Efren J. Flores

The 10 Pillars of Lung Cancer Screening: Rationale and Logistics of a Lung Cancer Screening Program

On the basis of the National Lung Screening Trial data released in 2011, the U.S. Preventive Services Task Force made lung cancer screening (LCS) with low-dose computed tomography (CT) a public health recommendation in 2013. The Centers for Medicare and Medicaid Services (CMS) currently reimburse LCS for asymptomatic individuals aged 55-77 years who have a tobacco smoking history of at least 30 pack-years and who are either currently smoking or had quit less than 15 years earlier. Commercial insurers reimburse the cost of LCS for individuals aged 55-80 years with the same smoking history. Effective care for the millions of Americans who qualify for LCS requires an organized step-wise approach. The 10-pillar model reflects the elements required to support a successful LCS program: eligibility, education, examination ordering, image acquisition, image review, communication, referral network, quality improvement, reimbursement, and research frontiers. Examination ordering can be coupled with decision support to ensure that only eligible individuals undergo LCS. Communication of results revolves around the Lung Imaging Reporting and Data System (Lung-RADS) from the American College of Radiology. Lung-RADS is a structured decision-oriented reporting system designed to minimize the rate of false-positive screening examination results. With nodule size and morphology as discriminators, Lung-RADS links nodule management pathways to the variety of nodules present on LCS CT studies. Tracking of patient outcomes is facilitated by a CMS-approved national registry maintained by the American College of Radiology. Online supplemental material is available for this article.

Applications of Dual-Energy CT in Emergency Radiology

OBJECTIVE Recent technologic advances in MDCT have led to the introduction of dual-energy CT (DECT). The basic principle of DECT is to acquire images at two different energy levels simultaneously and to use the attenuation differences at these different energy levels for deriving additional information, such as virtual monochromatic images, artifact suppression, and material composition of various tissues. CONCLUSION A variety of image reconstruction and postprocessing techniques are available for better demonstration and characterization of pathologic abnormalities. DECT can provide both anatomic and functional information of different organ systems. This article focuses on the main applications of DECT in emergency radiology.

Dual-Energy CT: Spectrum of Thoracic Abnormalities

Recent studies have demonstrated that dual-energy computed tomography (CT) can provide useful information in several chest-related clinical indications. Compared with single-energy CT, dual-energy CT of the chest is feasible with the use of a radiation-dose-neutral scanning protocol. This article highlights the different types of images that can be generated by using dual-energy CT protocols such as virtual monochromatic, virtual unenhanced (ie, water), and pulmonary blood volume (ie, iodine) images. The physical basis of dual-energy CT and material decomposition are explained. The advantages of the use of virtual low-monochromatic images include reduced volume of intravenous contrast material and improved contrast resolution of images. The use of virtual high-monochromatic images can reduce beam hardening and contrast streak artifacts. The pulmonary blood volume images can help differentiate various parenchymal abnormalities, such as infarcts, atelectasis, and pneumonias, as well as airway abnormalities. The pulmonary blood volume images allow quantitative and qualitative assessment of iodine distribution. The estimation of iodine concentration (quantitative assessment) provides objective analysis of enhancement. The advantages of virtual unenhanced images include differentiation of calcifications, talc, and enhanced thoracic structures. Dual-energy CT has applications in oncologic imaging, including diagnosis of thoracic masses, treatment planning, and assessment of response to treatment. Understanding the concept of dual-energy CT and its clinical application in the chest are the goals of this article.

Pitfalls in the Imaging and Interpretation of Benign Thymic Lesions: How Thymic MRI Can Help.

Received July 21, 2015; accepted after revision September 4, 2015. and by aiding in the discernment of thymoma from lymphoma [2, 3]. Thymic MRI typically is prompted by an incidental finding noted in the thymic bed on chest CT. A prior chest CT examination enables focused MRI to best answer a defined clinical question. Although MRI is useful in the diagnosis of thymic lesions, it can be helpful only if it is performed and interpreted correctly and if certain pitfalls are avoided. The purpose of this article is to heighten the awareness of these pitfalls.

Case records of the Massachusetts General Hospital. Case 17-2015. A 44-year-old woman with intractable pain due to metastatic lung cancer.

