rate of chronic necrotizing pulmonary aspergillosis was 50.2%. When clinical trials are designed and implemented to test effective drug therapies in patients with chronic necrotizing pulmonary aspergillosis, the trial patients should be stratified according to these prognostic factors prior to randomization.
    Internal Medicine 01/2013; 52(7):727-34. · 0.97 Impact Factor
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    ABSTRACT: The purpose of this study was to examine changes in the airway lumen and parenchyma in relation to lung function in patients with chronic obstructive pulmonary disease (COPD) compared with controls. We studied 70 patients with COPD and 15 normal subjects. Using reconstructed computed tomography (CT) images, we traced the bronchial trees and reconstructed 3 cm circle images around the airways exactly perpendicular to the airway axis at the peripheral, middle, and central zones of the bronchi. We measured the number of airways and vessels, the airway inner diameter, and the area of emphysema in the circles, and analyzed the relationship of these image parameters to lung function. Reduced airway numbers and increased upper lobe emphysema were observed even in early spirometric stages in patients with COPD compared with controls. Other findings included decreased airway inner diameter in advanced spirometric stages. The numbers of peripheral zone bronchi, the extent of the middle zone emphysematous area, and the mean airway inner diameter of the airways were the best predictors of spirometric parameters. A portion of the airways in patients with COPD showed a loss of airway patency at middle or central zone bronchi predominantly in the late spirometric stages. Lumen-obliterated bronchial trees could be traced into emphysematous areas showing air trapping. Compared with controls, our CT observations in patients with COPD showed that airway lumen and lung parenchyma changes along airways differed by spirometric stage, and these changes were associated with decreased lung function. A portion of CT-identified emphysema in patients with COPD appeared to be due to lumen-obliterated airways in the bronchial tree.
    International Journal of COPD 01/2013; 8:523-32.
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    ABSTRACT: Background and objective:  In some patients, desquamative interstitial pneumonia may progress to lung fibrosis. The aim of this study was to assess the long-term radiological follow-up results in patients with desquamative interstitial pneumonia. Methods:  Among 75 patients suspected of having desquamative interstitial pneumonia, 31 who fulfilled the criteria were included in this study. Clinical characteristics at presentation, responses to treatment and long-term follow-up were evaluated. Results:  The 31 patients were predominantly males (94%), and the mean age was 55 years; 93% (28/30) had a history of smoking. The clinical findings included high serum levels of lactate dehydrogenase and immunoglobulin G. Bronchoalveolar lavage (26 patients, 84% of cases) frequently showed an increased percentage of eosinophils (mean 17%). Computed tomography (CT) or high resolution (HR) CT at presentation showed ground glass opacities and/or consolidation in all patients, with one third of patients also showing thin-walled cysts within the ground glass opacities. There was no honeycombing on CT or HRCT scans at presentation. Corticosteroid therapy was effective early in the course of the disease; long-term follow-up (mean 99 months) of 31 patients showed only one death due to progression of the disease, but long-term follow-up of 14 patients (mean 125 months) by HRCT showed the development of new thin-walled cysts and honeycombing in five and lung cancer in four patients, respectively. Conclusions:  In a proportion of patients, desquamative interstitial pneumonia may progress to lung fibrosis with honeycombing on HRCT, despite therapy.
    Respirology 07/2012; 17(8):1214-1221. · 2.78 Impact Factor
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    ABSTRACT: PURPOSE: Pirfenidone is a new, anti-fibrotic drug used for the treatment of idiopathic pulmonary fibrosis (IPF). The aim of this study was to evaluate the utility of computed tomography (CT) in the imaging assessment of the response to pirfenidone therapy. MATERIALS AND METHODS: Subjects were 78 patients with IPF who underwent CT on two occasions with one-year interval (38 consecutive patients treated with pirfenidone and 40 age-matched control). Changes in the fibrous lesion on sequential CTs were assessed as visual score by two radiologists. We measured the volume and change per year of fibrous pattern (F-pattern) quantitatively using a computer-aided system on sequential CTs. RESULTS: The baseline vital capacity (%pred VC) was 74.0±14.0% in the pirfenidone group and 74.6±16.6% in controls (p=NS). Deterioration of respiratory status was defined as 10% or greater decline in %pred VC value after 12-month treatment. A significantly larger proportion of pirfenidone-treated patients showed stable respiratory status (21 of 38, 65.6%) than the control (15 of 40, 37.5%). The change in fibrous lesion was significantly smaller in the pirfenidone group than the control in both of visual score (p=0.006) and computer analysis (p<0.001). The decline in VC correlated significantly with the increase in fibrotic lesion (p<0.001). CONCLUSION: CT can be used to assess pirfenidone-induced slowing of progression of pulmonary fibrosis.
