Bart Ilsen

Pulmonary Disease in Cystic Fibrosis: Assessment with Chest CT at Chest Radiography Dose Levels

PURPOSE To investigate a computed tomographic (CT) protocol with iterative reconstruction at conventional radiography dose levels for the assessment of structural lung abnormalities in patients with cystic fibrosis ( CF cystic fibrosis ). MATERIALS AND METHODS In this institutional review board-approved study, 38 patients with CF cystic fibrosis (age range, 6-58 years; 21 patients <18 years and 17 patients >18 years) underwent investigative CT (at minimal exposure settings combined with iterative reconstruction) as a replacement of yearly follow-up posteroanterior chest radiography. Verbal informed consent was obtained from all patients or their parents. CT images were randomized and rated independently by two radiologists with use of the Bhalla scoring system. In addition, mosaic perfusion was evaluated. As reference, the previous available conventional chest CT scan was used. Differences in Bhalla scores were assessed with the χ(2) test and intraclass correlation coefficients ( ICC intraclass correlation coefficient s). Radiation doses for CT and radiography were assessed for adults (>18 years) and children (<18 years) separately by using technical dose descriptors and estimated effective dose. Differences in dose were assessed with the Mann-Whitney U test. RESULTS The median effective dose for the investigative protocol was 0.04 mSv (95% confidence interval [ CI confidence interval ]: 0.034 mSv, 0.10 mSv) for children and 0.05 mSv (95% CI confidence interval : 0.04 mSv, 0.08 mSv) for adults. These doses were much lower than those with conventional CT (median: 0.52 mSv [95% CI confidence interval : 0.31 mSv, 3.90 mSv] for children and 1.12 mSv [95% CI confidence interval : 0.57 mSv, 3.15 mSv] for adults) and of the same order of magnitude as those for conventional radiography (median: 0.012 mSv [95% CI confidence interval : 0.006 mSv, 0.022 mSv] for children and 0.012 mSv [95% CI confidence interval : 0.005 mSv, 0.031 mSv] for adults). All images were rated at least as diagnostically acceptable. Very good agreement was found in overall Bhalla score ( ICC intraclass correlation coefficient , 0.96) with regard to the severity of bronchiectasis ( ICC intraclass correlation coefficient , 0.87) and sacculations and abscesses ( ICC intraclass correlation coefficient , 0.84). Interobserver agreement was excellent ( ICC intraclass correlation coefficient , 0.86-1). CONCLUSION For patients with CF cystic fibrosis , a dedicated chest CT protocol can replace the two yearly follow-up chest radiographic examinations without major dose penalty and with similar diagnostic quality compared with conventional CT.

Predictive Value of Pattern Classification 24 Hours after Radiofrequency Ablation of Liver Metastases on CT and Positron Emission Tomography/CT

PURPOSE To assess a classification scheme for predicting local tumor progression (LTP) after radiofrequency (RF) ablation of liver metastases, using predefined patterns on contrast-enhanced computed tomography (CT) and positron emission tomography (PET) combined with CT (PET/CT) acquired 24 hours after RF ablation. MATERIALS AND METHODS There were 45 metastases in 20 patients treated. After 24 hours, imaging of the ablation zones was performed with contrast-enhanced PET/CT. Three independent radiologists prospectively assessed contrast-enhanced CT and combined PET/CT images to identify three patterns: pattern I, no tissue enhancement or fluorodeoxyglucose uptake between the ablation zone and the liver parenchyma; pattern II, a rimlike pattern; and pattern III, a peripheral nodule. PET/CT images obtained after 8-10 weeks were evaluated for LTP. The patterns were analyzed for their sensitivity, specificity, positive predictive value, and negative predictive value for predicting LTP. RESULTS Pattern I was most frequently observed (81% for contrast-enhanced CT and 61% for PET/CT) as well as for ablation zones that showed LTP (52% and 37%, respectively). Conversely, pattern II was observed for tumors that were completely ablated (6% and 29%, respectively). Patterns II and III together had the highest sensitivity for predicting LTP (48% and 63%, respectively); pattern III had the highest specificity (94% and 95%, respectively). For nodular patterns, test characteristics were better for PET/CT compared with contrast-enhanced CT, but the difference was not significant. Nodular patterns > 1 cm achieved high positive predictive value (both 100%). CONCLUSIONS Inflammation and hyperemia can hinder interpretation on imaging 24 hours after RF ablation, especially on PET/CT. Nodular patterns around the ablation zone on early contrast-enhanced CT and PET/CT have a high predictive value for LTP and should be taken into account for disease management.

Difficulties in the Interpretation of Chest Radiography

Reading chest X-rays is a difficult and challenging task, and is still important despite the development of powerful imaging techniques such as computed tomography, high-resolution computed tomography, and magnetic resonance. For a correct reading and interpretation of chest X-rays, it is necessary to understand the techniques, their limitations, basic anatomy and physiology, and to have a systematic system of scrutiny. However, we have to keep in mind that interpretation is submitted to perceptual and cognitive limitations and errors. In this chapter, chest X-ray will be discussed from prescription to report in all its facets.

