Tan Lucien H Mohammed

Small Pulmonary Nodule Management A Survey of the Members of the Society of Thoracic Radiology With Comparison to the Fleischner Society Guidelines

Purpose We surveyed the members of the Society of Thoracic Radiology regarding their interpretation of and management decision for small pulmonary nodules on computed tomography. We then compared their responses with the published guidelines set forth by the Fleischner Society. Materials and Methods A survey consisting of 13 case scenarios in which small pulmonary nodules were encountered on computed tomography examination was electronically mailed to 625 members of the Society of Thoracic Radiology. Statistical analysis was performed to determine associations between responses, years of experience, location in an endemic region of granulomatous disease, and setting of practice. To assess the relationship between recommendation (defined as appropriate or not appropriate based on the Fleischner Society guidelines) and the characteristics of the radiologist, univariate analyses were first carried out. Characteristics with evidence of association with recommendation (defined as P<0.10) were included in the multiple-variable analysis. Multiple-variable logistic regression was used to assess the simultaneous effects of reader characteristics on recommendation. A backward selection process was used applying a significance level of 0.05. This analysis was carried out for each question. Results One hundred and eighty-one surveys were completed (29%). Overall, 27% of the participants had made the appropriate recommendation based on the Fleischner Society guidelines. There was an overall trend for over-management in the various clinical scenarios. Radiologists who had been in practice for longer periods of time were less likely to select the appropriate management, as were radiologists who practiced outside the United States. In addition, in certain scenarios, radiologists in endemic areas were less likely to over-manage than their counterparts in nonendemic regions. Conclusions Among responding members of the Society of Thoracic Radiology, there was poor adherence to the published guidelines set forth by the Fleischner Society.

Complications of Aortic Valve Surgery: Manifestations at CT and MR Imaging

Aortic valve replacement accounts for a significant portion of cardiac surgeries in the United States. Despite advances in prosthetic heart valve design, surgical technique, and postoperative care, complications after aortic valve replacement remain a leading cause of morbidity and mortality. Routine surveillance of prosthetic heart valves with transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), and fluoroscopy is important, as these techniques allow accurate detection of prosthetic valve dysfunction. However, echocardiography and fluoroscopy may not allow identification of the specific underlying cause, including paravalvular leak, dehiscence, endocarditis, obstruction, structural failure, pseudoaneurysm formation, aortic dissection, and hemolysis. Magnetic resonance (MR) imaging and computed tomography (CT) have an emerging role as diagnostic tools complementary to conventional imaging for detection and monitoring of complications after aortic valve replacement. The choice between CT and MR imaging depends on individual patient characteristics, the type of prosthetic valve, and the acuity of the clinical situation. In general, screening with TTE followed by TEE is recommended. When results of TTE and TEE are inconclusive, cardiac CT and MR imaging should be considered. The choice between these imaging techniques depends on the presence of patient-specific contraindications to CT or MR imaging.

ACR Appropriateness Criteria® screening for pulmonary metastases.

Screening for pulmonary metastatic disease is an important step for staging a patient with a known or recently discovered malignancy. Here we present our recommendations for screening for metastatic disease based on recommendations from the literature and experiences of pulmonary radiologists. In short, chest computed tomographic (CT) screening is the most appropriate tool for evaluation of pulmonary metastasis in the majority of cases. Chest computed tomographic screening is also recommended for follow-up and to determine response to therapy. Other modalities such as chest radiography, magnetic resonance imaging, and scintigraphy will also be discussed. Please note that this study is a summary of the complete version of this topic, which is available on the ACR website at www.acr.org. Practitioners are encouraged to refer to the complete version.

ACR Appropriateness Criteria Blunt Chest Trauma

Imaging is paramount in the setting of blunt trauma and is now the standard of care at any trauma center. Although anteroposterior radiography has inherent limitations, the ability to acquire a radiograph in the trauma bay with little interruption in clinical survey, monitoring, and treatment, as well as radiographys accepted role in screening for traumatic aortic injury, supports the routine use of chest radiography. Chest CT or CT angiography is the gold-standard routine imaging modality for detecting thoracic injuries caused by blunt trauma. There is disagreement on whether routine chest CT is necessary in all patients with histories of blunt trauma. Ultimately, the frequency and timing of CT chest imaging should be site specific and should depend on the local resources of the trauma center as well as patient status. Ultrasound may be beneficial in the detection of pneumothorax, hemothorax, and pericardial hemorrhage; transesophageal echocardiography is a first-line imaging tool in the setting of suspected cardiac injury. In the blunt trauma setting, MRI and nuclear medicine likely play no role in the acute setting, although these modalities may be helpful as problem-solving tools after initial assessment. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

ACR appropriateness criteria routine chest radiographs in intensive care unit patients.

