In addition, there is an indeterminate low-attenuation nodule or complex cyst (white *) in the isthmus. Firstly, nodule diameter measurement is not a reliable method for assessing the entire nodule dimension and it is affected by non-negligible inter- and intra-observer variability. Individuals with ILA showed impaired gas exchange compared with those without ILA (mean diffusion capacity of carbon monoxide percent predicted in patients with ILA: 86% 14 [standard deviation] vs that in patients without ILA: 98% 15, P < .001) (6,15). Michigan [Ken Rosenman and Mary Jo Reilly, (517) 353-4979] Acute silico-proteinosis. The commercial-type saw consisted of a steel diamond-tipped blade in a large portable circular-saw housing. Amyloidosis is a disorder caused by misfolding of autologous protein and its extracellular deposition as fibrils, resulting in vital organ dysfunction and eventually death. [81] Although smoking represents a common risk factor for both entities, it has been hypothesized that pulmonary fibrosis per se promotes carcinogenesis through so far unclear mechanisms.[81,82,83]. Inflammatory changes of the paraspinal soft tissues also are usually present and include obscuration of paraspinal fat planes, paraspinal abscesses, and retropharyngeal edema (Fig E11). Pneumonia appears as nodular and/or consolidative opacities in the lung parenchyma. The aim of this article is to provide a comprehensive review of the current knowledge on lung nodules and an accurate approach of their management based on all currently available guideline recommendations. Malignant otitis externa of the right ear in a 55-year-old man. In the above-described scenario, a strong effect of the nodule size on predicting malignancy has been underlined, even though the management of a pulmonary nodule cannot solely rely on size. (b) Axial nonenhanced CT image obtained just superior to a shows an abscess with a low-attenuation center (*), a thicker abscess rim (white arrow), and surrounding edema (black arrow). Although the presence of mastoid air cell fluid is common, it does not necessarily indicate mastoiditis. [2] The Fleischner society guidelines, on the other hand, specifically state that perifissural or subpleural location does not per se definitely abolish the probability of malignancy and morphological (e.g., spiculation or fissure displacement), and clinical risk factors have to be considered for appropriate management.[1]. Arch Pathol Lab Med 112:673-720. Always use the dust control system, and keep it well maintained. In the clinical management of ILA, clinically significant interstitial lung disease should be excluded, and individuals with risk factors for ILA progression require active monitoring. Drilling of rock containing crystalline silica during highway construction. Ko JP, Berman EJ, Kaur M, Babb JS, Bomsztyk E, Greenberg AK, et al. A correlation of imaging with a patient's clinical features is useful in narrowing the diagnosis. Ground glass opacity on chest CT scans from screening to treatment: A literature review. CT is more sensitive than chest radiography for detection of pneumonia. A recent Fleischner position paper provided an updated definition of ILA, with descriptive terms, a summary of risk factors and clinical outcomes, and a proposed schema for management (2). Lorigan P, Radford J, Howell A, Thatcher N. Lung cancer after treatment for Hodgkin's lymphoma: A systematic review. Multidisciplinary evaluation of interstitial lung diseases: current insights. Additionally, pure ground-glass opacity nodules took longer to double in size than ground-glass opacity nodules with solid masses in these studies. [12] It is often suggestive of organizing pneumonia,[13] but is only seen in about 20% of individuals with this condition. (B) Abnormality disappeared (arrowhead) in same area on prone CT scan, indicating abnormality on A was atelectasis and not interstitial lung abnormality. Diffuse abnormalities of the lung parenchyma on HRCT can be broadly categorized into one of the following four patterns: reticular and short linear opacities; nodular opacities; increased lung opacity (ground-glass opacity or consolidation); and cystic airspaces and areas of decreased lung density. CT screening for lung cancer: Part-solid nodules in baseline and annual repeat rounds. The classic location of second branchial cleft anomalies is anterior to the sternocleidomastoid muscle, at the angle of the mandible; however, different types may manifest along a line between the oropharynx and the supraclavicular region (11). Although a lung biopsy revealed silicotic nodules, he was still working as of 1995. [11][18] This is sometimes accompanied by the development of a crazy paving pattern and interlobular septal thickening. [10,94,96] Therefore, BTS guidelines recommend against further investigation of small (<10 mm), homogeneous, smooth perifissural, and subpleural nodules. Sialadenitis in two patients. Clear algorithms for the imaging protocols and the management of positive findings should also exist in lung cancer screening programs, which are already established in the USA and which will hopefully be established worldwide. Further histopathologic evaluation is required to validate the correlation between ILA and histologic fibrosis and also to assess the importance of incidental histologic fibrosis identified in lung resection specimens. Swensen SJ, Silverstein MD, Ilstrup DM, Schleck CD, Edell ES. Uncomplicated otomastoiditis manifests at CT as opacification of the middle ear cavity and mastoid air cells, without osseous destruction. Owing to the permeative nature of this process, it may mimic a tumor (9). Instruction about the purpose and set-up of regulated areas marking the boundaries of work areas containing crystalline silica. Visualization of the spinal canal is quite limited with CT, even with administration of contrast material. Figure 5a. Ground-glass opacity is nonspecific, but a highly significant finding since 60-80% of patients with ground-glass opacity on HRCT have an active and potentially treatable lung disease. 