Spontaneous subcutaneous emphysema and pneumomediastinum in non-intubated patients with COVID-19.

PURPOSE: We describe the presenting characteristics and hospital course of 11 novel coronavirus (COVID-19) patients who developed spontaneous subcutaneous emphysema (SE) with or without pneumomediastinum (SPM) in the absence of prior mechanical ventilation. MATERIALS AND METHODS: A total of 11 non-intubated COVID-19 patients (8 male and 3 female, median age 61 years) developed SE and SPM between March 15 and April 30, 2020 at a multi-center urban health system in New York City. Demographics (age, gender, smoking status, comorbid conditions, and body-mass index), clinical variables (temperature, oxygen saturation, and symptoms), and laboratory values (white blood cell count, C-reactive protein, D-dimer, and peak interleukin-6) were collected. Chest radiography (CXR) and computed tomography (CT) were analyzed for SE, SPM, and pneumothorax by a board-certified cardiothoracic-fellowship trained radiologist. RESULTS: Eleven non-intubated patients developed SE, 36% (4/11) of whom had SE on their initial CXR. Concomitant SPM was apparent in 91% (10/11) of patients, and 45% (5/11) also developed pneumothorax. Patients developed SE on average 13.3 days (SD: 6.3) following symptom onset. No patients reported a history of smoking. The most common comorbidities included hypertension (6/11), diabetes mellitus (5/11), asthma (3/11), dyslipidemia (3/11), and renal disease (2/11). Four (36%) patients expired during hospitalization. CONCLUSION: SE and SPM were observed in a cohort of 11 non-intubated COVID-19 patients without any known cause or history of invasive ventilation. Further investigation is required to elucidate the underlying mechanism in this patient population.

Impact of PET and CT in PET/CT studies for staging and evaluating treatment response in bone and soft tissue sarcomas.

PURPOSE: Study impact of F-18 FDG PET/CT on initial staging, restaging, and evaluating treatment response (ETR) in bone and soft tissue sarcomas (BSTS), focusing on discrepancy between CT and PET portions. PATIENTS AND METHODS: Ninety-three BSTS patients having 204 F-18 FDG PET/CT studies were retrospectively reviewed. They were divided into 4 groups. Group I for initial staging included 16 patient studies. The other 3 groups were divided according to the time interval from last treatment received. Group II for ETR up to 2 months included 83 studies. Group III was for early restaging after 2 to 6 months included 45 studies. Group IV was for long-term follow-up after 6 months included 60 studies. All results were confirmed either by pathology, or by clinical follow-up. RESULTS: Sixteen studies for initial staging were concordant in 14 and discordant in 2 patients (48 lesions, 46 concordant, and 2 discordant). PET showed 97.2% sensitivity and 100% specificity versus 100% and 91.6% on CT. Regarding the other 3 groups, 498 lesions were detected; PET and CT were concordant in 436/498 (88%) and discordant in 62/498 (12%). In group II for ETR, PET and CT were concordant in 64/83 (77%) and discordant in 19/83(23%) studies-13 showed excellent to complete response on PET with partial response (PR) or stable disease (SD) on CT; 6 studies in PET showed PR versus SD or progression of disease (PD) on CT. In group III, for early restaging of disease 36/45 (80%) concordant and 9/45 (20%) discordant (3 showed excellent to complete response and 2 PR on PET versus CT SD, 3 PET PR versus CT PD, and 1 PET study showed PD while CT showed SD). In group IV, for long-term restaging, 49/60 (82%) were concordant and 11/60 (18%) were discordant; 9 PET studies were negative for active disease versus CT positive and 2 PET studies showed PD, CT was negative. PET alone showed 94.1% sensitivity and 94.6% specificity versus 97.2% and 63.5% for CT, 100% and 95.9% for PET/CT. CONCLUSIONS: In BSTS for the purpose of initial staging, ETR, short-term, or long-term restaging, FDG-PET is more accurate than CT. Combined PET/CT has higher accuracy than either alone.

Axial compression frame for MRI of thoracolumbar spine.

OBJECTIVE: Our objective was to present a method of performing thoracolumbar MRI with intervertebral disk pressure at 150 kPa without the patient being seated. CONCLUSION: Spine MRI with compression is more physiologic and will produce a higher yield than standard supine MRI.

Impact of PET/CT in comparison with same day contrast enhanced CT in breast cancer management.

PURPOSE: To evaluate the impact of F-18 fluorodeoxyglucose (FDG) positron emission tomography with fused computerized tomography (PET/CT) in comparison with same day contrast enhanced CT (CE-CT) in breast cancer management. METHOD: Seventy studies in 49 breast cancer patients, 17 for initial and 53 for restaging disease were included. All patients underwent PET/CT for diagnostic purposes followed by CE-CT scans of selected body regions. PET/CT was started approximately 90 minutes following IV injection of 10-15 mCi of F-18 FDG on a GE Discovery PET/CT system. Oral contrast was given before F-18 FDG injection. The CE-CT was performed according to departmental protocol. RESULTS: Out of a total of 257 lesions, 210 were concordant between PET/CT and CE-CT. There were 47 discordant lesions, which were verified by either biopsy (35) or follow-up (12 PET positive CE-CT negative lesions). PET/CT correctly identified 25 true positive (TP). CE-CT identified 2 TP lesions missed by PET/CT which were false negatives (FNs): one liver metastasis with necrosis, which was nonavid to FDG uptake because of necrosis and a second one missed on abdominal metastatic node, which did not change staging or treatment. PET/CT incorrectly identified 2 false positive lesions while CE-CT incorrectly identified 18 false positive. TP recurrence of the disease was found by PET/CT in 44% (15/34 pts), whereas 56% (19/34 pts) were free of disease. The CE-CT described progression of the disease in 1 true negative PET/CT study and no progression in 2 TP PET/CT studies. The sensitivity, specificity, accuracy, positive productive value, and negative productive value for PET/CT were 97.8%, 93.5%, 97.3%, 99.1%, 85% and for CE-CT were 87.6%, 42%, 82.1%, 91.6%, 31.7%. CONCLUSION: In this study, PET/CT played a more important role than CE-CT scans alone and provided an impact on the management of breast cancer patients.