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Rheumatoid pulmonary nodules: clinical and imaging features compared with malignancy

  • Matthew Koslow
  • Jason R. Young
  • Eunhee S. Yi
  • Misbah Baqir
  • Paul A. Decker
  • Geoffrey B. Johnson
  • Jay H. Ryu
Chest
  • 105 Downloads

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.

Keywords

Multidetector computed tomography PET-CT scan Multiple pulmonary nodules Rheumatoid arthritis Rheumatoid nodule 

Abbreviations

CCP

Cyclic citrullinated peptide

DLCO

Diffusing capacity for carbon monoxide

FEV1

Forced expiratory volume in 1 s

FDG

18F-fluorodeoxyglucose

FVC

Forced vital capacity

GGO

Ground glass opacity

HRCT

High-resolution computed tomography

IL-1

Interleukin-1

PET

Positron emission tomography

PFT

Pulmonary function test

RA

Rheumatoid arthritis

TLC

Total lung capacity

Notes

Funding

The authors state that this work has not received any funding.

Compliance with ethical standards

Guarantor

The scientific guarantor of this publication is Dr. Jay H. Ryu.

Conflict of interest

Dr. Johnson has received research funding from Pfizer which is not relevant to this work. None of the additional co-authors have relevant disclosures.

Statistics and biometry

Mr. Paul A. Decker kindly provided statistical advice for this manuscript.

Informed consent

The study was approved by the Mayo Clinic Institutional Review Board (IRB16-006571). According to Mayo Clinic institutional policy, patient information may be used for research purposes only with prior patient consent.

Ethical approval

Institutional Review Board approval was obtained by the Mayo Clinic Institutional Review Board (IRB16-006571).

Study subjects or cohorts overlap

None of the study subjects or cohorts have been previously reported except for abstract presentation at the American Thoracic Society International Conference 2017.

Methodology

• Retrospective

• Case-control study

• Performed at one institution

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Copyright information

© European Society of Radiology 2018

Authors and Affiliations

  1. 1.Division of Pulmonary and Critical Care Medicine, Department of MedicineMayo ClinicRochesterUSA
  2. 2.Division of Nuclear Medicine, Department of RadiologyMayo ClinicRochesterUSA
  3. 3.Division of Anatomic Pathology, Department of Laboratory Medicine and PathologyMayo ClinicRochesterUSA
  4. 4.Department of Health Sciences ResearchMayo ClinicRochesterUSA
  5. 5.Department of ImmunologyMayo ClinicRochesterUSA

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