2: Elicker BM, Kallianos KG, Henry TS. CT is 100% sensitive and 75% specific for detection of PTA, which on CT images most commonly appears as a rim-enhancing collection superolateral to the palatine tonsil (Fig 4) (21). However, when source controls cannot keep exposures below the NIOSH REL, controls should be supplemented with the use of respirators. From the Division of Emergency Radiology (M.H.S. Therefore, on the basis of the updated literature, recommendations from the Fleischner Society suggest the use of the lung window setting and the high spatial frequency (sharp) filter to judge the presence of a solid component, and the measurement of both the solid and nonsolid portions in a PSN. Whenever possible, neck CT should be performed with intravenous contrast material to maximize the ability to detect and characterize abscesses, masses, and vascular complications of infectious, inflammatory, and neoplastic conditions. Myers CE, Hayden C, Morgan J [1973]. [115] PET/CT may be helpful in these cases. At standard CT evaluation of the neck, the craniocervical junction and the entire cervical spine are included, and abnormalities of the cervical spine are commonly seen. Henschke CI, Yankelevitz DF, Yip R, Reeves AP, Farooqi A, Xu D, et al. The outlook and treatment options available will depend on the cause of the opacity. There is coalescence of the right mastoid air cells (black arrow) with breakthrough of the overlying cortex (white arrow). Moreover, Lee et al. This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. Ludwig angina in a 26-year-old man. Afterwards a segmentation algorithm is applied to outline 3D nodule borders and calculate the volume. Cincinnati, OH: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. Descending mediastinitis in a 50-year-old woman who recently underwent a dental procedure. [16][18] This is in contrast to the two similar coronaviruses, SARS and MERS, which more commonly involve only one lung on initial imaging. There is also bone dehiscence (black arrow) along the dorsal aspect of the petrous apex. Depending on their attenuation in CT imaging, lung nodules are categorized in three different types: (i) solid nodules, the most common type, characterized by homogeneous soft-tissue attenuation, (ii) ground-glass nodules, nonuniform in appearance with a hazy increase in local attenuation of lung parenchyma not obscuring the underlying bronchial and vascular structures, and (iii) part-solid nodules, comprising both solid and ground-glass attenuation components. In evaluating these patients, it is helpful to use the standardized radiologic descriptive terminology presented here. You can review and change the way we collect information below. These findings were confirmed at contrast-enhanced MRI (not shown). Noninfectious processes occasionally mimic the findings of discitis and osteomyelitis and should be considered if paraspinal inflammatory changes or abscesses are absent (63). His nursing assignments included 5 years with the U.S. Public Health Service, 27 years with an automobile manufacturer, 1 year with a paper manufacturer, 6 years with various hospitals, and 1 year with a magazine publisher. Inhalation cancer risk assessment of hexavalent chromium based on updated mortality for Painesville chromate production workers. Figure 24b. Drilling of rock containing crystalline silica during building site preparation. It is also possible that perceived opacities in the lung apices seen on a chest radiograph may not be present on a subsequently obtained CT image (69). The percentage of fibrosis extent according to the tool correlated well with the fibrosis extent according to the radiologists analysis (Pearson correlation coefficient = 0.88; P < .001) and was an independent predictor of poorer disease-free survival (HR = 1.3 [95% CI: 1.1, 1.6], P = .001). [6], There are numerous potential causes of nodular GGOs which can be broadly separated into benign and malignant conditions. National Library of Medicine 1974]. Use engineering controls and containment methods such as blast-cleaning machines and cabinets, wet drilling, or wet sawing of silica-containing materials to control the hazard and protect adjacent workers from exposure. [6], A reversed halo sign is a central ground-glass opacity surrounded by denser consolidation. The vessels should exhibit normal opacification, without filling defects. The axial diameter may not be the maximum one in the evaluation of lung nodules. Similarly, the American College of Radiology published the Lung CT Screening Reporting and Data System (Lung-RADS) in 2014 [135], a scoring system that considered nodule density, in addition to size and growth, as relevant predictor of malignancy to categorise screening-detected lung nodules. Siegel RL, Miller KD, Jemal A. Left petrous apicitis in an 11-year-old girl who presented with ear drainage and diplopia. A worker may develop any of three types of silicosis, depending on the airborne concentration of crystalline silica: Chronic silicosis, which usually occurs after 10 or more years of exposure to crystalline silica at relatively low concentrations, Accelerated silicosis, which results from exposure to high concentrations of crystalline silica and develops 5 to 10 years after the initial exposure, Acute silicosis, which occurs where exposure concentrations are the highest and can cause symptoms to develop within a few weeks to 4 or 5 years after the initial exposure [Peters 1986; Ziskind et al. Other workers in the area (such as elevator mechanics) were exposed without respiratory protection. [99,100,101,102,103,104], Composite prediction models developed with multivariate logistic regression analysis for malignant risk estimation in individuals with lung nodules, AUC=Area under the receiver operating characteristic curve, FDG=Fluorodeoxyglucose, FEV1=Forced expiratory volume in one second, CXR=Chest X-ray, PET=Positron emission tomography, LDCT=Low-dose computed tomography, COPD=Chronic obstructive pulmonary disease. 8890 This is most relevant for Fibrosis is characterized by the presence of architectural distortion with traction bronchiectasis or bronchiolectasis and/or honeycombing, and it is correlated with increased mortality when compared with individuals without ILA (hazard ratio [HR] = 1.5 [95% CI: 1.3, 1.6], P < .0001) (7,18). (A) Ground-glass abnormality (arrows) is seen in peripheral lung zone. Retropharyngeal edema involves the retropharyngeal space from side to side, with tapered superior and inferior ends; however, there is no rim enhancement (Fig 6) (24). (F) Individual developed severe architectural distortion with traction bronchiectasis in both lower lobes (circles). At CT, acute bacterial sinusitis is characterized by the presence of fluid and mucosal thickening in one or more sinuses (55). It detects more and smaller metastases (Fig. Holin SM, Dwork RE, Glaser S, Rikli AE, Stocklen JB. For the sandblaster, 60-minute personal air samples indicated a respirable quartz concentration of 0.68 mg/m3 inside and 1.83 mg/m3 outside the Type CE continuous-flow respirator. When they are detected, appropriate follow-up should be recommended and communicated. [1,2,3] The proposed intervals are shorter for the higher risk part-solid nodules compared to the more indolent pure ground-glass nodules. Similarly, in the international guidelines for the management of indeterminate nodules, time surveillance is dependent on the initial nodule size; the bigger the nodule diameter the shorter the follow-up interval time [2, 47]. [12] It can also be present in lung infarction where the halo consists of hemorrhage,[14] as well as in infectious diseases such as paracoccidioidomycosis, tuberculosis, and aspergillosis, as well as in granulomatosis with polyangiitis, lymphomatoid granulomatosis, and sarcoidosis.