Final Overall Results of a Study with a Novel Triplet Induction Chemotherapy Regimen (PACCAGE) Followed by Consolidation Radiotherapy in Locally Advanced Inoperable Non-small Cell Lung Cancer (NSCLC)

Introduction: We report the long term and overall results of a triplet induction chemotherapy regimen followed by standard radiotherapy in patients with locally advanced inoperable stage III non-small cell lung cancer. Methods: Three cycles of paclitaxel, carboplatin, and gemcitabine were administered every 3 weeks before standard fractionated consolidation radiotherapy starting at least 4 weeks after the last chemotherapy administration. Toxicity and antitumor response was assessed in detail as well as the progression free and overall survival. Results: Sixty-four patients (25 stage IIIA and 39 stage IIIB) received a total of 179 cycles of chemotherapy. Fifty-six received the planned three cycles. Full-dose radiotherapy was administered in 47 patients (73%), a reduced dose in 11 (17%) and none in six (10%). A 55% objective response rate (OR) (one complete and 34 partial responses) was observed after induction chemotherapy. After completing the whole treatment including radiotherapy, the OR was 40 of 47 evaluable patients (85%). Median time to progression was 10.9 month and median overall survival was 17.2 month, with a significant difference between stage IIIA and stage IIIB patients (23.4 versus 10.5 month; p = 0.011). The strongest predictor for a favorable long-term outcome was a metabolic complete response after chemotherapy. Conclusion: Induction chemotherapy with the paclitaxel, carboplatin, and gemcitabine regimen preceding radiotherapy in patients with locally advanced inoperable stage III non-small cell lung cancer was feasible and active. Radiotherapy could be administered at a full dose in the majority of patients with acceptable toxicity. Long-term survival results of this sequential chemoradiotherapy regimen appear similar to those of concurrent treatment. Patients not achieving a metabolic complete response after induction chemotherapy should be the focus of studies aiming at improved local control.

Comparative interpretation of CT and standard radiography of the chest

Many diseases affect the pleural space in both adults and children, including common diseases such as pneumonia, cancer and heart failure. Pleural effusion is the most common manifestation of pleural disease, and it is often a secondary effect of another disease process. Imaging plays a crucial role in the management of pleural disease. Chest radiography often remains the first examination in the assessment of these patients. Depending on the clinical context, the optimal imaging technique for further evaluation might be computed tomography (CT), ultrasound (US), or magnetic resonance (MR).

The quantitative link of lung clearance index to bronchial segments affected by bronchiectasis

In adult patients with cystic fibrosis (CF), the lung clearance index (LCI) derived from the multiple breath washout relates to both acinar and conductive ventilation heterogeneity. The latter component predicts an association between LCI and the number of bronchial segments affected by bronchiectasis. Here, we experimentally demonstrated this association in patients with CF, and also examined an ancillary group of patients with non-CF bronchiectasis. We conclude that lung disease severity in terms of number of bronchial segments results in an associated LCI increase, likely constituting a portion of LCI that cannot be reversed by treatment in patients with CF lung disease.

Interstitial Lung Disease

Interstitial lung disease (ILD), also known as diffuse parenchymal lung disease, is a broad category of lung diseases that are grouped together because of their similar clinical, radiographic, physiologic, or pathologic manifestations. It includes more than 130 disorders characterized by scarring (i.e., “fibrosis”) and/or inflammation of the lungs. The traditional approach to radiographic assessement of ILD consists primarily of determining whether the pulmonary parenchymal process is located within the interstitium. This is often difficult, although radiographic criteria have been established over the past years. Therefore, radiologists use a more descriptive approach to analyze the predominant pulmonary pattern, lung volumes, lesion distribution, and the presence of associated findings. High-resolution computed tomography (HRCT) has been widely accepted as the imaging gold standard for ILD. This chapter reviews the different interstitial patterns seen on chest radiograph classified and based on their appearance patterns on HRCT.

Significant response to dabrafenib in a patient with Erdheim–Chester disease with BRAFV600E mutation

386 Although many different treatment regimens have been proposed, only a few are based on ev‐ idence from randomized controlled trials. Only vemurafenib was approved by the Food and Drug Administration in November 2017 for patients with BRAFV600E ‐mutant ECD. The treatment reg‐ imens proposed in the literature include corti‐ coids, interferon alfa, anakinra, infliximab, tocili‐ zumab, cyclophosphamide, anthracyclines, vinca alkaloids, vemurafenib, dabrafenib, and a com‐ bination therapy of dabrafenib and trametinib. A large case series has been published that sup‐ ports the interferon alfa treatment.4 The efficacy of interferon α differs among pa‐ tients, depending on the site of disease involve‐ ment. In addition, interferon alfa has little or no impact in cases of severe disease, multiorgan disease, or specific organ involvement including the central nervous system as well as pulmonary and cardiovascular systems.5

Complete right-to-left shunt on lung perfusion SPECT results in the detection of a persistent left vena cava superior draining to the left atrium

In order to exclude acute pulmonary embolism, a lung perfusion scintigraphy was performed in a 53-year-old male, with a history of Fallot’s tetralogy. He had been immobilized because of a tibial fracture and complained of worsening chest pain and dyspnea.

The role of diffusion-weighted MR imaging and ADC values in the diagnosis of gastric tumors.

In order to exclude acute pulmonary embolism, a lung perfusion scintigraphy was performed in a 53-year-old male, with a history of Fallot’s tetralogy. He had been immobilized because of a tibial fracture and complained of worsening chest pain and dyspnea.