Carole A. Ridge

Epidemiology of Lung Cancer

Incidence and mortality attributed to lung cancer has risen steadily since the 1930s. Efforts to improve outcomes have not only led to a greater understanding of the etiology of lung cancer, but also the histologic and molecular characteristics of individual lung tumors. This article describes this evolution by discussing the extent of the current lung cancer epidemic including contemporary incidence and mortality trends, the risk factors for development of lung cancer, and details of promising molecular targets for treatment.

Pulmonary Embolism in Pregnancy: Comparison of Pulmonary CT Angiography and Lung Scintigraphy

OBJECTIVE The purpose of this study was to retrospectively compare the diagnostic adequacy of lung scintigraphy with that of pulmonary CT angiography (CTA) in the care of pregnant patients with suspected pulmonary embolism. MATERIALS AND METHODS Patient characteristics, radiology report content, additional imaging performed, final diagnosis, and diagnostic adequacy were recorded for pregnant patients consecutively referred for lung scintigraphy or pulmonary CTA according to physician preference. Measurements of pulmonary arterial enhancement were performed on all pulmonary CTA images of pregnant patients. Lung scintigraphy and pulmonary CTA studies deemed inadequate for diagnosis at the time of image acquisition were further assessed, and the cause of diagnostic inadequacy was determined. The relative contribution of the inferior vena cava to the right side of the heart was measured on nondiagnostic CTA images and compared with that on CTA images of age-matched nonpregnant women, who were the controls. RESULTS Twenty-eight pulmonary CTA examinations were performed on 25 pregnant patients, and 25 lung scintigraphic studies were performed on 25 pregnant patients. Lung scintigraphy was more frequently adequate for diagnosis than was pulmonary CTA (4% vs 35.7%) (p = 0.0058). Pulmonary CTA had a higher diagnostic inadequacy rate among pregnant than nonpregnant women (35.7% vs 2.1%) (p < 0.001). Transient interruption of contrast material by unopacified blood from the inferior vena cava was identified in eight of 10 nondiagnostic pulmonary CTA studies. CONCLUSION We found that lung scintigraphy was more reliable than pulmonary CTA in pregnant patients. Transient interruption of contrast material by unopacified blood from the inferior vena cava is a common finding at pulmonary CTA of pregnant patients.

Epidemiology and Staging of Renal Cell Carcinoma

Incidence and mortality trends attributed to kidney cancer exhibit marked regional variability, likely related to demographic, environmental, and genetic factors. Efforts to identify reversible factors, which lead to the development of renal cell carcinoma (RCC), have led not only to a greater understanding of the etiology of RCC but also the genetic and histologic characteristics of renal tumors. This article describes this evolution by discussing contemporary RCC incidence and mortality data, the risk factors for development of RCC, the histologic features, and anatomic and integrated staging systems that guide treatment.

Tracheobronchomalacia: current concepts and controversies.

Tracheobronchomalacia (TBM) results from weakness of the airway walls and/or supporting cartilage and affects both adult and pediatric populations. Diagnosing TBM is challenging because symptoms are nonspecific and overlap with those of other chronic respiratory disorders. Recent advances in multidetector computed tomography have facilitated the noninvasive diagnosis of TBM, and concurrent advances in management have improved clinical outcomes and created a need for greater awareness of the posttreatment appearance of the airways. This review discusses the physiology, histopathology, epidemiology, and clinical features of TBM; it also describes current methods of diagnosis, available therapies, and postoperative imaging evaluation.

Rapid needle-out patient-rollover time after percutaneous CT-guided transthoracic biopsy of lung nodules: effect on pneumothorax rate.