    European journal of radiology 03/2012; · 2.65 Impact Factor
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    ABSTRACT: The prognostic factors of Mycobacterium avium complex lung disease (MAC-LD) are not clearly defined. To assess the prognostic factors of all-cause and MAC-specific mortality in patients with MAC-LD, especially in accordance with radiographic features, first-line treatment, and host predisposition. Medical records of 634 HIV-negative patients with MAC-LD treated at our institution in Saitama, Japan were retrospectively analyzed. Patients' mean age was 68.9 years, and median follow-up period was 4.7 years. Radiographic features included nodular/bronchiectatic (NB) disease: 482 patients (76.0%); fibrocavitary (FC) disease: 105 patients (16.6%); FC+NB disease: 30 patients (4.7%); and other types: 17 patients (3.0%). First-line treatments were observation or one drug: 479 patients (75.6%); 2 to 5 drugs: 131 patients (20.7%); and unknown: 24 patients (3.8%). A multivariate Cox proportional hazard model showed male sex, older age, presence of systemic and/or respiratory comorbidity, non-NB radiographic features, body mass index (BMI) less than 18.5 kg/m(2), anemia, hypoalbuminemia, and erythrocyte sedimentation rate greater than or equal to 50 mm/h to be negative prognostic factors for all-cause mortality, and FC or FC+NB radiographic features, BMI less than 18.5 kg/m(2), anemia, and C-reactive protein greater than or equal to 1.0 mg/dl to be negative prognostic factors for MAC-specific mortality. The first-line treatment regimen was not associated with all-cause mortality. FC or FC+NB disease, BMI less than 18.5 kg/m(2), and anemia were negative prognostic factors for both all-cause and MAC-specific mortality.
    American Journal of Respiratory and Critical Care Medicine 12/2011; 185(5):575-83. · 11.04 Impact Factor
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    ABSTRACT: We analyzed the routes of draining veins in 7 cases of intralobar pulmonary sequestration (ILS) and 6 cases of bronchial atresia (BA) by multidetector CT and on 3D reconstructed images. In 2 cases of ILS with systemic venous drainage and 4 of 5 cases with pulmonary venous drainage, the primary veins penetrated the abnormal lungs. In another case, the main vein bypassed the border of the lung, but a small number of branches joined from the normal lung. In all cases of BA, draining veins distributed outside the abnormal lung. The finding that ILS has its own draining veins supports the theory of its congenital origin from an accessory lung bud.
    Nihon Kokyūki Gakkai zasshi = the journal of the Japanese Respiratory Society. 11/2011; 49(11):816-21.
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    ABSTRACT: We encountered 2 patients with novel influenza A (H1N1) pneumonia initially treated with steroid therapy after an incorrect diagnosis of cryptogenic organizing pneumonia and acute interstitial pneumonia, made because of atypical radiological findings and negative rapid antigen test results. After the patients were discharged, we performed reverse-transcriptase polymerase chain reaction tests for the presence of novel influenza A (H1N1); the results were positive, and we established the correct diagnosis of infection by novel influenza A (H1N1) virus pneumonia. Diagnostic clues included radiological findings similar to those of previously reported cases of novel influenza A (H1N1) virus pneumonia and an increase in similar cases due to the novel influenza A (H1N1) pandemic, suggesting that these 2 patients were also suffering from it. Similar cases of inappropriate treatment resulting from an initially incorrect diagnosis of cryptogenic organizing pneumonia or acute interstitial pneumonia may occur, and greater attention should be paid to accurate diagnosis.
    Nihon Kokyūki Gakkai zasshi = the journal of the Japanese Respiratory Society. 09/2010; 48(9):687-95.
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    ABSTRACT: In this study the prevalence, lung function and prognosis of IPF combined with emphysema were evaluated. Consecutive patients with usual interstitial pneumonia (UIP) on high-resolution computed tomography (HRCT), with or without emphysema, were assessed retrospectively. The area of fibrosis in the base of the lungs was assessed by HRCT as minimal (<2 cm from the subpleura), moderate (>or=2 cm from the subpleura, <1/3 of the area of the base of the lungs) or severe (>or=1/3 of the area of the base of the lungs). Among 660 patients with UIP on HRCT, 221 showed upper-lobe emphysema. Pulmonary function results for patients with UIP and UIP/emphysema, respectively, were: FVC, 71.8% and 87.1%; FEV1%, 86.7% and 87.9%; and DL(CO), 74.3% and 65.2% of predicted. The relationship between FVC, the extent of fibrosis and survival was investigated in 362 patients with records of pulmonary function tests and no lung cancer at the time of entry into the study. Although the extent of fibrosis was similar between the groups, 71.3% of UIP patients met the lung volume criteria for IPF (FVC <80% of predicted), whereas only 26.5% of UIP/emphysema patients met the lung volume criteria for IPF. Median survival was 7.5 years in the UIP group and 8.5 years in the UIP/emphysema group. Emphysema was a common finding in patients with UIP. Patients with UIP and emphysema had greater lung volumes and better survival compared with those with UIP alone.
