RadioGraphics Update: Lung-RADS 2022.

Editor's Note.-RadioGraphics Update articles supplement or update information found in full-length articles previously published in RadioGraphics. These updates, written by at least one author of the previous article, provide a brief synopsis that emphasizes important new information such as technological advances, revised imaging protocols, new clinical guidelines involving imaging, or updated classification schemes.

High-Resolution Computed Tomography of Cystic Lung Disease.

The cystic lung diseases (CLD) are characterized by the presence of multiple, thin-walled, air-filled spaces in the pulmonary parenchyma. Cyst formation may occur with congenital, autoimmune, inflammatory, infectious, or neoplastic processes. Recognition of cyst mimics such as emphysema and bronchiectasis is important to prevent diagnostic confusion and unnecessary evaluation. Chest CT can be diagnostic or may guide the workup based on cyst number, distribution, morphology, and associated lung, and extrapulmonary findings. Diffuse CLD (DCLDs) are often considered those presenting with 10 or more cysts. The more commonly encountered DCLDs include lymphangioleiomyomatosis, pulmonary Langerhans' cell histiocytosis, lymphoid interstitial pneumonia, Birt-Hogg-Dubé syndrome, and amyloidosis/light chain deposition disease.

Percutaneous Lung Biopsy with Pleural and Parenchymal Blood Patching: Results and Complications from 1,112 Core Biopsies.

PURPOSE: To evaluate the outcomes of computed tomography (CT) fluoroscopy-guided core lung biopsies with emphasis on diagnostic yield, complications, and efficacy of parenchymal and pleural blood patching to avoid chest tube placement. METHODS: This is a single-center retrospective analysis of CT fluoroscopy-guided percutaneous core lung biopsies between 2006 and 2020. Parenchymal blood patching during introducer needle withdrawal was performed in 74% of cases as a preventive measure, and pleural blood patching was the primary salvage maneuver for symptomatic or growing pneumothorax in 60 of 83 (72.2%) applicable cases. RESULTS: A total of 1,029 patients underwent 1,112 biopsies (532 men; mean age, 66 years; 38.6%, history of emphysema; lesion size, 16.7 mm). The diagnostic yield was 93.6% (1,032/1,103). Fewer complications requiring intervention were observed in patients who underwent parenchymal blood patching (5.7% vs 14.2%, P < .001). Further intervention was required in 83 of 182 pneumothorax cases, which included the following: (a) pleural blood patch (5.4%, 60/1,112), (b) chest tube placement without a pleural blood patch attempt (1.5%, 17/1,112), and (c) simple aspiration (0.5%, 6/1,112). Pleural blood patch as monotherapy was successful in 83.3% (50/60) of cases without need for further intervention. The overall chest tube rate was 2.6% (29/1,112). Emphysema was the only significant risk factor for complications requiring intervention (P ≤ .001). CONCLUSIONS: Parenchymal blood patching during introducer needle withdrawal decreased complications requiring intervention. Salvage pleural blood patching reduced the frequency of chest tube placement for pneumothorax.

Routes of Transdiaphragmatic Migration from the Abdomen to the Chest.

The diaphragm serves as an anatomic border between the abdominal and thoracic cavities. Pathologic conditions traversing the diaphragm are often incompletely described and may be overlooked, resulting in diagnostic delays. Several routes allow abdominal contents or pathologic processes to spread into the thorax, including along normal transphrenic structures, through congenital defects in the diaphragm, through inherent areas of weakness between muscle groups, or by pathways created by tissue destruction, trauma, or iatrogenic injuries. A thorough knowledge of the anatomy of the diaphragm can inform an accurate differential diagnosis. Often, intraperitoneal pathologic conditions crossing the diaphragm may be overlooked if axial imaging is the only approach to this complex region because of the horizontal orientation of much of the diaphragm. Multiplanar capabilities of volumetric CT and MRI provide insight into the pathways where pathologic conditions may traverse this border. Knowledge of these characteristic routes and use of multiplanar imaging are critical for depiction of specific transdiaphragmatic pathologic conditions.©RSNA, 2020.

Lymphangioleiomyomatosis Diagnosis and Management: High-Resolution Chest Computed Tomography, Transbronchial Lung Biopsy, and Pleural Disease Management. An Official American Thoracic Society/Japanese Respiratory Society Clinical Practice Guideline.