PURPOSE To assess the effect of a rapid needle-out patient-rollover time approach on the rate of pneumothorax after computed tomography (CT)-guided transthoracic needle biopsy of pulmonary nodules. MATERIALS AND METHODS The institutional review board approved the study, and all patients gave written informed consent. Between January 2008 and December 2009, percutaneous CT-guided lung biopsy was performed in 201 patients. Eighty-one biopsies were performed without (group 1) and 120 were performed with (group 2) a rapid needle-out patient-rollover time approach (defined as the time between removal of the biopsy needle and placing the patient biopsy-side down). Multivariate analysis was performed between groups for risk factors for pneumothorax, including patient demographic characteristics, lesion characteristics, and biopsy technique. RESULTS Mean rapid needle-out patient-rollover time (± standard deviation) was 9.5 seconds ± 4.8. Seventy-six percent of patients (75 of 98) achieved a needle-out patient-rollover time of 10 seconds or less. Unsuitability for the rapid needle-out patient-rollover time technique resulted in exclusion of 1.8% of patients. An increased number of pneumothoraces (25 [37%] vs 22 [23%]; P = .04) and an increased number of drainage catheter insertions were noted in group 1 compared with group 2 (10 [15%] versus four [4%], respectively; P = .029). At multiple regression analysis for group 1, lesion size and emphysema along the needle track were independent risk factors for pneumothorax (P = .032 and .021, respectively), and emphysema along the needle track was an independent predictor for insertion of a drainage catheter (P = .005). No independent predictor was identified for pneumothorax or insertion of a drainage catheter in group 2. CONCLUSION Rapid needle-out patient-rollover time during percutaneous CT-guided transthoracic lung biopsy reduces the rate of overall pneumothorax and pneumothorax necessitating a drainage catheter. Use of this technique attenuates the influence of traditional risk factors for pneumothorax.

Differentiating between Subsolid and Solid Pulmonary Nodules at CT: Inter- and Intraobserver Agreement between Experienced Thoracic Radiologists

PURPOSE To quantify the reproducibility and accuracy of experienced thoracic radiologists in differentiating between subsolid and solid pulmonary nodules at CT. MATERIALS AND METHODS The institutional review board of Beth Israel Deaconess Medical Center approved this multicenter study. Six thoracic radiologists, with a mean of 21 years of experience in thoracic radiology (range, 17-22 years), selected images of 10 solid and 10 subsolid nodules to create a database of 120 nodules; this selection served as the reference standard. Each radiologist then interpreted 120 randomly ordered nodules in two different sessions that were separated by a minimum of 3 weeks. The radiologists classified whether or not each nodule was subsolid. Inter- and intraobserver agreement was assessed with a κ statistic. The number of correct classifications was calculated and correlated with nodule size by using Bland-Altman plots. The relationship between disagreement and nodule morphologic characteristics was analyzed by calculating the intraclass correlation coefficient. RESULTS Interobserver agreement (κ) was 0.619 (range, 0.469-0.745; 95% confidence interval (CI): 0.576, 0.663) and 0.670 (range, 0.440-0.839; 95% CI: 0.608, 0.733) for interpretation sessions 1 and 2, respectively. Intraobserver agreement (κ) was 0.792 (95% CI: 0.750, 0.833). Averaged for interpretation sessions, correct classification was achieved by all radiologists for 58% (70 of 120) of nodules. Radiologists agreed with their initial determination (the reference standard) in 77% of cases (range, 45%-100%). Nodule size weakly correlated with correct classification (long axis: Spearman rank correlation coefficient, rs = 0.161 and P = .049; short axis: rs = 0.128 and P = .163). CONCLUSION The reproducibility and accuracy of thoracic radiologists in classifying whether or not a nodule is subsolid varied in the retrospective study. This inconsistency may affect surveillance recommendations and prognostic determinations.

Pulmonary CT Angiography Protocol Adapted to the Hemodynamic Effects of Pregnancy

