Florian J. Fintelmann

Can sarcopenia quantified by ultrasound of the rectus femoris muscle predict adverse outcome of surgical intensive care unit patients as well as frailty? a prospective, observational cohort study

Objective: To compare sarcopenia and frailty for outcome prediction in surgical intensive care unit (SICU) patients. Background: Frailty has been associated with adverse outcomes and describes a status of muscle weakness and decreased physiological reserve leading to increased vulnerability to stressors. However, frailty assessment depends on patient cooperation. Sarcopenia can be quantified by ultrasound and the predictive value of sarcopenia at SICU admission for adverse outcome has not been defined. Methods: We conducted a prospective, observational study of SICU patients. Sarcopenia was diagnosed by ultrasound measurement of rectus femoris cross-sectional area. Frailty was diagnosed by the Frailty Index Questionnaire based on 50 variables. Relationship between variables and outcomes was assessed by multivariable regression analysis NCT02270502. Results: Sarcopenia and frailty were quantified in 102 patients and observed in 43.1% and 38.2%, respectively. Sarcopenia predicted adverse discharge disposition (discharge to nursing facility or in-hospital mortality, odds ratio 7.49; 95% confidence interval 1.47–38.24; P = 0.015) independent of important clinical covariates, as did frailty (odds ratio 8.01; 95% confidence interval 1.82–35.27; P = 0.006); predictive ability did not differ between sarcopenia and frailty prediction model, reflected by &khgr;2 values of 21.74 versus 23.44, respectively, and a net reclassification improvement (NRI) of −0.02 (P = 0.87). Sarcopenia and frailty predicted hospital length of stay and the frailty model had a moderately better predictive accuracy for this outcome. Conclusions: Bedside diagnosis of sarcopenia by ultrasound predicts adverse discharge disposition in SICU patients equally well as frailty. Sarcopenia assessed by ultrasound may be utilized as rapid beside modality for risk stratification of critically ill patients.

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.

Jejunal Diverticulosis: Findings on CT in 28 Patients

OBJECTIVE The purpose of our study was to better characterize the CT findings of jejunal diverticulosis by retrospectively reviewing abdominal CT scans of 28 patients with this condition on barium examinations. CONCLUSION Jejunal diverticula have characteristic findings on CT, appearing as discrete round or ovoid, contrast-, fluid-, or air-containing structures outside the expected lumen of the small bowel, with a smooth, barely discernible wall and no recognizable small-bowel folds. Not infrequently, these structures are seen to communicate directly with an adjoining small-bowel loop, a feature best recognized by scrolling the images. Our experience suggests that jejunal diverticulosis can often be recognized on the basis of the characteristic CT features of this condition.

Novel Diagnostic Approaches in Bing-Neel Syndrome

The central nervous system (CNS) manifestations of Waldenströms macroglobulinemia (WM) are known as the Bing-Neel syndrome (BNS). Patients with BNS can be classified into Group A and Group B based on the presence of lymphoplasmacytoid (LMP) cells within the brain parenchyma, leptomeninges, dura, and/or cerebrospinal fluid (CSF). To identify characteristic imaging findings for both Group A and Group B patients, we reviewed all 36 cases (26 referenced, 10 unreported) of proven WM with CNS symptoms, CSF analysis and/or biopsy, and magnetic resonance imaging (MRI) of the brain and/or spinal cord. Enhancement on MRI suggests invasion of the central neuraxis by LMP cells, and can help distinguish between Group A and Group B patients. In addition to differentiating true WM lesions in the CNS from ischemia, hyperviscosity events, and demyelinating lesions, evaluation of brain and spinal cord with gadolinium-enhanced MRI has the potential to guide management.

Repeat rates in digital chest radiography and strategies for improvement.

Purpose: To determine the repeat rate (RR) of chest radiographs acquired with portable computed radiography (CR) and installed direct radiography (DR) and to develop and assess strategies designed to decrease the RR. Materials and Methods: The RR and reasons for repeated digital chest radiographs were documented over the course of 16 months while a task force of thoracic radiologists, technologist supervisors, technologists, and information technology specialists continued to examine the workflow for underlying causes. Interventions decreasing the RR were designed and implemented. Results: The initial RR of digital chest radiographs was 3.6% (138/3818) for portable CR and 13.3% (476/3575) for installed DR systems. By combining RR measurement with workflow analysis, targets for technical and teaching interventions were identified. The interventions decreased the RR to 1.8% (81/4476) for portable CR and to 8.2% (306/3748) for installed DR. Conclusions: We found the RR of direct digital chest radiography to be significantly higher than that of computed chest radiography. We believe this is due to the ease with which repeat images can be obtained and discarded, and it suggests the need for ongoing surveillance of RR. We were able to demonstrate that strategies to lower the RR, which had been developed in the era of film-based imaging, can be adapted to the digital environment. On the basis of our findings, we encourage radiologists to assess their own departmental RRs for direct digital chest radiography and to consider similar interventions if necessary to achieve acceptable RRs for this modality.

