COVID-19 pneumonia imaging follow-up: when and how? A proposition from ESTI and ESR.

This document from the European Society of Thoracic Imaging (ESTI) and the European Society of Radiology (ESR) discusses the role of imaging in the long-term follow-up of COVID-19 patients, to define which patients may benefit from imaging, and what imaging modalities and protocols should be used. Insights into imaging features encountered on computed tomography (CT) scans and potential pitfalls are discussed and possible areas for future review and research are also included. KEY POINTS: • Post-COVID-19 pneumonia changes are mainly consistent with prior organizing pneumonia and are likely to disappear within 12 months of recovery from the acute infection in the majority of patients. • At present, with the longest series of follow-up examinations reported not exceeding 12 months, the development of persistent or progressive fibrosis in at least some individuals cannot yet be excluded. • Residual ground glass opacification may be associated with persisting bronchial dilatation and distortion, and might be termed "fibrotic-like changes" probably consistent with prior organizing pneumonia.

Milestones towards lung cancer screening implementation.

The European Society of Radiology (ESR) and European Respiratory Society (ERS) published their joint statement paper on lung cancer screening (LCS), on 12 February 2020. This document joins and completes previous recommendations on LCS with specific emphasis on the analysis of issues encountered in the practical implementation of LCS in the community. Major milestones to enable the most efficient and equal dissemination of LCS are recognised as engagement of all stakeholders (e.g. candidate/participant, general practitioners, up to the specialised LCS facility), quality assurance, and primary prevention in the form of provision of counselling for smoking cessation.

Incidental diagnosis of Covid-19 pneumonia on chest computed tomography.

PURPOSE: The purpose of this study was to determine the prevalence and imaging characteristics of incidentally diagnosed COVID-19 pneumonia on computed tomography (CT). MATERIALS AND METHODS: This retrospective study was conducted between March 20th and March 31st, 2020 at Cochin hospital, Paris France. Thoracic CT examinations of all patients referred for another reason than a suspicion of SARS-CoV-2 infection were reviewed. CT images were analyzed by a chest radiologist to confirm the presence of findings consistent with COVID-19 pneumonia and quantify disease extent. Clinical and biological data (C-reactive protein serum level [CRP] and white blood cell count) of patients with CT findings suggestive for COVID-19 pneumonia were retrieved from the electronic medical chart. RESULTS: During the study period, among 205 diagnostic CT examinations, six examinations (6/205, 3%) in 6 different patients (4 men, 2 women; median age, 57 years) revealed images highly suggestive of COVID-19 pneumonia. The final diagnosis was confirmed by RT-PCR. Three inpatients were suspected of extra thoracic infection whereas three outpatients were either fully asymptomatic or presented with fatigue only. All had increased CRP serum level and lymphopenia. Disease extent on CT was mild to moderate in 5/6 patients (83%) and severe in 1/6 patient (17%). CONCLUSION: Cumulative incidence of fortuitous diagnosis if COVID-19 pneumonia did not exceed 3% during the highest pandemic phase and was predominantly associated with limited lung involvement.

Radiological assessment after stereotactic body radiation of lung tumours.

The increasing use of stereotactic body radiation therapy for lung tumours comes along with new post-therapeutic imaging findings that should be known by physicians involved in patient follow-up. Radiation-induced lung injury is much more frequent than after conventional radiation therapy, it can also be delayed and has a different radiological presentation. Radiation-induced lung injury after stereotactic body radiation therapy involves the lung parenchyma surrounding the target tumour and appears as a dynamic process continuing for years after completion of the treatment. Thus, the radiological pattern and the severity of radiation-induced lung injury are prone to changes during follow-up, which can make it difficult to differentiate from local recurrence. Contrary to radiation-induced lung injury, local recurrence after stereotactic body radiation therapy is rare. Other complications mainly depend on tumour location and include airway complications, rib fractures and organizing pneumonia. The aim of this article is to provide a wide overview of radiological changes occurring after SBRT for lung tumours. Awareness of changes following stereotactic body radiation therapy should help avoiding unnecessary interventions for pseudo tumoral presentations.

COVID-19 pneumonia: A review of typical CT findings and differential diagnosis.

The standard of reference for confirming COVID-19 relies on microbiological tests such as real-time polymerase chain reaction (RT-PCR) or sequencing. However, these tests might not be available in an emergency setting. Computed tomography (CT) can be used as an important complement for the diagnosis of COVID-19 pneumonia in the current epidemic context. In this review, we present the typical CT features of COVID-19 pneumonia and discuss the main differential diagnosis.