[15]. NIOSH [1991b]. Axial 0.625-mm images constructed by using bone and soft-tissue kernels also are sent to the picture archiving and communication system. Important non-infectious causes include granulomatosis with polyangiitis, metastatic disease with pulmonary hemorrhage, and some types of idiopathic interstitial pneumonias. a) A small part-solid nodule in the apico-posterior segment of the left upper lobe, with a maximum axial diameter of 1212.2mm; b) the sagittal multiplanar reconstruction shows that the largest diameter of the same nodule is the sagittal one of 24.7mm. Eur Respir Rev 2017; 26: 170008. Simple silicosis is present if the largest opacity is <1 cm in diameter. It is bound by the alar fascia anteriorly and the prevertebral fascia posteriorly (discussed in greater detail in the Superior Mediastinum section) (24). However, it is possible that the management scheme proposed in Figure 9 may be applied in individuals with connective tissue disease and ILA-like CT findings. (A) Centrilobular nodularity. [6] COVID-19 has also been shown to occasionally cause GGOs with a crazy paving pattern. Routinely maintain dust control systems to keep them in good working order. pGGN or PSN) [45, 46]. Patterns of recurrence and second primary lung cancer in early-stage lung cancer survivors followed with routine computed tomography surveillance. ), Table 4: Risk Factors for ILA Progression. (B) Reticular abnormality with ground-glass opacity (arrows) is seen in subpleural area. Finally, nodule CT attenuation has become a widely accepted significant determinant of prognosis over the past few years, specifically in SSNs. Subcutaneous edema (arrows) also is present. Ground-glass opacity can also indicate an infection or other inflammatory process, which is usually what a clinician will share with you or your loved one who has had a CT scan or X-ray. Are there different types of opacities in the lung? 4th ed. Eventually, severe bone destruction and deformity can develop. The incidental discovery and reporting of a thoracic aortic aneurysm seen on a neck CT image can affect the long-term survival of the patient (Fig E13) (74). In comparison, the right internal carotid artery (arrowhead) is normal. Some potential reasons for lung opacity include: Depending on the type of opacity found, your doctor may also do cardiac testing to determine if heart conditions are playing a role. Several predictors of malignancy have been identied in a number of studies that reported multivariate analyses. In PSNs, Lee et al. [16,17] Naturally, with the advent of chest CT imaging in daily clinical practice, the incidence of lung nodules has soared. WARNING! Age, smoking status, and nodule diameter are invariably included in all of them, while individual differences reflect discrepancies in the populations used for model derivation. The danger space is a potential space that extends from the skull base to the diaphragm. When surgery is feasible, surgical excision after staging is recommended in high-risk patients. The principal contributors to this Alert were Kenneth D. Linch; Dennis W. Groce; Karl J. Musgrave; Ruth A. Jajosky; Steven R. Short; and John E. Parker. For example, remove dust from equipment with a water hose rather than with compressed air. (b, c) Sagittal (b) and axial (c) contrast-enhanced CT images in a 21-year-old man with epiglottitis show thickening of the epiglottis (arrow in b) and aryepiglottic folds (arrows in c). What do you mean, a spot. ILA may progress to the commonly recognized CT features of idiopathic pulmonary fibrosis (IPF) and is correlated with worsened clinical outcomes. Figure 9: Proposed triage rubric for interstitial lung abnormalities (ILAs) found at chest CT. Action items for radiologist are in blue, action items for treating physician or pulmonologist are in green, and action items for a pulmonologist, ideally with interstitial lung disease (ILD) experience, are in orange. Enter your email address below and we will send you your username, If the address matches an existing account you will receive an email with instructions to retrieve your username. Coronal CT scan shows subpleural ground-glass abnormality (arrows) and nonemphysematous cyst in bilateral basal area. (a) Axial nonenhanced CT image shows an opacified right EAC (white arrow). On both x-ray and CT, this appears more grey or hazy as opposed to the normally dark-appearing lungs. Do not eat, drink, or use tobacco products in dusty areas. [1,2,3] In addition, in contrast to solid nodules, the available options for the evaluation of subsolid nodules are limited by the relative insensitivity of important diagnostic tools, namely PET scan[131,132] and nonsurgical biopsy. (a, b) Acute right submandibular sialadenitis in a 57-year-old woman. At the tooth apex, there is a periapical lucency and dehiscence of the bone plate (arrowhead) between the tooth and the maxillary sinus. When purchasing equipment, look for dust controls. It is worth noting that the maximum nodule diameter may be in nonaxial images (figure 1a and b). Ohio [Ed Socie and Nan Migliozzi, (614) 466-4183] Figure 3: Distribution of interstitial lung abnormalities (ILAs). Number 4 in the Series Radiology Edited by Nicola Sverzellati and Sujal Desai. Infante M, Berghmans T, Heuvelmans MA, Hillerdal G, Oudkerk M. Slow-growing lung cancer as an emerging entity: From screening to clinical management. Figure 6b. Guidelines for management of incidental pulmonary nodules detected on CT images: From the Fleischner Society 2017. As regards nodule morphological characteristics, besides small size, diffuse, central, laminated or popcorn calcifications, as well as fat tissue density and perifissural location have been recognised as indicative of benign lesions. Risk factors for the presence of ILA include increasing age, tobacco smoke exposure, other inhalational exposures (eg, vapors, gases, dusts, fumes, and traffic-related air pollution), and genetic factors (eg, gene encoding mucin 5B variant) (4,6,7,9,13,27). Patient preferences should always be included in management decisions, and multidisciplinary tumor boards are of cardinal importance. Pulmonary adenocarcinomas appearing as part-solid ground-glass nodules: is measuring solid component size a better prognostic indicator? Radiographs interpreted by NIOSH-certified B readers should have profusion categories of 1/0 or greater by the International Labour Organization classification system [ILO Committee on Pneumoconiosis 1981]. He wore a respirator when he was working in dusty conditions. Lemierre syndrome in a 15-year-old girl. Despite rather minor discrepancies, all proposed approaches take into consideration clinical risk factors for lung cancer, nodules imaging features, and previous imaging studies to assess the probability of malignancy and the most appropriate management. 