OBJECTIVE The purpose of this study was to compare the image quality of a standard pulmonary CT angiography (CTA) protocol with a pulmonary CTA protocol optimized for use in pregnant patients with suspected pulmonary embolism (PE). MATERIALS AND METHODS Forty-five consecutive pregnant patients with suspected PE were retrospectively included in the study: 25 patients (group A) underwent standard-protocol pulmonary CTA and 20 patients (group B) were imaged using a protocol modified for pregnancy. The modified protocol used a shallow inspiration breath-hold and a high concentration, high rate of injection, and high volume of contrast material. Objective image quality and subjective image quality were evaluated by measuring pulmonary arterial enhancement, determining whether there was transient interruption of the contrast bolus by unopacified blood from the inferior vena cava (IVC), and assessing diagnostic adequacy. RESULTS Objective and subjective image quality were significantly better for group B-that is, for the group who underwent the CTA protocol optimized for pregnancy. Mean pulmonary arterial enhancement and the percentage of studies characterized as adequate for diagnosis were higher in group B than in group A: 321 ± 148 HU (SD) versus 178 ± 67 HU (p = 0.0001) and 90% versus 64% (p = 0.05), respectively. Transient interruption of contrast material by unopacified blood from the IVC was observed more frequently in group A (39%) than in group B (10%) (p = 0.05). CONCLUSION A pulmonary CTA protocol optimized for pregnancy significantly improved image quality by increasing pulmonary arterial opacification, improving diagnostic adequacy, and decreasing transient interruption of the contrast bolus by unopacified blood from the IVC.

Incidentally detected lung nodules: clinical predictors of adherence to Fleischner Society surveillance guidelines.

Objective The objective of this study was to determine adherence to incidentally detected lung nodule computed tomographic (CT) surveillance recommendations and identify demographic and clinical factors that increase the likelihood of CT surveillance. Materials and Methods A total of 419 patients with incidentally detected lung nodules were included. Recorded data included patient demographic, radiologic, and clinical characteristics and outcomes at a 4-year follow-up. Multivariate logistic regression models determined the factors associated with likelihood of recommended CT surveillance. Results At least 1 recommended surveillance chest CT was performed on 48% of the patients (148/310). Computed tomographic result communication to the patient (odds ratio [OR], 2.2; P = 0.006; confidence interval [CI], 1.3–4.0) or to the referring physician (OR, 2.8; P = 0.001; CI, 1.7–4.5) and recommendation of a specific surveillance time interval (OR, 1.7; P = 0.023; CI, 1.08–2.72) increased the likelihood of surveillance. Other demographic, radiologic, and clinical factors did not influence surveillance. Conclusions Documented physician and patient result communication as well as the recommendation of a specific surveillance time interval increased the likelihood of CT surveillance of incidentally detected lung nodules.

Computed tomography angiography for suspected pulmonary embolism: comparison of 2 adaptive statistical iterative reconstruction blends to filtered back-projection alone.

Objective The objective of this study was to analyze pulmonary computed tomography angiography image quality and pulmonary embolism (PE) depiction comparing 2 blends of adaptive statistical iterative reconstruction (ASIR) to filtered back-projection alone. Methods Seventy-nine consecutive patients (49 women, 30 men; 52 ± 18 years) underwent pulmonary computed tomography angiography (120 kVp, 100–600 mA) reconstructed with filtered back-projection alone (ASIR0), 30% ASIR (ASIR30), and 50% ASIR (ASIR50) for this institutional review board–approved study. Two radiologists independently assessed PE depiction and vascular characterization, which was correlated with body mass index. Results Twelve patients (15%) had PE. No difference in PE depiction (P = 0.536), pulmonary arterial attenuation (P = 0.22–0.99), or subjective vascular characterization score (P = 0.58–.016) was observed for either blend. ASIR30 and ASIR50 achieved higher signal-to-noise ratio (P = 0.001–0.003). Body mass index inversely correlated with vascular characterization scores (P < 0.001). Conclusions ASIR0, ASIR30, and ASIR50 accurately depict PE using the imaging parameters described. ASIR30 and ASIR50 improve objective image quality without altering subjective vascular characterization scores particularly when body mass index was less than 30 kg/m2.

Giant right atrial myxoma: characterization with cardiac magnetic resonance imaging☆

A 53-year-old woman presented to the emergency department with a 2-week history of dyspnoea and chest pain. Computed tomography pulmonary angiography was performed to exclude acute pulmonary embolism (PE). This demonstrated a large right atrial mass and no evidence of PE. Transthoracic echocardiography followed by cardiac magnetic resonance imaging confirmed a mobile right atrial mass. Surgical resection was then performed confirming a giant right atrial myxoma. We describe the typical clinical, radiologic, and pathologic features of right atrial myxoma.