Effectiveness of radiologist training in improving reader agreement for Lung-RADS 4X categorization.

OBJECTIVES: To identify the agreement on Lung CT Screening Reporting and Data System 4X categorization between radiologists and an expert-adjudicated reference standard and to investigate whether training led to improvement of the agreement measures and diagnostic potential for lung cancer. METHODS: Category 4 nodules in the Korean Lung Cancer Screening Project were identified retrospectively, and each 4X nodule was matched with one 4A or 4B nodule. An expert panel re-evaluated the categories and determined the reference standard. Nineteen radiologists were asked to determine the presence of CT features of malignancy and 4X categorization for each nodule. A review was performed in two sessions, and training material was given after session 1. Agreement on 4X categorization between radiologists and the expert-adjudicated reference standard and agreement between radiologist-assessed 4X categorization and lung cancer diagnosis were evaluated. RESULTS: The 48 expert-adjudicated 4X nodules and 64 non-4X nodules were evenly distributed in each session. The proportion of category 4X decreased after training (56.4% ± 16.9% vs. 33.4% ± 8.0%; p < 0.001). Cohen's κ indicated poor agreement (0.39 ± 0.16) in session 1, but agreement improved in session 2 (0.47 ± 0.09; p = 0.03). The increase in agreement in session 2 was observed among inexperienced radiologists (p < 0.05), and experienced and inexperienced reviewers exhibited comparable agreement performance in session 2 (p > 0.05). All agreement measures between radiologist-assessed 4X categorization and lung cancer diagnosis increased in session 2 (p < 0.05). CONCLUSION: Radiologist training can improve reader agreement on 4X categorization, leading to enhanced diagnostic performance for lung cancer. KEY POINTS: • Agreement on 4X categorization between radiologists and an expert-adjudicated reference standard was initially poor, but improved significantly after training. • The mean proportion of 4X categorization by 19 radiologists decreased from 56.4% ± 16.9% in session 1 to 33.4% ± 8.0% in session 2. • All agreement measures between the 4X categorization and lung cancer diagnosis increased significantly in session 2, implying that appropriate training and guidance increased the diagnostic potential of category 4X.

Diagnostic Accuracy of CT-Guided Core Needle Biopsy for Thin-Walled Cavitary Pulmonary Lesions.

OBJECTIVE. The purpose of this article is to evaluate the accuracy of and complications with CT-guided percutaneous core needle biopsy (CNB) of thin-walled cavitary pulmonary lesions. MATERIALS AND METHODS. This retrospective study involved 32 CNBs in 30 patients who had thin-walled cavitary pulmonary lesions (wall thickness < 5 mm) and underwent CT-guided CNB. After the 30 patient records were evaluated for the diagnostic accuracy, sensitivity, and specificity of CT-guided CNB, the results were compared with the final diagnosis after surgery or clinical follow-up. Each patient was reviewed for complications including pneumothorax, thoracotomy tube insertion, hemorrhage, and hemoptysis. RESULTS. The final diagnosis indicated 19 malignant and 11 benign lesions. Two lesions with indeterminate biopsy results (anthracofibrosis and focal interstitial thickening) were excluded. The sensitivity, specificity, and diagnostic accuracy of thin-walled cavities were 89.5%, 100%, and 93.3%, respectively. There were no statistical differences in the accuracy, sensitivity, or specificity according to wall thickness, cavity size, or lesion depth. Chest CT immediately after biopsy revealed mild pneumothorax in seven patients and moderate to severe pneumothorax requiring placement of a thoracotomy tube in one patient. CT after biopsy indicated mild parenchymal hemorrhage in 15 patients and hemoptysis in one patient. CONCLUSION. CT-guided CNB is a useful and accurate diagnostic technique for biopsy of a pulmonary thin-walled cavity.

Low-dose CT screening in an Asian population with diverse risk for lung cancer: A retrospective cohort study.