    Respirology 07/2010; 15(5):843-8. · 2.78 Impact Factor
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    ABSTRACT: A 55-year-old man was admitted to our hospital with chronic cough. Although his chest X-ray was normal, chest computed tomography revealed a nodular lesion that was causing beaded stenosis of the lumen of the upper lobe bronchus. Nodules approximately 10 mm in size were seen in the mediastinum. We could not deny the possibility of vascular disease, and enhanced chest computed tomography was performed, which showed these abnormalities to be caused by a dilated and convoluted bronchial artery. Because no pulmonary diseases that would lead to secondary vascular dilatation were evident, a diagnosis of primary racemose hemangioma of the bronchial artery was made. We performed bronchial artery embolization to prevent potential fatal bleeding from vascular rupture. The patient has been followed regularly as an outpatient, and recanalization has not been detected. Primary racemose hemangioma of the bronchial artery is a rare entity; it is also rare for this entity to be detected by findings of a nodular protrusion in the bronchial wall or in a patient presenting with a cough. Here, we report this case and review previous reports.
    Nihon Kokyūki Gakkai zasshi = the journal of the Japanese Respiratory Society. 09/2009; 47(9):805-11.
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    ABSTRACT: The effects of tiotropium, a long-acting anticholinergic drug, were compared with those of the combination of salmeterol, a long-acting beta(2)-agonist, and fluticasone, an inhaled corticosteroid, in patients with COPD. A 4-month, randomized, open cross-over study of tiotropium, 18 microg once daily, versus salmeterol, 50 microg, plus fluticasone, 200 microg, twice daily, was conducted in patients with COPD. Efficacy was assessed by spirometry and responses to the St George's Respiratory Questionnaire (SGRQ). After 4 months, patients were asked to select their subsequent therapy and indicate the reasons for their selection. A total of 78 patients completed the study. There were no significant differences in the improvements in FEV(1) or SGRQ scores between the therapies. Similar numbers of patients selected tiotropium (42.3%) and salmeterol plus fluticasone (57.7%). However, those who preferred one of the therapies demonstrated greater improvements in SGRQ scores with that therapy. One subgroup of patients (30.8%) showed greater improvements in dyspnoea and FEV(1) in response to tiotropium, and the other subgroup of patients (35.9%) showed greater improvements in dyspnoea and FEV(1) in response to salmeterol plus fluticasone. Some patients (14.1%) selected salmeterol plus fluticasone because of positive effects on sputum expectoration. The study was unblinded and the results need to be interpreted with caution. However, tiotropium and salmeterol plus fluticasone had similar overall effects on pulmonary function and SGRQ scores in patients with COPD. Responses to the two therapies were heterogeneous, and the patients who showed greater improvements in FEV(1) or SGRQ scores with one of the therapies preferred it for their subsequent treatment.
    Respirology 01/2009; 14(2):239-44. · 2.78 Impact Factor
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    ABSTRACT: The aim of this study was to determine whether early versus late initiation of long-term inhaled corticosteroid (ICS) therapy decreases airway wall thickness in patients with asthma. One hundred and eighty-one patients with asthma not previously treated with ICS were given inhaled budesonide for 1 year. These patients were divided into five groups according to the duration of their asthma symptoms, which ranged from less than 1 year to more than 10 years. High-resolution CT images and post-bronchodilator FEV1 were examined before and 1 year after treatment. Before treatment, airway wall thickness was increased relative to the duration of asthma. Disease severity improved with ICS treatment even in patients who had suffered asthma symptoms for more than 10 years. Post ICS treatment, airway wall thickness decreased in patients with a duration of symptoms less than 3 years, and a minor response was seen in patients with a duration of symptoms from 3 to 5 years. However, there was no change in airway wall thickness in patients who had suffered asthma for more than 5 years. Post-bronchodilator FEV1 improved only in patients who had suffered asthma for less than 3 years. ICS therapy may improve asthma control in all asthma patients despite the disease duration, but early ICS treatment may be critical to reverse airway wall thickening associated with asthma.
    Respirology 09/2008; 13(7):1008-13. · 2.78 Impact Factor
  • Haigan 01/2008; 48(4):254-260.