1, 2022 Radiological Society of North America, Epidemiological profile of non-traumatic emergencies of the neck in CT imaging: our experience, Emergency imaging assessment of deep neck space infections, Imaging evaluation of the suprahyoid neck, Value of helical computed tomography in the management of upper esophageal foreign bodies, Imaging features of midface injectable fillers and associated complications, Usefulness of CT scans in malignant external otitis: effective tool for the diagnosis, but of limited value in predicting outcome, Clinical practice guideline: acute otitis externa, Clival osteomyelitis presenting as a skull base mass, Malignant external otitis: utility of CT in diagnosis and follow-up, Congenital cystic masses of the neck: radiologic-pathologic correlation, Branchial cleft anomalies: a pictorial review of embryological development and spectrum of imaging findings, Imaging of Patients with Head and Neck Cancer: From Staging to Surveillance, Chapter 2 Squamous Cell Carcinoma of the Head and Neck: Imaging Evaluation of Regional Lymph Nodes and Implications for Management, Soft tissue tumors of the head and neck: imaging-based review of the WHO classification. It was published as part of a glossary of recommended nomenclature from the Fleischner Society, a group of thoracic imaging radiologists. It is considered one of the rarest of idiopathic interstitial pneumonias 11.. The potential role of emphysema. It is important to note that while many of the pulmonary infections listed below may lead to GGOs, this does not occur in every case. In contrast, a longer follow-up period is required for classifying for SSNs as benign with a reasonable certainty. Finally, important information regarding the fluid status of the patient can be gleaned from an assessment of the lung apices. If the address matches an existing account you will receive an email with instructions to reset your password. Moolgavkar SH, Holford TR, Levy DT, Kong CY, Foy M, Clarke L, et al. [16] GGOs with mixed consolidation has most often been found in elderly populations. Antoniou KM, Tomassetti S, Tsitoura E, Vancheri C. Idiopathic pulmonary fibrosis and lung cancer: A clinical and pathogenesis update. Given the limitations of chest radiography in the diagnosis of pneumonia, one must take advantage of any opportunity to scrutinize a portion of the lungs with a more sensitive imaging modality. Are two-dimensional CT measurements of small noncalcified pulmonary nodules reliable? Cohen JG, Reymond E, Lederlin M, Medici M, Lantuejoul S, Laurent F, et al. Health at a Glance 2019, Computed tomography and patient risk: Facts, perceptions and uncertainties, Sources of variation in quantitative computed tomography of the lung, The Impact of Sources of Variability on Parametric Response Mapping of Lung CT Scans, Current applications and future impact of machine learning in radiology, Convolutional neural networks: an overview and application in radiology, An Ensemble Method for Classifying Regional Disease Patterns of Diffuse Interstitial Lung Disease Using HRCT Images from Different Vendors, Comparison of Shallow and Deep Learning Methods on Classifying the Regional Pattern of Diffuse Lung Disease, Feasibility of automated quantification of regional disease patterns depicted on high-resolution computed tomography in patients with various diffuse lung diseases, Prediction of survival by texture-based automated quantitative assessment of regional disease patterns on CT in idiopathic pulmonary fibrosis, Texture-based automated quantitative assessment of regional patterns on initial CT in patients with idiopathic pulmonary fibrosis: Relationship to decline in forced vital capacity, Quantitative assessment of change in regional disease patterns on serial HRCT of fibrotic interstitial pneumonia with texture-based automated quantification system, Computed Tomographic Biomarkers in Idiopathic Pulmonary Fibrosis. (b, c) Sagittal (b) and axial (c) contrast-enhanced CT images in a 21-year-old man with epiglottitis show thickening of the epiglottis (arrow in b) and aryepiglottic folds (arrows in c). Future research should focus on the development and validation of simpler nodule evaluation algorithms, possibly incorporating novel diagnostic modalities, such as molecular signatures, biomarkers, and liquid biopsies. In the most current Fleischner society guidelines, the adoption of prediction models is clearly discouraged. In general, these patients are followed up with a sequential pulmonary function test and CT. The accumulated evidence on lung cancer and environmental tobacco smoke. In addition, major technical concerns exist regarding nodule volumetry during follow-up. This tool showed that the quantified interstitial features were associated with reduced lung function, worse quality of life, and increased mortality, and more of the lung was affected by interstitial features for each copy of the minor allele of the gene encoding mucin 5B promoter polymorphism (1; minor allele as heterozygote: 2; minor allele as homozygote) (31). With petrous apicitis, CT images show opacification of the petrous apex air cells, which may also demonstrate coalescence, with more extensive erosion of the petrous apex in advanced cases (Fig 20). In fact, contrast material may obscure or confound the detection of a small foreign body. Carotidynia in a 29-year-old woman. A jugular venous thrombus may be bland, tumorous, or septic. AAH is a pre-malignant cause of nodular GGO and is more commonly associated with lower attenuation on CT and smaller nodule size (<10mm) compared to adenocarcinoma. The current OSHA PEL for respirable dust containing crystalline silica (quartz) for general industry is as follows [29 CFR 1910.1000]: The NIOSH recommended exposure limit (REL) for respirable crystalline silica is 0.05 mg/m3 (50 g/m3) as a TWA for up to 10 hours/day during a 40-hour workweek [NIOSH 1974]. Intraparotid ducts typically are not visible unless they are dilated. Valves, which are visible in the internal jugular veins occasionally, and heterogeneous enhancement due to the mixing of opacified and nonopacified blood should not be mistaken for thrombosis. However, the role of ILA as a risk factor for COVID-19 infection and the prognostic significance of ILA identified at CT after COVID-19 infection remain to be investigated. A chronic form of invasive fungal sinusitis may occur in immunocompetent patients, in whom the condition progresses over months to years (57). Many times they are benign (noncancerous). It indicates increased density in these areas. This defect leads to the formation of a false lumen, which is frequently accompanied by narrowing or occlusion of the true lumen (51). 0, 30 August 2022 | Radiology, Vol. Kim HY, Shim YM, Lee KS, et al. The left superior ophthalmic vein (black arrowhead) is dilated and not enhanced. We take your privacy seriously. Small cell lung cancer with nodal metastases; Nodular pattern: Silicosis / Pneumoconiosis: predominantly centrilobular and subpleural nodules. MMWR 39(25):433-437. V. Courtney Broaddus MD, in Murray & Nadel's Textbook of Respiratory Medicine, 2022. Xiao F, Liu D, Guo Y, Shi B, Song Z, Tian Y, et al. Axial nonenhanced CT images show the radiodense bone (black arrows) in the cervical esophagus, posterior to the larynx. Identify common pathologic entities found at neck CT in the emergency department. Wooden foreign bodies have air attenuation in the acute phase and therefore are best detected by using lung windows, and they may mineralize and increase in attenuation with time (30). The importance of shared decision-making between patients and clinicians could not be overstated. [98] When encountered, they obviate the need for further lung nodule investigation. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) Non-Small Cell Lung Cancer Version 2.2019. Increasing age is a clear risk factor for ILA (40,41). Additional similar lesions were seen on other images (not shown). Medical examinations should be available to all workers who may be exposed to respirable crystalline silica. The amount of air flow through the supplied-air respirator was not determined. The trachea (black arrow) and esophagus (black arrowhead) also are seen. Chronic rhinitis occurs when there's long-term inflammation in the lining of your nose. Exposures to respirable crystalline silica at the following construction sites were below the NIOSH REL of 0.05 mg/m3 for up to 10 hours/day during a 40-hour workweek [NIOSH 1974]. Please direct comments, questions, or requests for additional information to Dr. Gregory Wagner, Director, Division of Respiratory Disease Studies, NIOSH, 1095 Willowdale Road, Morgantown, West Virginia 26505-2888; Telephone: (304) 285-5749. [107,108] It has been shown that information on the probability of cancer is actually deemed reassuring by most patients;[107] a detailed discussion including expected risks and benefits associated with the different management options promotes adherence to evaluation plans. Viral infections are the most common cause of reactive adenopathy in children and young adults. Nocardia and Cryptococcus may also cause infections in silicosis victims [Ziskind et al. The performance of 1D and 2D measurements depends mainly on nodule size, technical conditions and reading setting. Second lung cancers in patients after treatment for an initial lung cancer. By using semi-automated/automated methods the ROI is defined automatically or by starting from a point inside the nodule selected by the user. [1,2,3,4] Based on observations in high-risk patients from lung cancer screening trials,[10,84] a cut diameter below 6 mm is proposed by most recent guidelines as an indicator of acceptably low cancer risk (<1%). When gray areas are visible instead, it means that something is partially filling this area inside the lungs. Figure 3. Rare intracranial manifestations include sigmoid sinus thrombosis, meningitis, and brain abscess. Learn about the benefits, risks, and accuracy of low dose CT scans for lung cancer detection, as well as who should be screened for lung cancer, and, PET scan is an imaging technique that uses a radioactive tracer to locate tissue differences at a molecular level. Viewer, CT of the Neck: Image Analysis and Reporting in the Emergency Setting, Skull Baserelated Lesions at Routine Head CT from the Emergency Department: Pearls, Pitfalls, and Lessons Learned, Imaging Evaluation of Pediatric Parotid Gland Abnormalities, Imaging the External Ear: Practical Approach to Normal and Pathologic Conditions, Non-Traumatic Head and Neck Emergencies and Their Mimics: A Review of CT and MRI Findings and Differential Diagnostic Considerations. [51] reported a maximum measurement error of 6.38% (upper limit of the 95% limit of acceptability) and underlined that a 6.38% increase in volume corresponds to a 2.1% increase in diameter (e.g. Axial contrast-enhanced CT images show opacification of the frontal sinuses (* in a) and a rim-enhancing epidural fluid collection (black arrow in b) just superior to the frontal sinus, which is consistent with an epidural abscess. After a CT scan or X-ray, a radiologist will look at the scan to determine if there are areas of concern. 2. Hasegawa M, Sone S, Takashima S, Li F, Yang ZG, Maruyama Y, et al. Similar results have been reported in the detection and segmentation of PSNs and, interestingly, a quantification of the solid component was related to pathological prognostic factors, such as lymphatic, vascular and pleural invasion [75, 81, 82]. supported by the National Institutes of Health (grant nos. Finally, the risk prediction models that integrate clinical and nodule characteristics besides size and the role of nodule size as a factor affecting the critical time for follow-up are briefly discussed. Graves disease is the most common autoimmune disease and the most common cause of hyperthyroidism. Pulmonary amyloidosis may be localised or part of systemic amyloidosis. Follow-up is recommended for those with <10% malignancy risk based either on the Brock or the Herder model, while those with a higher Herder model risk score are candidates for nonsurgical biopsy (10%-70% risk) or surgical excision (>70% risk). Normal epiglottis versus epiglottitis in two patients. Focal interstitial fibrosis presents a unique challenge when differentiating from malignant nodular GGOs on CT imaging. Descending mediastinitis in a 50-year-old woman who recently underwent a dental procedure. Regarding technical issues, nodules are better detected and characterised using thin and contiguous CT sections, as confirmed by results in the literature [2, 5761]. There is also bone dehiscence (black arrow) along the dorsal aspect of the petrous apex. Determination of lung nodule malignancy is pivotal, because the early diagnosis of lung cancer could lead to a definitive intervention. 42, No. (c) Axial contrast-enhanced CT image (lung window) obtained inferior to a shows a nodular opacity (arrow) at the left lung apex, consistent with a septic pulmonary embolus. Chang B, Hwang JH, Choi YH, Chung MP, Kim H, Kwon OJ, et al. The parotid gland is the only salivary gland that contains lymph nodes. Complicated silicosis (also known as progressive massive fibrosis [PMF]) is present if the largest opacity is 1 cm in diameter. Han D, Heuvelmans MA, Oudkerk M. Volume versus diameter assessment of small pulmonary nodules in CT lung cancer screening. Nodal metastases usually lack the surrounding inflammatory stranding that is seen with bacterial adenitis. However, in the setting of neck pain, degenerative disease may be relevant with regard to the symptoms reported by the patient. Exposure-response analysis and risk assessment for lung cancer in relationship to silica exposure: A 44-year cohort study of 34,018 workers. Kodama K, Higashiyama M, Takami K, et al. Chen CL, Hsu LI, Chiou HY, Hsueh YM, Chen SY, Wu MM, et al. However, there are already experimental data showing that electronic cigarette use is associated with exposure to well-known lung carcinogens[35,36] and may cause DNA damage in vitro and in vivo. The danger space is a well-described potential space between the alar fascia anteriorly and the prevertebral fascia posteriorly. The various management recommendations according to nodule size and attenuation, reported in published guidelines, are discussed below and comparatively summarized in Table 4. McWilliams et al. In the United States, the most common cause of goiter is Hashimoto thyroiditis, whereby the gland is unable to produce an adequate amount of thyroid hormone and is continuously stimulated by thyroid-stimulating hormone to enlarge. NIOSH testimony to the U.S. Department of Labor: statement of the National Institute for Occupational Safety and Health. Lin YH, et al. Liu