OBJECTIVES: To evaluate the performance of low-dose CT (LDCT) screening for lung cancer (LCA) detection in an Asian population with diverse risks for LCA. MATERIALS AND METHODS: LCA screening was performed in 12,427 symptomless Asian subjects using either LDCT (5,771) or chest radiography (CXR) (6,656) in a non-trial setting. Subjects were divided into high-risk and non-high-risk groups. Data were collected on the number of patients with screening-detected LCAs and their survival in order to compare outcomes between LDCT and CXR screening with the stratification of risks considering age, sex and smoking status. RESULTS: In the non-high-risk group, a significant difference was observed for the detection of lung cancer (adjusted OR, 5.07; 95 % CI, 2.72-9.45) and survival (adjusted HR of LCA survival between LDCT vs. CXR group, 0.08; 95 % CI, 0.01-0.62). No difference in detection or survival of LCA was noticed in the high-risk group. LCAs in the non-high-risk group were predominantly adenocarcinomas (96 %), and more likely to be part-solid or non-solid compared with those in the high-risk group (p = 0.023). CONCLUSIONS: In the non-high-risk group, LDCT helps detect more LCAs and offers better survival than CXR screening, due to better detection of part solid or non-solid lung adenocarcinomas. KEY POINTS: • In an Asian non-high-risk group, LDCT helps detect more early-staged LCAs. • CT-detected lung cancers in non-high-risk subjects demonstrate better survival than CXR-detected cancers. • CT-detected lung cancers in non-high-risk subjects are predominantly part-solid or non-solid adenocarcinomas. • Mortality benefit of LDCT screening in non-high-risk subjects needs to be investigated.

Diffusion-weighted MRI for distinguishing non-neoplastic cysts from solid masses in the mediastinum: problem-solving in mediastinal masses of indeterminate internal characteristics on CT.

OBJECTIVES: To evaluate the usefulness of diffusion-weighted (DW) magnetic resonance images for distinguishing non-neoplastic cysts from solid masses of indeterminate internal characteristics on computed tomography (CT) in the mediastinum. METHODS: We enrolled 25 patients with pathologically proved mediastinal masses who underwent both thoracic CT and magnetic resonance imaging (MRI) including diffusion-weighted imaging (DWI). MRI was performed in patients with mediastinal masses of indeterminate internal characteristics on CT. Two thoracic radiologists evaluated the morphological features and quantitatively measured the net enhancement of the masses at CT. They also reviewed MR images including unenhanced T1- and T2-weighted images, gadolinium-enhanced images and DW images. RESULTS: The enrolled patients had 15 solid masses and ten non-neoplastic cysts. Although the morphological features and the extent of enhancement on CT did not differ significantly between solid and cystic masses in the mediastinum (P > 0.05), non-neoplastic cysts were distinguishable from solid masses by showing signal suppression on high-b-value DW images or high apparent diffusion coefficient (ADC) values of more than 2.5 × 10(-3) mm(2)/s (P < 0.001). ADC values of non-neoplastic cysts (3.67 ± 0.87 × 10(-3) mm(2)/s) were significantly higher than that of solid masses (1.46 ± 0.50 × 10(-3) mm(2)/s) (P < 0.001). CONCLUSIONS: DWI can help differentiate solid and cystic masses in the mediastinum, even when CT findings are questionable. KEY POINTS: • Non-invasive diagnosis of non-neoplastic cysts can save surgical biopsy or excision. • Conventional CT or MRI findings cannot always provide a confident diagnosis. • Mediastinal masses can be well-characterised with DWI. • Non-neoplastic mediastinal cysts show significantly higher ADC values than cystic tumours. • DWI is useful to determine treatment strategy.

Subcentimeter lung nodules stable for 2 years at LDCT: long-term follow-up using volumetry.