Catecholamine Surge during Image-Guided Ablation of Adrenal Gland Metastases: Predictors, Consequences, and Recommendations for Management

PURPOSE To identify retrospectively predictors of catecholamine surge during image-guided ablation of metastases to the adrenal gland. MATERIALS AND METHODS Between 2001 and 2014, 57 patients (39 men, 18 women; mean age, 65 y ± 10; age range, 41-81 y) at two academic medical centers underwent ablation of 64 metastatic adrenal tumors from renal cell carcinoma (n = 27), lung cancer (n = 23), melanoma (n = 4), colorectal cancer (n = 3), and other tumors (n = 7). Tumors measured 0.7-11.3 cm (mean, 4 cm ± 2.5). Modalities included cryoablation (n = 38), radiofrequency (RF) ablation (n = 20), RF ablation with injection of dehydrated ethanol (n = 10), and microwave ablation (n = 4). Fisher exact test, univariate, and multivariate logistical regression analysis was used to evaluate factors predicting hypertensive crisis (HC). RESULTS HC occurred in 31 sessions (43%). Ventricular tachycardia (n = 1), atrial fibrillation (n = 2), and troponin leak (n = 4) developed during HC episodes. HC was significantly associated with maximum tumor diameter ≤ 4.5 cm (odds ratio [OR], 26.36; 95% confidence interval [CI], 5.26-131.99; P < .0001) and visualization of normal adrenal tissue on CT or MR imaging before the procedure (OR, 8.38; 95% CI, 2.67-25.33; P < .0001). No HC occurred during ablation of metastases in previously irradiated or ablated adrenal glands. CONCLUSIONS Patients at high risk of catecholamine surge during ablation of non-hormonally active adrenal metastases can be identified by the presence of normal adrenal tissue and tumor diameter ≤ 4.5 cm on pre-procedure CT or MR imaging.

Lung Cancers Associated With Cystic Airspaces: Natural History, Pathologic Correlation, and Mutational Analysis

Purpose: The aim of the study was to investigate the natural history of non–small cell lung cancers (NSCLCs) associated with cystic airspaces, including histopathology and molecular analysis. Materials and Methods: A total of 34,801 computed tomographic (CT) scans of 2954 patients diagnosed with NSCLC between 2010 and 2015 were evaluated for association with a cystic airspace. Characteristics on serial CT, 18F-fludeoxyglucose positron emission tomography, and pathologic analysis were recorded. Results: Cystic airspaces were associated with 1% of NSCLC cases (12 men and 18 women; median age, 66 y [range, 44 to 87 y]). Of the total number of patients, 97% had a smoking history. Twenty-four adenocarcinomas, 4 squamous cell carcinomas, and 2 poorly differentiated carcinomas were distributed throughout all lobes and were predominantly peripheral. Some cystic airspaces appeared in previously normal lungs, whereas others were preceded by subcentimeter nodules. Twenty of 30 cases demonstrated increased soft tissue due to wall thickening, increased loculations, enlargement and/or increased attenuation of a mural nodule, or replacement by a mass. 18F-fludeoxyglucose uptake was present if solid components measured >8 mm. Twenty of 30 patients demonstrated >1 cystic lesion or ground-glass nodule, lymphadenopathy, or evidence of prior lung resection. Pathologic analysis revealed that cystic airspaces correspond to a check-valve mechanism, adenocarcinoma superimposed on emphysema, cystification, and adenocarcinoma parasitizing a preexisting bulla. Fourteen of 26 tumors and 64% of adenocarcinomas tested positive for an alteration of KRAS with or without other alterations. Conclusions: Cystic airspaces preceded by nodules can evolve into NSCLCs. Wall thickening and/or mural nodularity may develop. Location in the periphery of the upper lobes, emphysema, additional cystic lesions or ground-glass nodules, lymphadenopathy, and prior lung cancer should further increase suspicion. Cystic airspaces on CT can be due to a check-valve mechanism obstructing the small airways, lepidic growth of adenocarcinoma in an area of emphysema, cystification of tumor due to degeneration, or adenocarcinoma growing along the wall of a preexisting bulla. KRAS mutations are the predominant genetic alterations.