BACKGROUND: Recommendations regarding key aspects related to the diagnosis and pharmacological treatment of lymphangioleiomyomatosis (LAM) were recently published. We now provide additional recommendations regarding four specific questions related to the diagnosis of LAM and management of pneumothoraces in patients with LAM. METHODS: Systematic reviews were performed and then discussed by a multidisciplinary panel. For each intervention, the panel considered its confidence in the estimated effects, the balance of desirable (i.e., benefits) and undesirable (i.e., harms and burdens) consequences, patient values and preferences, cost, and feasibility. Evidence-based recommendations were then formulated, written, and graded using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. RESULTS: For women who have cystic changes on high-resolution computed tomography of the chest characteristic of LAM, but who have no additional confirmatory features of LAM (i.e., clinical, radiologic, or serologic), the guideline panel made conditional recommendations against making a clinical diagnosis of LAM on the basis of the high-resolution computed tomography findings alone and for considering transbronchial lung biopsy as a diagnostic tool. The guideline panel also made conditional recommendations for offering pleurodesis after an initial pneumothorax rather than postponing the procedure until the first recurrence and against pleurodesis being used as a reason to exclude patients from lung transplantation. CONCLUSIONS: Evidence-based recommendations for the diagnosis and treatment of patients with LAM are provided. Frequent reassessment and updating will be needed.

Comparison of digital and film chest radiography for detection and medical surveillance of silicosis in a setting with a high burden of tuberculosis.

BACKGROUND: Continuing use of analog film and digital chest radiography for screening and surveillance for pneumoconiosis and tuberculosis in lower and middle income countries raises questions of equivalence of disease detection. This study compared analog to digital images for intra-rater agreement across formats and prevalence of changes related to silicosis and tuberculosis among South African gold miners using the International Labour Organization classification system. METHODS: Miners with diverse radiological presentations of silicosis and tuberculosis were recruited. Digital and film chest images on each subject were classified by four expert readers. RESULTS: Readings of film and soft copy digital images showed no significant differences in prevalence of tuberculosis or silicosis, and intra-rater agreement across formats was fair to good. Hard copy images yielded higher prevalences. CONCLUSION: Film and digital soft copy images show consistent prevalence of findings, and generally fair to good intra-rater agreement for findings related to silicosis and tuberculosis.

Lung-RADS: Pushing the Limits.

In response to the recommendation of the U.S. Preventive Services Task Force and the coverage decision by the Centers for Medicare and Medicaid Services for lung cancer screening (LCS) computed tomography (CT), the American College of Radiology introduced the Lung CT Screening Reporting and Data System (Lung-RADS) in 2014 to standardize the reporting and management of screening-detected lung nodules. As with many first-edition guidelines, questions arise when such reporting systems are used in daily practice. In this article, a collection of 15 LCS-related scenarios are presented that address situations in which the Lung-RADS guidelines are unclear or situations that are not currently addressed in the Lung-RADS guidelines. For these 15 scenarios, the authors of this article provide the reader with recommendations that are based on their collective experiences, with the hope that future versions of Lung-RADS will provide additional guidance, particularly as more data from widespread LCS are collected and analyzed. ©RSNA, 2017.

A 30-year mortality and respiratory morbidity study of refractory ceramic fiber workers.

AIM: Report mortality (n = 1119), cancer incidence (n = 1207) and radiographic (n = 1451) findings from a 30-year investigation of current and former refractory ceramic fiber (RCF) workers. METHODS: Cause of death, health and work histories, radiographs and spirometry were collected. Mortality and cancer incidence were analyzed. Logistic regression analysis investigated the associations of latency and cumulative fiber exposure (CFE) on radiographic changes. RESULTS: The mortality study showed no increase in standardized mortality rates (SMR) for lung cancer, but urinary cancers were significantly elevated in the higher exposed group (SMR = 3.62, 95% CI: 1.33-7.88) and leukemia in the total cohort (SMR = 2.51, 95% CI: 1.08-4.94). One death attributed to mesothelioma was identified (SMR = 2.86, 95% CI: 0.07-15.93) in a worker reporting some asbestos exposure. The overall rate of pleural changes was 6.1%, attaining 21.4% in the highest CFE category for all subjects (adjusted odds ratio (aOR) = 6.9, 95% CI: 3.6-13.4), and 13.0% for those with no reported asbestos exposure (OR= 9.1, 95% CI: 2.5-33.6). Prevalence for recent hires (≥1985) was similar to the background. Interstitial changes were not elevated. Localized pleural thickening was associated with small decreases in spirometry results. CONCLUSION: Increases in leukemia and urinary cancer but not lung cancer mortality were found. One death attributed to mesothelioma was observed in a worker with self-reported asbestos exposure and a work history where occupational asbestos exposure may have occurred, rendering uncertainties in assigning causation. Radiographic analyses indicated RCF exposure alone is associated with increased pleural but not interstitial changes. Reductions in RCF exposure should continue. The mortality study is ongoing.