BACKGROUND AND OBJECTIVE: Subcentimeter nodules without change in size during long-term follow-up period (for minimum 2 years) are assumed as benign lesions. However, the 2-year stability rule has not been fully verified so far and is still questionable. Thus, we aimed to retrospectively investigate long-term follow-up results for 2-year stable subcentimeter nodules at screening low-dose computed tomography (LDCT). METHODS: A total of 635 subjects having had follow-up LDCTs for the initial 2-year screening period and additional 3 years thereafter and having had non-calcified subcentimeter nodules were included. By using computed tomography (CT) nodule volumetry software, we measured interval changes in nodule volume. RESULTS: A total of 1107 subcentimeter nodules (1037 solid, 70 ground-glass opacity nodules (GGNs)) were detected at baseline CT. Of 1037 solid nodules, 1032 showed no growth during the initial 2-year and 5-year follow-up period. Fifty-nine GGNs were stable for initial 2 years, but two (3.4%) were later proved as adenocarcinomas. Among five solid nodules that showed growth during the initial 2-year follow-up period, one (20%) proved to be an adenocarcinoma, whereas four (36.4%) of 11 GGNs that demonstrated growth were diagnosed as lung cancers. CONCLUSIONS: All solid subcentimeter nodules having initial 2-year stability at screening LDCT can be considered benign because none shows growth at further follow-up CT. On the other hand, subcentimeter GGNs have more chance of growth than solid nodules and need further follow-up CT for more than 2 years.

Diagnostic criterion to distinguish between incomplete and complete discoid lateral meniscus on MRI.

PURPOSE: To determine a new cutoff value that can further distinguish between the incomplete and complete discoid lateral meniscus (DLM). MATERIALS AND METHODS: Twenty-one cases of incomplete DLM and 42 cases of complete DLM without tear were included. In all, 105 patients with normal lateral menisci were included as a control group. We measured the ratio of the shortest width of the lateral meniscus to the longest width of the tibia (ratio 1) and the ratio of the shortest width of the medial meniscus to the shortest width of the lateral meniscus (ratio 2). RESULTS: By applying a cutoff value of ratio 1 as 0.32 between two incomplete and complete DLM groups, the proportion of the complete and incomplete DLM diagnosed cases among the true cases were 84% and 94%, respectively. By applying a cutoff value of ratio 2 as 0.40 between two incomplete and complete DLM groups, the proportion of the complete and incomplete DLM diagnosed cases among the true cases were 84% and 75%, respectively. CONCLUSION: A cutoff value of 0.32 using the ratio of the shortest width of the lateral meniscus and the longest width of the tibia are probably useful to help distinguish between complete DLM and incomplete DLM. Additionally, the new ratio using the width of the medial meniscus is also useful to improve distinguishing between the types of DLM.

Relationships Between High-Resolution Computed Tomographic Features and Lung Function Trajectory in Patients With Asthma.

PURPOSE: A subset of asthmatics suffers from persistent airflow limitation, known as remodeled asthma, despite optimal treatment. Typical quantitative scoring methods to evaluate structural changes of airway remodeling on high-resolution computed tomography (HRCT) are time-consuming and laborious. Thus, easier and simpler methods are required in clinical practice. We evaluated the clinical usefulness of a simple, semi-quantitative method based on 8 HRCT parameters by comparing asthmatics with a persistent decline of post-bronchodilator (BD)-FEV1 to those with a BD-FEV1 that normalized over time and evaluated the relationships of the parameters with BD-FEV1. METHODS: Asthmatics (n = 59) were grouped into 5 trajectories (Trs) according to the changes of BD-FEV1 over 1 year. After 9-12 months of guideline-based treatment, HRCT parameters including emphysema, bronchiectasis, anthracofibrosis, bronchial wall thickening (BWT), fibrotic bands, mosaic attenuation on inspiration, air-trapping on expiration, and centrilobular nodules were classified as present (1) or absent (0) in 6 zones. RESULTS: The Tr5 group (n = 11) was older and exhibited a persistent decline in BD-FEV1. The Tr5 and Tr4 groups (n = 12), who had a lower baseline BD-FEV1 that normalized over time, had longer durations of asthma, frequent exacerbations, and higher doses of steroid use compared to the Tr1-3 groups (n = 36), who had a normal baseline BD-FEV1. The Tr5 group had higher emphysema and BWT scores than the Tr4 (P = 8.25E-04 and P = 0.044, respectively). Scores for the other 6 parameters were not significantly different among the Tr groups. BD-FEV1 was inversely correlated with the emphysema and BWT scores in multivariate analysis (P = 1.70E-04, P = 0.006, respectively). CONCLUSIONS: Emphysema and BWT are associated with airway remodeling in asthmatics. Our simple, semi-quantitative scoring system based on HRCT may be an easy-to-use method for estimating airflow limitation.