Y, Steenland K, Rong Y, Hnizdo E, Huang X, Zhang H, et al. Figure 15. There is bone erosion of the anterior wall of the right EAC, which is also the posterior wall of the temporomandibular joint (black arrowhead). NIOSH respirator user notice: type CE abrasive-blast supplied-air respirators. There are several technical factors affecting nodule volume estimation, such as section thickness [40, 68, 69, 8689] and overlapping [90, 91], pitch mode [92], reconstruction algorithm [86, 8991, 9395] and intravenous contrast medium injection [9597], as summarised in table 2. ILA is associated with reduced exercise capacity (6-minute walk distance: 19 m [95% CI: 33, 5], P = .008) (10). Sometimes it is temporary and the result of a short-term illness. Findings of pulmonary edema include interlobular septal thickening and nodular or confluent ground-glass opacities, which are often accompanied by pleural effusions (Fig E12). CT images are acquired helically, from the orbital roofs to the aortic arch, by using 120 kVp and 100300 mA, with the exact tube current varying according to patient factors. Retropharyngeal edema due to calcific tendinitis of the longus colli in a 71-year-old woman. Tonsillitis in a 34-year-old man. If there has been a perforation, extraluminal gas and fluid may be present. The incidence of indeterminate pulmonary nodules has risen constantly over the past few years. Young RP, Duan F, Chiles C, Hopkins RJ, Gamble GD, Greco EM, et al. Sawing of concrete pavement containing crystalline silica during highway construction. [92,93], Perifissural nodules, defined as solid nodules in contact with a fissure or the pleural surface,[94] are considered benign, most probably depicting intrapulmonary lymph nodes. Boffetta P, Pershagen G, Jckel KH, Forastiere F, Gaborieau V, Heinrich J, et al. Clinical model to estimate the pretest probability of malignancy in patients with pulmonary focal ground-glass opacity. (b) Image in a obtained in soft-tissue windows shows epidural phlegmon (white arrow) and nonenhanced foci (black arrows), consistent with abscess. (E) Honeycombing is demonstrated as appearance of clustered cystic air spaces (arrow). As for volumetric measurement, an existing interscan variability has been described for nodule mass assessment, and an increase in nodule mass of 30% has been regarded as a significant growth [134]. Vol. In the Spring of 1994, while he was on a ventilator, he died from respiratory failure. There is usually bilateral involvement, which may lead to airway obstruction at the level of the oral cavity and oropharynx (4). (b, c) Sagittal (b) and axial (c) contrast-enhanced CT images in a 21-year-old man with epiglottitis show thickening of the epiglottis (arrow in b) and aryepiglottic folds (arrows in c). Male sex has been identified as a risk factor in some studies (9,16) but not in all studies. In patients with pneumatized petrous apices, petrous apicitis, a condition analogous to mastoiditis, can develop in the petrous apex (61). However, a longer period before the initial follow-up has been recommended for managing SSNs, because of their indolent nature when cancerous [7]. Lee KH, Goo JM, Park SJ, Wi JY, Chung DH, Go H, et al. When considering subsolid nodules the presence and size of a solid component is the major determinant of malignancy and nodule management, as reported in the latest guidelines. He wore a disposable particulate respirator and used a floor-stand fan to direct dust out the window. Measurement variability of persistent pulmonary subsolid nodules on same-day repeat CT: what is the threshold to determine true nodule growth during follow-up? Ground-glass opacity nodules can be divided into two types: pure and partially solid. In a preliminary experience with nodule 3D evaluation, Revel et al. NIOSH [1991a]. CT image showing halo sign in patient with pulmonary aspergillosis. Internal cysts and a calcification also are noted. Axial nonenhanced CT image shows an enlarged thyroid gland (black *) surrounding the trachea (arrow), which is narrowed to 8 5 mm. Numerous veins are visible on contrast-enhanced neck CT images. (c) Coronal contrast-enhanced CT image at the level of the parotid glands in a 22-year-old woman with acute left parotiditis shows edema, enlargement, and hyperenhancement of the left parotid gland (white arrowhead). [84] Most of these cases represent lung adenocarcinomas. Risk of second primary cancer among bladder cancer patients: A population-based cohort study in korea. The presence of degenerative changes should be noted, at least in general terms, and if severe spinal canal stenosis or an alignment abnormality is present, a more detailed description is warranted. Potential causes of centrilobular GGOs include pulmonary calcifications from metastatic disease, some types of idiopathic interstitial pneumonias, hypersensitivity pneumonitis, aspiration pneumonitis, cholesterol granulomas, and pulmonary capillary hemangiomastosis. [7] Rounded lesions measuring more than 3 cm in diameter are termed lung masses and should be considered indicative of lung cancer until histologically proven otherwise. Study findings have shown that a significant proportion of lung cancers missed at chest radiography are in the upper regions of the lung (70). Use Type CE pressure-demand or positive-pressure, abrasive-blasting respirators when sandblasting. ncbi.nlm.nih.gov/pmc/articles/PMC7935089/, sciencedirect.com/science/article/abs/pii/S036301881400005X?via%3Dihub, ncbi.nlm.nih.gov/pmc/articles/PMC6909955/, ncbi.nlm.nih.gov/pmc/articles/PMC7434019/, nhlbi.nih.gov/news/2020/medical-imaging-advances-may-reduce-radiation-risk-vulnerable-patients, ncbi.nlm.nih.gov/pmc/articles/PMC7350036/. However, extracapsular tumor extension can mimic inflammatory stranding where there are indistinct nodal margins or after biopsy and radiation when the lymph node may have poorly defined margins (45). By using a field of view of 360mm and an electronic matrix of 512512, as is commonly applied in chest CT scan acquisition, the pixel dimension is 0.7mm [56]. It extends from the skull base to the diaphragm, through which head and neck infection can extend into the mediastinum (24). Although classically thought of as a disease of children, epiglottitis also affects adults, being most famously the likely cause of the death of George Washington in 1799 (16). Sample warning sign for silica work area requiring respirators. [4], Ground-glass opacity is most often used to describe findings in high-resolution CT imaging of the thorax, although it is also used when describing chest radiographs. ). Additive synergism between asbestos and smoking in lung cancer risk: A Systematic review and meta-analysis. Suggested CT protocols for quantitative imaging analysis have been published by the Quantitative Imaging Biomarkers Alliance of the Radiological Society of North America (53). CT image showing mosaic attenuation pattern in patient with hypersensitivity pneumonitis. This information can be helpful to the emergency and admitting physicians, particularly when the diagnosis was not made at chest radiography. The