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    ABSTRACT: Chronic Chlamydia pneumoniae infection has been identified serologically in patients with COPD. The aim of this study was to examine whether the severity of emphysema is related to elevated antibody titres against C. pneumoniae. We measured antibody titres against C. pneumoniae using ELISA, and assessed the severity of emphysema by the percentage of low attenuation area (%LAA) using high resolution (HR) CT in patients with COPD and in non-smoking control subjects. The mean %LAA was 2.2% in non-smoking controls (n = 28) and 13.3% in COPD patients (n = 94). COPD patients with a high IgG antibody index to C. pneumoniae (> or =2.0, n = 42) had a significantly higher %LAA (16.8%) than those with a low IgG index (<2.0, n = 52) (10.6%, P = 0.01). In addition, COPD patients with a high IgA antibody index (> or =2.0, n = 46) had a significantly higher %LAA (15.9%) than those with a low IgA index (<2.0, n = 48) (10.9%, P = 0.048). COPD patients with a high IgA antibody index also had a significantly lower %DLco than that associated with a low IgA index (68.1% and 80.3%, respectively, P = 0.007). There were no significant differences in age, smoking index or FEV(1)/FVC between these groups. These results suggest that high antibody titres against C. pneumoniae are linked with the severity of emphysema on high resolution CT and decreased diffusing capacity to carbon monoxide.
    Respirology 11/2005; 10(5):572-8. · 2.78 Impact Factor
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    ABSTRACT: COPD is defined by airflow limitation that is not fully reversible and is associated with relevant risk factors. The diagnosis requires that other causes of chronic airflow limitation (CAL) be excluded. We assessed the diagnostic utility of high resolution thoracic CT (HRCT) and bronchodilator reversibility to assist in making a diagnosis of COPD. We investigated 516 consecutive patients whose FEV1/FVC was less than 70% after inhalation of bronchodilator. HRCT was performed on all subjects and a final diagnosis was made only after 3 months of treatment and repeated spirometry. Of 516 cases, 54.3% had COPD, 19.8% had asthma plus emphysema, and 13.2% had chronic asthma. The remaining 12.7% of patients with CAL had diffuse panbronchiolitis, bronchiectasis, bronchiolitis obliterans, or other miscellaneous diseases. In these minor diseases HRCT was essential in making a definitive diagnosis. The sensitivities of emphysema on HRCT and of absence of bronchodilator response for the diagnosis of COPD were 81% and 90%, respectively, and the specificities of the tests were 57% and 37%, respectively. In addition, HRCT revealed considerable heterogeneity of COPD. Emphysema was not recognized on HRCT in 18.6% of COPD patients. HRCT also revealed that 17.5% of COPD patients had other pulmonary complications including lung fibrosis compatible with usual interstitial pneumonia in the lung bases. HRCT and the bronchial reversibility test had reasonable sensitivities but low specificities for diagnosing COPD. HRCT has some additional advantages in detecting heterogeneity and concomitant lung diseases in COPD.
    Respirology 07/2005; 10(3):316-22. · 2.78 Impact Factor
  • Tetsu Kanauchi, Toshiko Hoshi, Akihiro Kato
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    ABSTRACT: The purpose of this study was to clarify the characteristic CT findings of pulmonary hamartoma. The thin-section CT and multiplanar reformation images of 19 pulmonary hamartomas diagnosed by surgical resection were analyzed and correlated with the pathological findings. Most hamartomas presented lobulated nodules apart from pleura. There was no case in which fat density was recognized. Only one case was recognized as having calcification. Air density in the connection of the side or the inside was pointed out in 5 cases (26%). Air density reflected epithelial-lined cleft. The connection with the bronchus was recognized in 4 cases (21%), and the connection with the pulmonary artery branch was recognized in 10 cases (53%). However, the connection of the pulmonary artery and bronchus could not be pathologically confirmed in most cases. The connection with the pulmonary vein was not recognized in any of the cases. Air density in the connection of the side or the inside is characteristic of pulmonary hamartoma. Pulmonary artery branches connect beyond half of hamartomas. This finding suggests close relations in the bronchus along the artery. It is important that there is no connection of the pulmonary vein, to differentiate it from lung cancer.
    Nihon Igaku Hoshasen Gakkai zasshi. Nippon acta radiologica 08/2004; 64(5):300-4.
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    ABSTRACT: The purpose of this article is to describe the radiologic findings to diagnose congenital bronchial atresia. Chest radiographs, CT scans, and MRI of nine patients with congenital bronchial atresia were reviewed. Six patients (67%) had hilar mass-like shadows and hyperlucency of the peripheral lung field on chest radiographs. On chest CT scans, all patients demonstrated mucocele, occlusion of bronchus central to mucocele, and emphysematous change of the peripheral lung field. On chest MRI, performed in seven patients, all mucoceles demonstrated very high signal intensity on T2-weighted image, indicating that mucoceles were filled with fluid. Diagnosis of congenital bronchial atresia can be confirmed based on the findings of chest CT: mucocele, occlusion of bronchus central to mucocele, and emphysematous change of the peripheral lung field.
    Journal of Computer Assisted Tomography 26(5):860-4. · 1.58 Impact Factor