Generative Adversarial Network-Based Image Conversion Among Different Computed Tomography Protocols and Vendors: Effects on Accuracy and Variability in Quantifying Regional Disease Patterns of Interstitial Lung Disease.

OBJECTIVE: To assess whether computed tomography (CT) conversion across different scan parameters and manufacturers using a routable generative adversarial network (RouteGAN) can improve the accuracy and variability in quantifying interstitial lung disease (ILD) using a deep learning-based automated software. MATERIALS AND METHODS: This study included patients with ILD who underwent thin-section CT. Unmatched CT images obtained using scanners from four manufacturers (vendors A-D), standard- or low-radiation doses, and sharp or medium kernels were classified into groups 1-7 according to acquisition conditions. CT images in groups 2-7 were converted into the target CT style (Group 1: vendor A, standard dose, and sharp kernel) using a RouteGAN. ILD was quantified on original and converted CT images using a deep learning-based software (Aview, Coreline Soft). The accuracy of quantification was analyzed using the dice similarity coefficient (DSC) and pixel-wise overlap accuracy metrics against manual quantification by a radiologist. Five radiologists evaluated quantification accuracy using a 10-point visual scoring system. RESULTS: Three hundred and fifty CT slices from 150 patients (mean age: 67.6 ± 10.7 years; 56 females) were included. The overlap accuracies for quantifying total abnormalities in groups 2-7 improved after CT conversion (original vs. converted: 0.63 vs. 0.68 for DSC, 0.66 vs. 0.70 for pixel-wise recall, and 0.68 vs. 0.73 for pixel-wise precision; P < 0.002 for all). The DSCs of fibrosis score, honeycombing, and reticulation significantly increased after CT conversion (0.32 vs. 0.64, 0.19 vs. 0.47, and 0.23 vs. 0.54, P < 0.002 for all), whereas those of ground-glass opacity, consolidation, and emphysema did not change significantly or decreased slightly. The radiologists' scores were significantly higher (P < 0.001) and less variable on converted CT. CONCLUSION: CT conversion using a RouteGAN can improve the accuracy and variability of CT images obtained using different scan parameters and manufacturers in deep learning-based quantification of ILD.

Epidural abscess formation after chemoradiation therapy for esophageal cancer: A case report and literature review.

RATIONALE: Esophageal cancer is one of the leading causes of death worldwide; the treatments vary according to the stage at diagnosis. Advanced esophageal cancer is usually treated by concurrent chemoradiation which is associated with complications including esophagitis, esophageal stricture or perforation, radiation pneumonitis, and/or cardiac toxicity. Herein, we describe epidural abscess, which is a very rare but severe complication that can occur after concurrent chemoradiation therapy for advanced esophageal cancer. PATIENT CONCERNS: A 75-year-old man developed a fever during concurrent chemoradiation therapy for advanced esophageal cancer, which progressed to neurological deficit and paraplegia. Enhanced chest computed tomography and C-spine magnetic resonance imaging were performed. DIAGNOSIS: Chest computed tomography revealed a poorly enhanced necrotic change in the cervical esophageal cancer, with mottled dirty material and fluid collection. C-spine magnetic resonance imaging revealed a prevertebral abscess with pyogenic spondylitis at the C6-T2 level. In addition, an anterior epidural abscess at the C6-7 level compressed the spinal cord. INTERVENTIONS: The patient underwent emergency anterior cervical discectomy and decompression corpectomy. OUTCOMES: : After surgery, the neurological symptoms gradually improved. LESSONS: Pyogenic spondylitis with an epidural abscess is a rare but life-threatening complication that can develop after concurrent chemoradiation therapy for advanced esophageal cancer. Rapid, accurate diagnosis and prompt surgical treatment are important to ensure a favorable long-term prognosis and a good quality of life.