Dr. Lecia V. Sequist: A 44-year-old woman with metastatic (stage IV) non–small-cell lung carcinoma was seen in the outpatient cancer center of this hospital because of intractable pain. The patient had been well until approximately 1 year before this evaluation, when pain in her right shoulder and scapula developed, followed by cough and an episode of hemoptysis. A chest radiograph that was obtained at another hospital reportedly showed findings suggestive of pneumonia. Antibiotic agents were administered, but the pain and radiographic abnormalities persisted. Nine months before this evaluation, computed tomography (CT) of the chest revealed an irregular mass (3.5 cm by 3.7 cm by 5.0 cm) in the anterior right upper lobe, along with multiple pleural nodules (most <1 cm in diameter) in the right hemithorax and mediastinal and right hilar lymphadenopathy (with nodes ≤12 mm in diameter). 18F-fluorodeoxyglucose positron-emission tomography and CT (PET–CT) reportedly revealed two indeterminate foci in the first and fifth lumbar vertebrae. Flexible bronchoscopy and mediastinoscopy with biopsy were performed. Dr. Mari Mino-Kenudson: Examination of a pretracheal lymph node–biopsy specimen revealed that multiple lymph-node fragments had been almost completely replaced by metastatic tumor deposits (Fig. 1A through 1D). There was a solid growth of tumor cells with infrequent and incomplete gland formation, a finding consistent with poorly differentiated adenocarcinoma. Immunohistochemical staining for thyroid transcription factor 1 was positive in the tumor cells, a finding consistent with adenocarcinoma of the lung. Because the patient had never smoked tobacco, genetic testing of tumor tissue for a mutation of the epidermal growth factor receptor gene (EGFR) was performed and revealed a deletion of 15 bp in exon 19 (Fig. 1E). A frameshift deletion mutation in exon 19 is known to confer sensitivity to EGFR tyrosine kinase inhibitors. Dr. Sequist: Therapy with erlotinib hydrochloride (150 mg daily) was begun 7 months From the Departments of Anesthesia, Critical Care, and Pain Medicine (M.M.K.), Palliative Care (M.M.K., K.P.D., T.J.R.), Medical Oncology (L.V.S.), Psychiatry (G.M.), Radiology (E.J.F.), and Pathology (M.M.-K.), Massachusetts General Hospital; and the Departments of Anesthesia, Critical Care, and Pain Medicine (M.M.K.), Palliative Care (M.M.K., K.P.D., T.J.R.), Medical Oncology (L.V.S.), Psychiatry (G.M.), Radiology (E.J.F.), and Pathology (M.M.-K.), Harvard Medical School — both in Boston.

Case 17-2015

Dr. Lecia V. Sequist: A 44-year-old woman with metastatic (stage IV) non–small-cell lung carcinoma was seen in the outpatient cancer center of this hospital because of intractable pain. The patient had been well until approximately 1 year before this evaluation, when pain in her right shoulder and scapula developed, followed by cough and an episode of hemoptysis. A chest radiograph that was obtained at another hospital reportedly showed findings suggestive of pneumonia. Antibiotic agents were administered, but the pain and radiographic abnormalities persisted. Nine months before this evaluation, computed tomography (CT) of the chest revealed an irregular mass (3.5 cm by 3.7 cm by 5.0 cm) in the anterior right upper lobe, along with multiple pleural nodules (most <1 cm in diameter) in the right hemithorax and mediastinal and right hilar lymphadenopathy (with nodes ≤12 mm in diameter). 18F-fluorodeoxyglucose positron-emission tomography and CT (PET–CT) reportedly revealed two indeterminate foci in the first and fifth lumbar vertebrae. Flexible bronchoscopy and mediastinoscopy with biopsy were performed. Dr. Mari Mino-Kenudson: Examination of a pretracheal lymph node–biopsy specimen revealed that multiple lymph-node fragments had been almost completely replaced by metastatic tumor deposits (Fig. 1A through 1D). There was a solid growth of tumor cells with infrequent and incomplete gland formation, a finding consistent with poorly differentiated adenocarcinoma. Immunohistochemical staining for thyroid transcription factor 1 was positive in the tumor cells, a finding consistent with adenocarcinoma of the lung. Because the patient had never smoked tobacco, genetic testing of tumor tissue for a mutation of the epidermal growth factor receptor gene (EGFR) was performed and revealed a deletion of 15 bp in exon 19 (Fig. 1E). A frameshift deletion mutation in exon 19 is known to confer sensitivity to EGFR tyrosine kinase inhibitors. Dr. Sequist: Therapy with erlotinib hydrochloride (150 mg daily) was begun 7 months From the Departments of Anesthesia, Critical Care, and Pain Medicine (M.M.K.), Palliative Care (M.M.K., K.P.D., T.J.R.), Medical Oncology (L.V.S.), Psychiatry (G.M.), Radiology (E.J.F.), and Pathology (M.M.-K.), Massachusetts General Hospital; and the Departments of Anesthesia, Critical Care, and Pain Medicine (M.M.K.), Palliative Care (M.M.K., K.P.D., T.J.R.), Medical Oncology (L.V.S.), Psychiatry (G.M.), Radiology (E.J.F.), and Pathology (M.M.-K.), Harvard Medical School — both in Boston.