Daily routine chest radiographs in the intensive care unit (ICU) have been a tradition for many years. Anecdotal reports of misplacement of life support items, acute lung processes, and extra pulmonary air collections in a small number of patients served as a justification for routine chest radiographs in the ICU. Having analyzed this practice, the ACR Appropriateness Criteria Expert Panel on Thoracic Imaging has made the following recommendations: • When monitoring a stable patient or a patient on mechanical ventilation in the ICU, a portable chest radiograph is appropriate for clinical indications only. • It is appropriate to obtain a chest radiograph after placement of an endotracheal tube, central venous line, Swan-Ganz catheter, nasogastric tube, feeding tube, or chest tube. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. The strongest data contributing to these recommendations were derived from a meta-analysis of 8 trials comprising 7,078 ICU patients by Oba and Zaza [1].

Metastatic Melanoma to the Heart

Melanoma is a common neoplasm with a propensity to metastasize to the heart. Although cardiac metastasis is rarely diagnosed ante mortem, using a multimodality approach, several imaging findings may be seen. Echocardiography is often the initial imaging method used to detect cardiac metastases and their complications. On computed tomography, intraluminal filling defects and myocardial/pericardial nodules may be seen. On magnetic resonance imaging, metastatic melanoma is classically hyperintense on T1 images and hypointense on T2 images, a result of the T1 shortening of melanin; however, this is seen in a minority of cases. As melanoma metastases are fluorine-18-fluorodeoxyglucose avid, fluorine-18-fluorodeoxyglucose positron emission tomography may also be used to detect cardiac metastases.

ACR Appropriateness Criteria® noninvasive clinical staging of bronchogenic carcinoma.

In order to appropriately manage patients with lung cancer, it is necessary to properly stage the tumor. The ACR Appropriateness Criteria is designed to provide an overview of the value of different imaging techniques in the non-invasive staging of lung cancer and allow for the rational selection of imaging studies to arrive at the appropriate clinical stage.

ACR appropriateness Criteria ® rib

Rib fracture is the most common thoracic injury, present in 10% of all traumatic injuries and almost 40% of patients who sustain severe nonpenetrating trauma. Although rib fractures can produce significant morbidity, the diagnosis of associated complications (such as pneumothorax, hemothorax, pulmonary contusion, atelectasis, flail chest, cardiovascular injury, and injuries to solid and hollow abdominal organs) may have a more significant clinical impact. When isolated, rib fractures have a relatively low morbidity and mortality, and failure to detect isolated rib fractures does not necessarily alter patient management or outcome in uncomplicated cases. A standard posteroanterior chest radiograph should be the initial, and often the only, imaging test required in patients with suspected rib fracture after minor trauma. Detailed radiographs of the ribs rarely add additional information that would change treatment, and, although other imaging tests (eg, computed tomography, bone scan) have increased sensitivity for detection of rib fractures, there are little data to support their use. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review process include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Computed tomography findings of spontaneous porto-pulmonary shunts in 3 patients with portal hypertension.

Spontaneous portopulmonary shunts in the setting of cirrhosis have been associated with the embolization of gelfoam during the treatment of esophageal varices, resulting in strokes. Currently there is minimal data describing the prevalence of spontaneous portopulmonary shunts. Our aim is to demonstrate computed tomography (CT) imaging findings of spontaneous portopulmonary venous anastomoses in patients with underlying portal hypertension. Clinical cases with accompanying CT images are presented and described. A review of the literature is discussed. CT is a useful method for identifying shunting, both spontaneous and surgical, of the portal circulation secondary to hypertension. A less known type of anastomosis involves the pulmonary circulation, specifically the pulmonary veins and left atrium, that can also be recognized with CT.

ACR Appropriateness Criteria Imaging in the Diagnosis of Thoracic Outlet Syndrome

Thoracic outlet syndrome is a clinical entity characterized by compression of the neurovascular bundle, and may be associated with additional findings such as venous thrombosis, arterial stenosis, or neurologic symptoms. The goal of imaging is to localize the site of compression, the compressing structure, and the compressed organ or vessel, while excluding common mimics. A literature review is provided of current indications for diagnostic imaging, with discussion of potential limitations and benefits of the respective modalities. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. In this document, we provided guidelines for use of various imaging modalities for assessment of thoracic outlet syndrome.