Quantitative computed tomographic indexes in diffuse interstitial lung disease: correlation with physiologic tests and computed tomography visual scores.

PURPOSE: To assess the correlation among quantitative indexes of computed tomography (CT), spirometric pulmonary function tests (PFTs), and visual scores (VSs) of CT in patients with diffuse interstitial lung disease (DILD) and to prove the estimated value of CT quantification for the prediction of the possibility of pulmonary function impairment. METHODS AND MATERIALS: A total of 157 patients (male to female ratio, 96:61; mean age, 63 ± 11 years) with DILD were enrolled in this study. All patients underwent volume thin-section CT in the supine position at full inspiration. During the same period, 23 people (male to female ratio, 10:13; mean age, 55 ± 13 years) with no history of DILD and with normal PFTs and CT findings were used as a control group. Quantitative indexes were obtained using a commercial CAD system (Brilliance Workspace v3.0; Philips Medical Systems). Quantitative indexes included total lung volume (TLV), mean lung attenuation, variation of lung attenuation, emphysema volume (<-950 Hounsfield units [HU]), functioning lung volume (-700 HU > pixel > -950 HU), and interstitial lung disease volume (>-700 HU). Visual scores were measured semiquantitatively and included the overall extent of pulmonary parenchymal abnormality as well as the extent of consolidation, ground glass opacity, reticulation, and honeycomb opacities. Quantitative indexes were correlated with PFT and VSs using the Pearson correlation test. RESULTS: Quantitative indexes, PFT results, and VSs differed significantly between the DILD group and the control group, except for emphysematous parameters (P < 0.05).Pulmonary function test results showed significant correlation with quantitative indexes in the DILD group. Functioning lung volume showed positive correlation with forced vital capacity and forced expiratory volume in 1 second (r = 0.80 and 0.73, P < 0.001). Total lung capacity showed positive correlation with TLV (r = 0.83, P < 0.001).Visual scores were correlated with the ratio of a specific volume to TLV (indicated as ®). Interstitial lung disease volume® showed positive correlation (r = 0.53, P < 0.001), and FLV® showed a negative correlation with the overall extent of ILD (r = -0.52, P < 0.001). variation of lung attenuation showed a positive correlation with honeycombing extent (r = 0.37, P < 0.001), and mean lung attenuation showed a positive correlation with reticulation extent (r = 0.42, P < 0.001). CONCLUSIONS: Quantitative indexes measured by a commercial workstation showed good correlation not only with the extent of DILD estimated by visual inspection but also with PFT results. Quantitative indexes can be used as an objective tool for quantitative evaluation of disease extent and for follow-up of the progression or improvement of a DILD.

MR staging accuracy for endometrial cancer based on the new FIGO stage.

BACKGROUND: Magnetic resonance imaging (MRI) has been frequently used to determine a preoperative treatment plan for gynecologic cancers. However, the MR accuracy for staging an endometrial cancer is not satisfactory based on the old FIGO staging system. PURPOSE: To evaluate MR accuracy for staging endometrial cancer using the new FIGO staging system. MATERIAL AND METHODS: Between January 2005 and May 2009, 199 women underwent surgery due to endometrial cancer. In each patient, an endometrial cancer was staged using MR findings based on the old FIGO staging system and then repeated according to the new FIGO staging system for comparison. Histopathologic findings were used as a standard of reference. RESULTS: The accuracy of MRI in the staging of endometrial carcinoma stage I, II, III, and IV using the old FIGO staging system were 80% (159/199), 89% (178/199), 90% (179/199), and 99% (198/199), respectively, compared to 87% (174/199), 97% (193/199), 90% (179/199), and 99% (198/199), respectively, when using the new FIGO staging criteria. The overall MR accuracy of the old and new staging systems were 51% (101/199) and 81% (161/199), respectively. CONCLUSION: MRI has become a more useful tool in the preoperative staging of endometrial cancers using the new FIGO staging system compared to the old one with increased accuracy.

