Matthew Koslow1, Jason R Young2, Eunhee S Yi3, Misbah Baqir4, Paul A Decker5, Geoffrey B Johnson2,6, Jay H Ryu4. 1. Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Gonda 18 South, 200 First St. SW, Rochester, MN, 55905, USA. mkoslow73@gmail.com. 2. Division of Nuclear Medicine, Department of Radiology, Mayo Clinic, Rochester, MN, USA. 3. Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA. 4. Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Gonda 18 South, 200 First St. SW, Rochester, MN, 55905, USA. 5. Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA. 6. Department of Immunology, Mayo Clinic, Rochester, MN, USA.
Abstract
OBJECTIVES: The objective of this study was to identify clinical and imaging features that distinguish rheumatoid lung nodules from malignancy. METHODS: We conducted a retrospective review of 73 rheumatoid patients with histologically-proven rheumatoid and malignant lung nodules encountered at Mayo Clinic, Rochester, MN (2001-2016). Medical records and imaging were reviewed including a retrospective blinded review of CT and PET/CT studies. RESULTS: The study cohort had a mean age of 67 ± 11 years (range 45-86) including 44 (60%) women, 82% with a smoking history, 38% with subcutaneous rheumatoid nodules, and 78% with rheumatoid factor seropositivity. Subjects with rheumatoid lung nodules compared to malignancy were younger (59 ± 12 vs 71 ± 9 years, p < 0.001), more likely to manifest subcutaneous rheumatoid nodules (73% vs 20%, p < 0.001) and rheumatoid factor seropositivity (93% vs 68%, p = 0.034) but a history of smoking was common in both groups (p = 0.36). CT features more commonly associated with rheumatoid lung nodules compared to malignancy included multiplicity, smooth border, cavitation, satellite nodules, pleural contact, and a subpleural rind of soft tissue. Optimal sensitivity (77%) and specificity (92%) (AUC 0.85, CI 0.75-0.94) for rheumatoid lung nodule were obtained with ≥ 3 CT findings (≥ 4 nodules, peripheral location, cavitation, satellite nodules, smooth border, and subpleural rind). Key 18FDG-PET/CT features included low-level metabolism (SUVmax 2.7 ± 2 vs 7.2 ± 4.8, p = 0.007) and lack of 18F-fluorodeoxyglucose (FDG)-avid draining lymph nodes. CONCLUSION: Rheumatoid lung nodules have distinct CT and PET/CT features compared to malignancy. Patients with rheumatoid lung nodules are younger and more likely to manifest subcutaneous rheumatoid nodules and seropositivity. KEY POINTS: • Rheumatoid lung nodules have distinct clinical and imaging features compared to lung malignancy. • CT features of rheumatoid lung nodules include multiplicity, cavitation, satellite nodules, smooth border, peripheral location, and subpleural rind. • Key PET/CT features include low-level metabolism and lack of FDG-avid draining lymph nodes.
OBJECTIVES: The objective of this study was to identify clinical and imaging features that distinguish rheumatoid lung nodules from malignancy. METHODS: We conducted a retrospective review of 73 rheumatoidpatients with histologically-proven rheumatoid and malignant lung nodules encountered at Mayo Clinic, Rochester, MN (2001-2016). Medical records and imaging were reviewed including a retrospective blinded review of CT and PET/CT studies. RESULTS: The study cohort had a mean age of 67 ± 11 years (range 45-86) including 44 (60%) women, 82% with a smoking history, 38% with subcutaneous rheumatoid nodules, and 78% with rheumatoid factor seropositivity. Subjects with rheumatoid lung nodules compared to malignancy were younger (59 ± 12 vs 71 ± 9 years, p < 0.001), more likely to manifest subcutaneous rheumatoid nodules (73% vs 20%, p < 0.001) and rheumatoid factor seropositivity (93% vs 68%, p = 0.034) but a history of smoking was common in both groups (p = 0.36). CT features more commonly associated with rheumatoid lung nodules compared to malignancy included multiplicity, smooth border, cavitation, satellite nodules, pleural contact, and a subpleural rind of soft tissue. Optimal sensitivity (77%) and specificity (92%) (AUC 0.85, CI 0.75-0.94) for rheumatoid lung nodule were obtained with ≥ 3 CT findings (≥ 4 nodules, peripheral location, cavitation, satellite nodules, smooth border, and subpleural rind). Key 18FDG-PET/CT features included low-level metabolism (SUVmax 2.7 ± 2 vs 7.2 ± 4.8, p = 0.007) and lack of 18F-fluorodeoxyglucose (FDG)-avid draining lymph nodes. CONCLUSION:Rheumatoid lung nodules have distinct CT and PET/CT features compared to malignancy. Patients with rheumatoid lung nodules are younger and more likely to manifest subcutaneous rheumatoid nodules and seropositivity. KEY POINTS: • Rheumatoid lung nodules have distinct clinical and imaging features compared to lung malignancy. • CT features of rheumatoid lung nodules include multiplicity, cavitation, satellite nodules, smooth border, peripheral location, and subpleural rind. • Key PET/CT features include low-level metabolism and lack of FDG-avid draining lymph nodes.
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