Immune Checkpoint Inhibitor Cancer Therapy: Spectrum of Imaging Findings

Immune checkpoint inhibitors are a new class of cancer therapeutics that have demonstrated striking successes in a rapid series of clinical trials. Consequently, these drugs have dramatically increased in clinical use since being first approved for advanced melanoma in 2011. Current indications in addition to melanoma are non-small cell lung cancer, head and neck squamous cell carcinoma, renal cell carcinoma, urothelial carcinoma, and classical Hodgkin lymphoma. A small subset of patients treated with immune checkpoint inhibitors undergoes an atypical treatment response pattern termed pseudoprogression: New or enlarging lesions appear after initiation of therapy, thereby mimicking tumor progression, followed by an eventual decrease in total tumor burden. Traditional response standards applied at the time of initial increase in tumor burden can falsely designate this as treatment failure and could lead to inappropriate termination of therapy. Currently, when new or enlarging lesions are observed with immune checkpoint inhibitors, only follow-up imaging can help distinguish patients with pseudoprogression from the large majority in whom this observation represents true treatment failure. Furthermore, the unique mechanism of immune checkpoint inhibitors can cause a distinct set of adverse events related to autoimmunity, which can be severe or life threatening. Given the central role of imaging in cancer care, radiologists must be knowledgeable about immune checkpoint inhibitors to correctly assess treatment response and expeditiously diagnose treatment-related complications. The authors review the molecular mechanisms and clinical applications of immune checkpoint inhibitors, the current strategy to distinguish pseudoprogression from progression, and the imaging appearances of common immune-related adverse events. ©RSNA, 2017.

Immune Checkpoint Inhibitors in Lung Cancer: Imaging Considerations

OBJECTIVE The purpose of this article is to review the mechanisms of action of immune checkpoint inhibitors in the treatment of non-small cell lung cancer (NSCLC), highlight imaging manifestations of common adverse events, and discuss new criteria for using imaging to assess unique treatment response patterns. CONCLUSION Immune checkpoint inhibitor therapy is a breakthrough in cancer treatment that has shown unprecedented success when used for a variety of malignancies. In recent phase 3 clinical trials for NSCLC, monoclonal antibodies that target the programmed death-1 (PD-1) receptor and its ligand PD-L1 (i.e., the PD-1/PD-L1 axis) were associated with better overall survival in head-to-head comparisons with conventional cytotoxic chemotherapy. On the strength of the results of these trials, the PD-1 inhibitors nivolumab and pembrolizumab and the PD-L1 inhibitor atezolizumab recently received regulatory approval by the U.S. Food and Drug Administration for the treatment of advanced NSCLC. Because of their unique mechanisms of action, these agents differ from conventional cytotoxic chemotherapy in both patterns of treatment response and treatment-related adverse events. Given the rapidly expanding clinical use of immune checkpoint inhibitors and the central role of radiology in the care of patients with lung cancer, it is important for radiologists to be familiar with these agents and their unique imaging findings.

Case records of the Massachusetts General Hospital. Case 38-2014. An 87-year-old man with sore throat, hoarseness, fatigue, and dyspnea.

Dr. Leigh H. Simmons: An 87-year-old man with multiple chronic medical problems was seen in an outpatient clinic of this hospital because of sore throat and fatigue. The patient had been in his usual health until several weeks before presentation, when hoarseness, sore throat, and increasing fatigue developed. At the urging of his family, he was seen by his physician in an outpatient clinic of this hospital. He reported hoarseness, increasing facial puffiness, and periorbital swelling, with no chest pain, dyspnea, or new joint pains or muscle aches. The patient had hypertension, hyperlipidemia, and chronic kidney disease. Two months earlier, the creatinine level was 2.22 mg per deciliter (196 μmol per liter; reference range, 0.60 to 1.50 mg per deciliter [53 to 133 μmol per liter]), which was stable, as compared with values obtained the previous year. He also had hypothyroidism, with a normal thyrotropin level 8 months earlier (3.38 μU per milliliter [reference range, 0.40 to 5.00]), as well as gastroesophageal reflux disease, esophageal motility disorder, an abdominal aortic aneurysm, chronic back pain, depression related to the death of his wife several years before, and recurrent urinary tract infections. In the past, he had had pneumonia and had undergone angioplasty of the right renal artery (10 years earlier), a cholecystectomy, a lobectomy of the right middle lobe due to a spiculated nodule that was found to be benign, photoselective vaporization of the prostate due to obstructive benign prostatic hypertrophy (2 months before this presentation), and wrist surgery. Medications included atenolol, vitamin D3, a fluticasone propionate and salmeterol inhaler, aspirin, citalopram, a fluticasone nasal spray, atorvastatin, omeprazole, and levothyroxine. Lisinopril had caused a cough, and zolpidem tartrate had caused nightmares. The patient was retired and lived alone. He could independently perform activities of daily living, and he managed his own medications. His three children lived nearby and were in frequent contact with him, but he came to most medical appointments unaccompanied. He was under the regular care of an internist, a nephrologist, a cardiologist, and a urologist. Immunizations were up to date. He had stopped smoking many years earlier and did not drink alcohol. His father had died of liver cancer, and a son had sarcoidosis; his two other children were healthy. On examination, the patient was pleasant, smiling, and in no distress; he spoke From the Departments of Medicine (C.A.I.), Internal Medicine (L.H.S.), Radi‐ ology (F.J.F.), and Pathology (A.S.D.), Massachusetts General Hospital, and the Departments of Medicine (C.A.I.), Inter‐ nal Medicine (L.H.S.), Radiology (F.J.F.), and Pathology (A.S.D.), Harvard Medical School — both in Boston.