Extravalidation and reproducibility results of a commercial deep learning-based automatic detection algorithm for pulmonary nodules on chest radiographs at tertiary hospital.

INTRODUCTION: To extra validate and evaluate the reproducibility of a commercial deep convolutional neural network (DCNN) algorithm for pulmonary nodules on chest radiographs (CRs) and to compare its performance with radiologists. METHODS: This retrospective study enrolled 434 CRs (normal to abnormal ratio, 246:188) from 378 patients that visited a tertiary hospital. DCNN performance was compared with two radiology residents and two thoracic radiologists. Abnormality assessment (using the area under the receiver operating characteristics (AUROC)) and nodule detection (using jackknife alternative free-response ROC (JAFROC)) were compared among three groups (DCNN only, radiologist without DCNN and radiologist with DCNN). A subset of 56 paired cases, having two CRs taken within a 7-day period, were assessed for intraobserver reproducibility using the intraclass correlation coefficient. Independent characteristics of pulmonary nodules detected by DCNN were assessed by multiple logistic regression analysis. RESULTS: The AUROC for abnormality detection for the three groups were 0.87, 0.93 and 0.96, respectively (P < 0.05), whereas the JAFROC analysis of nodule detection was 0.926, 0.929 and 0.964. Reproducibility for the three groups was 0.80, 0.67 and 0.80, which shows an increase in radiologists using DCNN (P < 0.05). Nodules detected by DCNN were more solid, round-shaped and well marginated, not masked and laterally located (P < 0.05). CONCLUSIONS: Extra validation results of DCNN showed high ROC results and there was a significant improvement in the performance when radiologists used DCNN. Reproducibility by DCNN alone showed good agreement, and there was an improvement from moderate to good agreement for radiologists using DCNN.

Intralobar pulmonary sequestration with cystic degeneration mimicking a bronchogenic cyst in an elderly patient: A case report and literature review.

INTRODUCTION: Pulmonary sequestration (PS) is a rare congenital malformation defined as nonfunctioning lung tissue supplied by systemic circulation. It is uncommonly diagnosed in adults. Herein, we describe a clinical case of PS with cystic degeneration mimicking a bronchogenic cyst in an elderly patient. PATIENT CONCERNS: A huge cystic mass was incidentally found in a 65-year-old man on chest computed tomography (CT) scans during preoperative workup for a hand laceration. A 15-cm-sized round cystic mass was detected in the right lower lobe. DIAGNOSIS: After reviewing the chest CT scan, we decided to perform contrast-enhanced chest magnetic resonance imaging (MRI) and CT-guided lung aspiration biopsy. On MRI, the lesion had the appearance of a cystic mass with hemorrhagic clots, such as an intrapulmonary bronchogenic cyst. The aspirated specimen was nondiagnostic; thus, we decided to surgically remove the mass. INTERVENTIONS: Upon right lower lobectomy, the mass was diagnosed as a PS. A thin systemic artery supplying the cystic mass was visualized during surgery. OUTCOMES: The patient is undergoing regular follow-up at the outpatient clinic. CONCLUSIONS: PS should be considered as a differential diagnosis in patients with a cystic lung mass. Identification of a systemic artery on radiologic imaging is important in the diagnosis of PS before preoperative workup to prevent unpredicted massive bleeding during surgery.

Diagnostic value of using epicardial fat measurement on screening low-dose chest CT for the prediction of metabolic syndrome: A cross-validation study.