Case 37-2017

A 36-year-old man was seen in the emergency department because of opioid overdose. The patient was found unresponsive and cyanotic in a park. Naloxone was administered and his mental status normalized, but hypoxemia persisted. A diagnosis and management decisions were made.

Should Dual-Energy Computed Tomography Pulmonary Angiography Replace Single-Energy Computed Tomography Pulmonary Angiography in Pregnant and Postpartum Patients?

Objective The study aims to compare single-energy (SE) and dual-energy (DE) computed tomography pulmonary angiography (CTPA) for evaluation of suspected pulmonary embolism in pregnant and postpartum patients. Materials and Methods Our study included 59 CTPA performed in pregnant/postpartum women (study group) comprised of 38 SE-CTPA and 21 DE-CTPA. The control group of 21 age- and weight-matched nonpregnant/nonpostpartum women underwent DE-CTPA. Two radiologists assessed pulmonary arterial enhancement, image quality, and artifacts. &kgr; Test and analysis of variance were performed. Results Fourteen of 38 pregnant/postpartum women (37%) had suboptimal SE-CTPA compared with just 10% (2/21) suboptimal DE-CTPA studies (P = 0.02). Mean Hounsfield unit (HU) in the pulmonary trunk was 550 ± 68 HU in the DE-CTPA pregnant/postpartum group and 245 ± 12 HU in the SE-CTPA (P < 0.001). The mean volume computed tomography dose index in the pregnant/postpartum patients for DE-CTPA and SE-CTPA were 9 ± 2 and 19 ± 8 mGy, respectively (P < 0.001). Conclusions Dual-energy CTPA substantially increased arterial enhancement for evaluation of pulmonary embolism in pregnant and postpartum women compared with SE-CTPA.

Impact of Delayed Time to Advanced Imaging on Missed Appointments Across Different Demographic and Socioeconomic Factors

PURPOSE The aim of this study was to investigate the impact of wait days (WDs) on missed outpatient MRI appointments across different demographic and socioeconomic factors. METHODS An institutional review board-approved retrospective study was conducted among adult patients scheduled for outpatient MRI during a 12-month period. Scheduling data and demographic information were obtained. Imaging missed appointments were defined as missed scheduled imaging encounters. WDs were defined as the number of days from study order to appointment. Multivariate logistic regression was applied to assess the contribution of race and socioeconomic factors to missed appointments. Linear regression was performed to assess the relationship between missed appointment rates and WDs stratified by race, income, and patient insurance groups with analysis of covariance statistics. RESULTS A total of 42,727 patients met the inclusion criteria. Mean WDs were 7.95 days. Multivariate regression showed increased odds ratio for missed appointments for patients with increased WDs (7-21 days: odds ratio [OR], 1.39; >21 days: OR, 1.77), African American patients (OR, 1.71), Hispanic patients (OR, 1.30), patients with noncommercial insurance (OR, 2.00-2.55), and those with imaging performed at the main hospital campus (OR, 1.51). Missed appointment rate linearly increased with WDs, with analysis of covariance revealing underrepresented minorities and Medicaid insurance as significant effect modifiers. CONCLUSIONS Increased WDs for advanced imaging significantly increases the likelihood of missed appointments. This effect is most pronounced among underrepresented minorities and patients with lower socioeconomic status. Efforts to reduce WDs may improve equity in access to and utilization of advanced diagnostic imaging for all patients.

Population-Based Health Engagement Opportunities Through Breast Imaging: A Population-Based Cross-Sectional Survey

PURPOSE As health care payment systems transition from fee-for-service to bundled payments, there is an increasing opportunity for radiologists to collaborate to improve population-based health care outcomes. Our purpose was to estimate the extent to which patients engaged in mammography underwent other additional imaging- and non-imaging-based preventative health services using Centers for Disease Control National Population Health Surveys. METHODS Women aged 40 to 74 in the 2014 Behavioral Risk Factor Surveillance System cross-sectional survey without histories of breast cancer who reported having a mammogram within the past 2 years were included. Adherence to recommended preventative services was based on US Preventive Services Task Force Recommendations, relative to the time at which the survey participant responded to the survey. Among women reporting being engaged in mammography, proportions of eligible women obtaining recommended preventative health services were calculated and stratified by demographics. RESULTS Of 172,245 women, 122,434 (71.1%) reported mammography within 2 years. The following percentages obtained recommended flu vaccines (49.2%), pneumococcal vaccines (69.5%), colorectal cancer screening (74.8%), and Papanicolaou test (93.2%). Women reporting mammography within the last 2 years with lower levels of education and income and who lacked health insurance or personal doctors were less likely to report receiving recommended preventative services (P < .001). CONCLUSIONS National population-based survey results suggest that large proportions of women engaged in mammography report are not up to date with a wide variety of recommended preventative health services, suggesting ample opportunities for radiology practices to partner with providers to improve population-based health outcomes and add value to health care systems.