Optimization of acquisition parameters for reduced-dose thoracic CT: A phantom study.

PURPOSE: The purpose of this study was to analyze the impact of different options for reduced-dose computed tomography (CT) on image noise and visibility of pulmonary structures in order to define the best choice of parameters when performing ultra-low dose acquisitions of the chest in clinical routine. MATERIALS AND METHODS: Using an anthropomorphic chest phantom, CT images were acquired at four defined low dose levels (computed tomography dose index [CTDIvol]=0.15, 0.20, 0.30 and 0.40mGy), by changing tube voltage, pitch factor, or rotation time and adapting tube current to reach the predefined CTDIvol-values. Images were reconstructed using two different levels of iteration (adaptive statistical iterative reconstruction [ASIR®]-v70% and ASIR®-v100%). Signal-to-noise ratio (SNR) as well as contrast-to-noise ratio (CNR) was calculated. Visibility of pulmonary structures (bronchi/vessels) were assessed by two readers on a 5-point-Likert scale. RESULTS: Best visual image assessments and CNR/SNR were obtained with high tube voltage, while lowest scores were reached with lower pitch factor followed by high tube current. Protocols favoring lower pitch factor resulted in decreased visibility of bronchi/vessels, especially in the periphery. Decreasing radiation dose from 0.40 to 0.30mGy was not associated with a significant decrease in visual scores (P<0.05), however decreasing radiation dose from 0.30mGy to 0.15mGy was associated with a lower visibility of most of the evaluated structures (P<0.001). While image noise could be significantly reduced when ASIR®-v100% instead of ASIR®-v70% was used, the visibility-scores of pulmonary structures did not change significantly. CONCLUSION: Favoring high tube voltage is the best option for reduced-dose protocols. A decrease of SNR and CNR does not necessarily go along with reduced visibility of pulmonary structures.

Nodular reverse halo sign in active pulmonary tuberculosis: A rare CT feature?

PURPOSE: The purpose of this study was to investigate the prevalence of the nodular reverse halo sign (NRHS) in chest computed tomography (CT) in patients with active pulmonary tuberculosis. MATERIALS AND METHODS: From March 2018 to March 2019, 29 consecutive patients with a culture-confirmed active pulmonary tuberculosis and who underwent chest CT examination during hospital-admission were retrospectively included in the study. There were 24 men and 5 women with a mean age of 40.9±16.7 (SD) years (range: 18-80years). Chest CT examinations of included patients were evaluated for the presence of NRHS and other tuberculosis-related CT signs. RESULTS: CT revealed the NRHS in 5 patients (5/29; 17%). The other CT signs of tuberculosis included consolidations in 18 patients (18/29; 62%), tree-in-bud pattern in 14 patients (14/29; 48%), cavitation in 12 patients (12/29; 41%), sparse nodules in 10 patients (10/29; 34%), and pleural effusion in 8 patients (8/29; 28%). CONCLUSION: CT shows NRHS in 17% of patients with active pulmonary tuberculosis, indicating that the sign is not as rare as previously thought in patients with this condition.

Cumulative radiation dose after lung transplantation in patients with cystic fibrosis.

PURPOSE: The purpose of this study was first to evaluate the imaging-related cumulative post-transplantation radiation dose in cystic fibrosis (CF) lung transplantation (LT) recipients and second, to identify the occurrence and type of malignancies observed after LT. MATERIALS AND METHODS: A total of 52 patients with CF who underwent LT at our institution between January 2001 and December 2006 with at least 3 years of survival were retrospectively included. There were 27 men and 25 women with a mean age of 24.4±9.2 (SD) years (range: 7.6-52.9 years) at the time of LT. Calculation of cumulative effective and organ doses after LT were based on dosimetry information and acquisition parameters of each examination. Cumulative radiation doses were calculated until June 2016, but stopped at the time of de novomalignancy diagnosis, for patients developing the condition. RESULTS: Patients received a mean cumulative effective dose of 110.0±51.6 (SD) mSv (range: 13-261.3 mSv) over a mean follow-up of 8.1±3.6 (SD) years (range: 0.5-13.5 years), with more than 100mSv in 5 years in 19/52 patients (37%). Chest CT accounted for 73% of the cumulative effective dose. Mean doses to the lung, breast and thyroid were 152.8±61.1 (SD) mGy (range: 21.2-331.6 mGy), 106.5±43.2 (SD) mGy (range: 11.9-221.4 mGy) and 72.7±31.8 (SD) mGy (range: 9.5-165.0 mGy), respectively. Nine out of 52 patients (17%) developed a total of 10 de novo malignancies, all but one attributable to immunosuppression after a mean post-transplantation follow-up period of 11.1±3.5 (SD) years (range: 3.7-16.3 years). Six-month cumulative effective dose was not greater in patients with de novomalignancies than in those without de novomalignancies (28.9±14.5 (SD) mGy (range: 13.0-53.4) vs 25.6±15.3 (range: 5.0-69.7), respectively, P>0.05). CONCLUSION: The cumulative effective dose exceeded 100 mSv in 5 years in 37% of LT recipients, the reason why continuous efforts should be made to optimize chest CT acquisitions accounting for 73% of the radiation dose.