There has been a marked increase in the use of low-dose computed tomography (LDCT) for lung cancer screening. However, the potential of LDCT to predict metabolic syndrome (MetS) has not been well-documented in this risk-sharing population. We assessed the reliability of epicardial fat volume (EFV) and epicardial fat area (EFA) measurements on chest LDCT for prediction of MetS.A total of 130 (mean age, 50.2 ±â€Š10.77 years) asymptomatic male who underwent nonelectrocardiography (ECG)-gated LDCT were divided into 2 groups for the main analysis (n = 75) and validation (n = 55). Each group was further divided into subgroups with or without MetS. EFV and EFA were calculated semiautomatically using commercially available software with manual assistance. The area under the curve (AUC) on receiver operating characteristic (ROC) analysis and cutoff values to predict MetS on LDCT were then calculated and validated. Female data were not available for analysis due to small sample size in this self-referred lung cancer screening program.In the analysis group, the mean EFV was 123.12 ±â€Š42.29 and 67.30 ±â€Š20.68 cm for the MetS and non-MetS subgroups, respectively (P < .001), and the mean EFA was 7.95 ±â€Š3.10 and 4.04 ±â€Š1.73 cm, respectively (P < .001). Using 93.65 and 4.94 as the cutoffs for EFV and EFA, respectively, the sensitivity, specificity, positive and negative predictive values, and accuracy for predicting MetS were 84.2% and 84.2%, and 92.9% and 64.3% (P < .001); 80% and 44.4% (P = .01); 94.5% and 92.3%; and 90.7% and 69.3% (P < .001), respectively. The AUC for EFV and EFA for predicting MetS was 0.909 and 0.808 (95% confidence interval, 0.819-1.000 and 0.702-0.914, respectively) (P = .02). Using the same cutoff values in the analysis group, there was no significant difference in diagnostic performance using EFV and EFA between the analysis and validation sets.Although quantification of both EFA and EFV is feasible on non-ECG-gated LDCT, EFV may be used to reliably predict MetS with fairly high and better diagnostic performance in selected population.

Myocardial CT perfusion imaging for pre- and postoperative evaluation of myocardial ischemia in a patient with myocardial bridging: A case report.

RATIONALE: Although myocardial bridging (MB) is usually considered as benign, initial medical therapy and following surgical treatment in drug-refractory cases has been widely accepted for managing symptomatic MB. Before the patient proceeds to percutaneous or surgical intervention, however, the presence of objective ischemia in the corresponding myocardial territory should be documented. PATIENT CONCERN AND INTERVENTION: We herein report a 43-year-old male complaining of chest pain in whom cardiac CT with myocardial perfusion (cCTP) showed an MB of left anterior descending artery (LAD) with preoperative perfusion defect in corresponding myocardium and normalization of perfusion after supra-arterial myotomy. DIAGNOSIS: Myocardial bridging-induced ischemia. LESSONS: This case illustrates the potential utility of cCTP for the simultaneous assessment of MB and its hemodynamic significance for treatment planning and post-therapeutic evaluation although further research is needed to establish the clinical usefulness of this technique.

The Impact of Iterative Reconstruction in Low-Dose Computed Tomography on the Evaluation of Diffuse Interstitial Lung Disease.