higher rate of stone formation in the submandibular gland is due to the small papillary orifice, ascending course of the (Wharton) duct, higher viscosity of saliva, and slow salivary flow rate (25). Table 5: Scenario and Radiologic Reporting Examples. Before this workers diagnosis, he had never seen a doctor and had never had a chest X-ray. It is marked by inflammation and scarring in the form of nodular lesions in the upper lobes of the lungs.It is a type of pneumoconiosis. The diesel exhaust in miners study: A nested case-control study of lung cancer and diesel exhaust. We avoid using tertiary references. Likewise, the ratio of the solid component to total tumour is related with tumour histology and therefore is a useful method of estimating prognosis [128, 129]. Differences in volume estimation have been reported when using different software and different algorithms of correction of partial volume effect artefacts [57, 67, 116118]. Calcific tendinitis of the longus colli, technically a prevertebral process, results from an inflammatory reaction to hydroxyapatite deposits within the longus colli muscle or tendon (27). Bland thrombus is frequently associated with indwelling venous catheters, such as hemodialysis catheters, and can also be seen in thrombophilic conditions. (B) ILA with central predominance. When a substance other than air fills an area of the lung it increases that A study in family members of patients with familial interstitial pneumonia showed that deep learningbased textural evaluation had a sensitivity of 84% and a specificity of 86% for the detection of early interstitial change (19). DHHS [1991]. Use abrasives containing less than 1% crystalline silica during abrasive blasting to prevent quartz dust from being released in the air. NIOSH [1988]. Nevertheless, other nodule morphological characteristics have been associated with an increased risk of malignancy. Mucor sinusitis in a 59-year-old woman with diabetes. Diffuse, central, laminated, and popcorn calcification patterns are predictors of benign etiology. Due to the novelty of COVID-19, large studies investigating the long-term pulmonary CT changes have yet to be completed. According to the glossary of terms for chest imaging proposed by the Fleischner Society, a lung nodule is defined as an approximately rounded opacity more or less well-defined measuring up to 3 cm in diameter. Cigarette smoking and lung cancer Relative risk estimates for the major histological types from a pooled analysis of case-control studies. Respiratory protection was not used by any of the workers present. [1] Equivalence of these approaches remains unknown, and choice is usually guided by nodule exact size, location, and morphology as well as patient- (clinical risk factors, comorbidities, suitability for lung resection, and preferences) and health-care system-related (resource availability and local expertise) factors. Learn about causes and treatment. Rarely, such infections extend into the mediastinum and result in a life-threatening complication known as descending necrotizing mediastinitis. Reports in the current literature [17, 141] state that GGNs with diameter 6mm should be followed-up for 5years, with time scan intervals of 2years, while PSN with a solid component <6mm should be evaluated annually for 5years. Typically, the growth of these microorganisms is favored by particular soil characteristics and may involve complex life cycles including amoebae or animal hosts. [49] observed that a maximum diameter of the solid component of 3mm was predictive of a pre-invasive or minimally invasive histology and two volumetric measurements (solid volume 1.5cm3; percentage of solid volume 63%) were found to be independent indicators associated with increased likelihood of recurrence and/or death in patients with stage I adenocarcinoma [127]. Information about dust controls was not available. Truong MT, Ko JP, Rossi SE, Rossi I, Viswanathan C, Bruzzi JF, et al. patients with AIDS) or immunosuppressed individuals, is a classic cause of diffuse GGOs. Radiologists should systematically record the presence, morphologic characteristics, distribution, and subcategories of ILA (ie, nonsubpleural, subpleural nonfibrotic, and subpleural fibrotic), as these are informative for predicting progression and mortality. Figure 17c. Multiple bilateral alveolar opacities suggest bacterial infection (most commonly staphylococcal) or fungal disease.Opportunistic infections in immunocompromised patients are much more likely to be Sinusitis may be acute or chronic and have an allergy-related, viral, bacterial, or fungal cause. In the setting of suspected cervical spine disease, dedicated CT or MRI of the spine is preferred over neck CT. A larger number of results derived from studies using newer generation scanners did not confirm the previous observations. On CT images, the subcutaneous fat and muscular structures should have sharp definition without infiltration of the subcutaneous fat. The major salivary glands include the parotid, submandibular, and sublingual glands. Note the tapered superior and inferior margins in b. an evaluation of the workers ability to perform the work while wearing a respirator. Online ISSN: 1600-0617, Copyright 2022 by the European Respiratory Society, Institute of Radiology, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy. Therefore, in the acute setting, careful inspection of the cervical spine is mandatory at neck CT. Bacterial infection of an intervertebral disk, or discitis, is typically accompanied by infection of the adjoining vertebrae (osteomyelitis) and may be due to hematogenous seeding, direct spread from retropharyngeal or paraspinal infection, or inoculation by way of spinal instrumentation. How Long Does It Take for Long COVID Symptoms to Go Away? Gradenigo syndrome is a classic manifestation of petrous apicitis and constitutes the triad of facial pain (reflecting involvement of the trigeminal nerve in Meckels cave), ophthalmoplegia (reflecting involvement of the sixth cranial nerve in Dorellos canal), and otalgia and otorrhea (reflecting otomastoiditis). 3: Robbie H, Daccord C, Chua F, et al. Risk for second malignancies in non-Hodgkin's lymphoma survivors: A meta-analysis. Few studies have reported the pathologic correlation of ILA (34,35). The diagnosis of angioedema as the cause of head and neck swelling is usually based on clinical examination findings and the exclusion of other serious diagnoses. Pulmonary fibrosis (fibrous tissue in the lung) may or may not develop in acute cases of silicosis, depending on the time between exposure and onset of symptoms. Twelve Areas of Assessment on the Neck CT Analysis Checklist. The absence of these characteristics defines low probability of malignancy (<5%), while patients with a mixture of high- and low-risk features are considered to have an intermediate probability (5%-65%), BTS guidelines are the only to emphasize the use of prediction models for nodule risk assessment. Although it can sometimes be seen in normal lungs, common pathologic causes include infections, interstitial lung disease, and pulmonary edema. MAC lung disease in this population is sometimes labeled the Lady Windomere syndrome . selection of proper NIOSH-approved respirators. Retropharyngeal edema due to calcific tendinitis of the longus colli in a 71-year-old woman. Zygomycetes fungi such as Mucor species cause up to 80% of cases in patients with diabetes, while Aspergillus species cause up to 80% of cases in patients with neutropeniafor example, in cases of chemotherapy, bone marrow transplant, and acquired immunodeficiency syndrome (57). Lee SM, Park CM, Goo JM, Lee HJ, Wi JY, Kang CH, et al. [10] In addition, AAH often lacks the solid features and spiculated appearance that are often associated with malignant growths. People affected by this type of lung [3] A defining feature of these GGOs is the lack of involvement of the interlobular septum. [10,38,39,40] More than half of all cancers, including lung cancer, develop above the age of 70. We do not capture any email address. 