Combined pulmonary fibrosis and emphysema in systemic sclerosis: A syndrome associated with heavy morbidity and mortality.

BACKGROUND: The syndrome of combined pulmonary fibrosis and emphysema (CPFE) primarily due to tobacco smoking has been reported in connective tissue disease, but little is known about its characteristics in systemic sclerosis (SSc). METHODS: In this retrospective multi-center case-control study, we identified 36 SSc patients with CPFE, and compared them with 72 SSc controls with interstitial lung disease (ILD) without emphysema. RESULTS: Rate of CPFE in SSc patients with CT scan was 3.6%, and 7.6% among SSc patients with ILD. CPFE-SSc patients were more likely to be male (75 % vs 18%, p < 0.0001), smokers (83 % vs 33%, p < 0.0001), and to have limited cutaneous SSc (53 % vs 24% p < 0.01) than ILD-SSc controls. No specific autoantibody was significantly associated with CPFE. At diagnosis, CPFE-SSc patients had a greater decrease in carbon monoxide diffusing capacity (DLCO 39 ± 13 % vs 51 ± 12% of predicted value, p < 0.0001) when compared to SSc-ILD controls, whereas lung volumes (total lung capacity and forced vital capacity) were similar. During follow-up, CPFE-SSc patients more frequently developed precapillary pulmonary hypertension (PH) (44 % vs 11%, p < 10-4), experienced more frequent unscheduled hospitalizations (50 % vs 25%, p < 0.01), and had decreased survival (p < 0.02 by Kaplan-Meier survival analysis) as compared to ILD-SSc controls. CONCLUSIONS: The CPFE syndrome is a distinct pulmonary manifestation in SSc, with higher morbidity and mortality. Early diagnosis of CPFE by chest CT in SSc patients (especially smokers) may result in earlier smoking cessation, screening for PH, and appropriate management.

[Bronchiectasis imaging]. / Imagerie des dilatations des bronches.

Bronchiectasis are defined as an irreversible focal or diffuse dilatation of the bronchi and can be associated with significant morbidity. The prevalence is currently increasing, probably due to an increased use of thoracic computed tomography (CT). Indeed, the diagnosis relies on imaging and chest CT is the gold standard technique. The main diagnosis criterion is an increased bronchial diameter as compared to that of the companion artery. However, false positives are possible when the artery diameter is decreased, which is called pseudo-bronchiectasis. Other features such as the lack of bronchial tapering, and visibility of bronchi within 1cm of the pleural surface are also diagnostic criteria, and other CT features of bronchial disease are commonly seen. Thoracic imaging also allows severity assessment and long-term monitoring of structural abnormalities. The distribution pattern and the presence of associated findings on chest CT help identifying specific causes of bronchiectasis. Lung MRI and ultra-low dose CT and are promising imaging modalities that may play a role in the future. The objectives of this review are to describe imaging features for the diagnosis and severity assessment of bronchiectasis, to review findings suggesting the cause of bronchiectasis, and to present the new developments in bronchiectasis imaging.

[New TNM classification of non-small cell lung cancer]. / Nouvelle classification TNM des cancers du poumon non à petites cellules.

Initial staging is a key part of the initial evaluation of non-small cell lung cancer. It relies on the 7th edition of the TNM classification. Proposals have been recently developed for the 8th edition of the classification, which is due to be enacted in early 2017. Among these proposals, the weight of tumor size has been increased and new N descriptors have been introduced to further describe N category depending on the number station involved. Regarding M descriptors, oligometastatic disease is distinguished from multiple distant extrathoracic metastases.