OBJECTIVE: To evaluate the impact of iterative reconstruction (IR) on the assessment of diffuse interstitial lung disease (DILD) using CT. MATERIALS AND METHODS: An American College of Radiology (ACR) phantom (module 4 to assess spatial resolution) was scanned with 10-100 effective mAs at 120 kVp. The images were reconstructed using filtered back projection (FBP), adaptive statistical iterative reconstruction (ASIR), with blending ratios of 0%, 30%, 70% and 100%, and model-based iterative reconstruction (MBIR), and their spatial resolution was objectively assessed by the line pair structure method. The patient study was based on retrospective interpretation of prospectively acquired data, and it was approved by the institutional review board. Chest CT scans of 23 patients (mean age 64 years) were performed at 120 kVp using 1) standard dose protocol applying 142-275 mA with dose modulation (high-resolution computed tomography [HRCT]) and 2) low-dose protocol applying 20 mA (low dose CT, LDCT). HRCT images were reconstructed with FBP, and LDCT images were reconstructed using FBP, ASIR, and MBIR. Matching images were randomized and independently reviewed by chest radiologists. Subjective assessment of disease presence and radiological diagnosis was made on a 10-point scale. In addition, semi-quantitative results were compared for the extent of abnormalities estimated to the nearest 5% of parenchymal involvement. RESULTS: In the phantom study, ASIR was comparable to FBP in terms of spatial resolution. However, for MBIR, the spatial resolution was greatly decreased under 10 mA. In the patient study, the detection of the presence of disease was not significantly different. The values for area under the curve for detection of DILD by HRCT, FBP, ASIR, and MBIR were as follows: 0.978, 0.979, 0.972, and 0.963. LDCT images reconstructed with FBP, ASIR, and MBIR tended to underestimate reticular or honeycombing opacities (-2.8%, -4.1%, and -5.3%, respectively) and overestimate ground glass opacities (+4.6%, +8.9%, and +8.5%, respectively) compared to the HRCT images. However, the reconstruction methods did not differ with respect to radiologic diagnosis. CONCLUSION: The diagnostic performance of LDCT with MBIR was similar to that of HRCT in typical DILD cases. However, caution should be exercised when comparing disease extent, especially in follow-up studies with IR.

Single nodular opacity of granulomatous pneumocystis jirovecii pneumonia in an asymptomatic lymphoma patient.

The radiologic findings of a single nodule from Pneumocystis jirovecii pneumonia (PJP) have been rarely reported. We described a case of granulomatous PJP manifesting as a solitary pulmonary nodule with a halo sign in a 69-year-old woman with diffuse large B cell lymphoma during chemotherapy. The radiologic appearance of the patient suggested an infectious lesion such as angioinvasive pulmonary aspergillosis or lymphoma involvement of the lung; however, clinical manifestations were not compatible with the diseases. The nodule was confirmed as granulomatous PJP by video-assisted thoracoscopic surgery biopsy.

Ultra-Low-Dose Chest CT in Patients with Neutropenic Fever and Hematologic Malignancy: Image Quality and Its Diagnostic Performance.

PURPOSE: The aim of this study was to evaluate the image quality of ultra-low-dose computed tomography (ULDCT) and its diagnostic performance in making a specific diagnosis of pneumonia in febrile neutropenic patients with hematological malignancy. MATERIALS AND METHODS: ULDCT was performed prospectively in 207 febrile neutropenic patients with hematological malignancy. Three observers independently recorded the presence of lung parenchymal abnormality, and also indicated the cause of the lung parenchymal abnormality between infectious and noninfectious causes. If infectious pneumonia was considered the cause of lung abnormalities, they noted the two most appropriate diagnoses among four infectious conditions, including fungal, bacterial, viral, and Pneumocystis pneumonia. Sensitivity for correct diagnoses and receiver operating characteristic (ROC) curve analysis for evaluation of diagnostic accuracy were calculated. Interobserver agreements were determined using intraclass correlation coefficient. RESULTS: Of 207 patients, 139 (67%) had pneumonia, 12 had noninfectious lung disease, and 56 had no remarkable chest computed tomography (CT) (20 with extrathoracic fever focus and 36 with no specific disease). Mean radiation expose dose of ULDCT was 0.60±0.15 mSv. Each observer regarded low-dose CT scans as unacceptable in only four (1.9%), one (0.5%), and three (1.5%) cases of ULDCTs. Sensitivity and area under the ROC curve in making a specific pneumonia diagnosis were 63.0%, 0.65 for reader 1; 63.0%, 0.61 for reader 2; and 65.0%, 0.62 for reader 3; respectively. CONCLUSION: ULDCT, with a sub-mSv radiation dose and acceptable image quality, provides ready and reasonably acceptable diagnostic information for pulmonary infection in febrile neutropenic patients with hematologic malignancy.