1988]. Many clinical studies have investigated various aspects of ILA such as risk factors (4,6,7,9,12,27,28), imaging progression (7,8,23), association with clinical outcomes (4,6,810,15,27,2933), pathologic correlation (34,35), and quantification (19,31,3638). Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years' observations on male British doctors. The populations that are most at risk for acute sialadenitis are elderly persons and neonates. CT screening for lung cancer: Importance of emphysema for never smokers and smokers. Furthermore, mucosal thickening can persist for 8 weeks following the resolution of sinusitis (56). Few experiences reported a low performance of volumetry due to tube current reduction [76, 99, 100]. The utility of nodule volume in the context of malignancy prediction for small pulmonary nodules. Engineering controls are hazard controls designed into equipment and workplaces. These findings are merged in the Impression section, with the final diagnosis being Lemierre syndrome (Figure E15). Update in the evaluation of the solitary pulmonary nodule. [17][21], Preliminary reports have shown many patients have residual GGOs at time of discharge from the hospital. Currently, four Type CE abrasive-blasting respirators are certified by NIOSH [NIOSH 1996]: NIOSH recommends that workers wear a Type CE, pressure-demand or positive-pressure, abrasive-blasting respirator (APF of 1,000 or 2,000) during abrasive-blasting operations that involve crystalline silica. Some of these determinants have been included and tested in composite prediction models, developed with the scope to assist clinicians in the difficult task of nodule characterisation [3, 10, 137]. Eur Respir Rev 2017; 26: 170051. Cavernous sinus thrombosis in a 14-year-old girl. Wiener RS, Gould MK, Woloshin S, Schwartz LM, Clark JA. Nodule growth, determined by imaging surveillance, could be used as a diagnostic tool for assessing malignancy [5]. Mehta HJ, Ravenel JG, Shaftman SR, Tanner NT, Paoletti L, Taylor KK, et al. Detection of Post-COVID-19 Lung Abnormalities: Photon-counting CT versus Same-day Energy-integrating Detector CT, Interstitial Lung Abnormalities at CT: Subtypes, Clinical Significance, and Associations with Lung Cancer, Prevalence and Long-term Outcomes of CT Interstitial Lung Abnormalities in a Health Screening Cohort, Time to Start Describing Fibrotic Interstitial Lung Abnormalities in the Chest CT Report, Traction Bronchiectasis/Bronchiolectasis on CT Scans in Relationship to Clinical Outcomes and Mortality: The COPDGene Study, Traction Bronchiectasis and Bronchiolectasis at CT Predicts Survival in Individuals with Interstitial Lung Abnormalities: The COPDGene Study, Long-Term Lung Abnormalities Associated with COVID-19 Pneumonia, Interstitial Lung Abnormalities: Poor Prognosis for Patients with Lung Cancer, Interstitial Lung Abnormality: Recognition and Perspectives, Reviewing Idiopathic Interstitial Pneumonia's Radiographic Features According to the Latest American Thoracic Society / European Respiratory Society Updates, What's New in Interstitial Lung Disease? Left retropharyngeal suppurated lymph node and retropharyngeal abscess in a 5-year-old boy. Use drills that have a positive-pressure cab with air conditioning and filtered air supply to isolate the driller from the dust. Evaluation of individuals with pulmonary nodules: When is it lung cancer? Low-dose computed tomography, lung cancer screening, lung nodule management, lung nodules. (a) Axial contrast-enhanced CT image (bone window) shows tympanomastoid opacification (*). Pneumonia appears as nodular and/or consolidative opacities in the lung parenchyma. Federal government websites often end in .gov or .mil. A 324-minute personal air sample indicated a respirable quartz concentration of 0.80 mg/m3. Subcutaneous edema (arrows) also is present. sharing sensitive information, make sure youre on a federal Another method of measuring nodule size is to assess the average diameter, calculated between the maximal long-axis and perpendicular maximal short-axis diameters assessed on transverse CT sections. When possible, specific involvement of the sublingual and submandibular spaces should be described owing to potential implications for drainage. More recently, the Bayesian inference malignancy calculator model proved to be an accurate tool for characterising pulmonary nodules by guiding lesion-tailored diagnostic and interventional procedures during work-up [138]. Management of lung nodules detected by volume CT scanning. The prognostic significance of pure ground glass opacities in lung cancer computed tomographic images. A detailed history of present and past occupations must be an integral part of the initial evaluation of any patient with lung nodules. Pleuroparenchymal fibroelastosis is a distinct radiologic entity, which has not been systematically studied in asymptomatic patients. Since the advent of the Haemophilus influenzae type B vaccine, there has been a dramatic reduction in epiglottitis cases among children. From a practical standpoint, this entails examination of the nasal cavity and nasopharynx, oral cavity and oropharynx, hypopharynx, larynx, and imaged portions of the trachea and esophagus. Visualized structures include the trachea, esophagus, aortic arch, and arch vessels, as well as the distal internal jugular veins, brachiocephalic veins, and superior vena cava. A white male nonsmoker was diagnosed with advanced silicosis, emphysema, and asthma at age 49 after working 23 years as a tile installer. However, the symptoms of cervical spine disease may mimic those of extraspinal entities, prompting the use of neck CT with a soft-tissue protocol. Physician assessment of pretest probability of malignancy and adherence with guidelines for pulmonary nodule evaluation. Typically, the lungs appear black on a CT scan or X-ray. It is often the result of occlusion of small pulmonary arteries or obstruction of small airways leading to air trapping. Figure 11b. Potential chest CT pitfalls and overlaps in ILA are summarized in Table 3. 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