Histiocytic disorders of the chest: imaging findings.

Histiocytic disorders of the chest comprise a broad spectrum of diseases. The lungs may be involved in isolation or as part of systemic disease. Some of these disorders are primary and have unknown etiology, and others result from a histiocytic response to a known cause. Among primary histiocytic disorders, pulmonary Langerhans cell histiocytosis (PLCH) is the most common; others include Erdheim-Chester disease and Rosai-Dorfman disease. Adult PLCH occurs almost exclusively in adults aged 20-40 years who smoke. Pediatric PLCH is extremely rare and typically occurs as part of multisystemic disease. Erdheim-Chester disease affects middle-aged and older adults; thoracic involvement usually occurs as part of systemic disease. Rosai-Dorfman disease affects children and young adults and manifests as painless cervical lymphadenopathy. Examples of secondary histiocytic disorders are storage diseases such as Gaucher disease, Niemann-Pick disease, and Fabry disease; pneumoconiosis such as silicosis and coal workers' pneumoconiosis; and infections such as Whipple disease and malakoplakia. These disorders are characterized at histopathologic examination on the basis of infiltration of alveoli or the pulmonary interstitium by histiocytes, which are a group of cells that includes macrophages and dendritic cells. Dendritic cells are a heterogeneous group of nonphagocytic antigen-presenting immune cells. Immunohistochemical markers help to distinguish among various primary histiocytic disorders. Characteristic radiologic findings in the appropriate clinical context may obviate biopsy to establish a correct diagnosis. However, in the absence of these findings, integration of clinical, pathologic, and radiologic features is required to establish a diagnosis.

Unreimbursed Costs of Multidisciplinary Conferences to a Radiology Department: A Prospective Analysis at an Academic Medical Center.

PURPOSE: Multidisciplinary conferences (MDCs) are important for clinical care but are unreimbursed and can be time-consuming for radiologists to prepare for and present. The purpose of this single-center, prospective, survey-based study is to measure the per-conference time and total time radiologists devote to MDCs at a single academic medical center. Secondary objectives are to determine the source of radiologist preparation time, and calculate the per conference and overall radiology departmental costs of MDC participation. METHODS: A prospective survey was performed to capture all radiology preparation and presentation time for MDCs in a 3-month period, which was then annualized. Total cost was calculated on the basis of Association of Administrators in Academic Radiology survey data for nonchair academic radiologist compensation plus a 30% fringe-benefit rate. RESULTS: The survey response rate was 86.9%. A total of 3,358 hours were devoted annually to MDCs, which represents time equivalent to 1.9 full-time equivalents or $1,155,152 in unreimbursed radiology departmental costs. Per-MDC total preparation and presentation time was 2.7 hours, at an annual cost of $46,440 for each weekly MDC. Radiologists used a combination of personal time (49.7%), academic time (42%), and/or clinical time (35.4%) to prepare for MDCs. Radiologists devoted a mean of 47.9 hours (1.2 weeks) of time per annum to MDCs. CONCLUSIONS: Radiologist time devoted to MDCs at the survey institution was substantial, and preparation time was drawn disproportionately from personal and academic time, which may have negative implications for burnout, recruitment and retention, and academic productivity unless it is effectively mitigated.

Cardiothoracic Radiologist Workload, Work Capacity, and Burnout Post-COVID: Results of a Survey From the Society of Thoracic Radiology.

In this report and analysis of the results of a late 2021 post-COVID pandemic survey of members of the Society of Thoracic Radiology, we compared cardiothoracic radiologist workloads and burnout rates with those obtained from a prepandemic survey of society members. The more recent survey also asked respondents to provide a subjective assessment of their individual workload capacity should they be required to read cases at a section average daily case work volume, and this assessment was correlated with burnout rates. To measure nonrelative value unit workload, we requested data on non-case-related work responsibilities including teaching and multidisciplinary conferences that were not assessed in the first survey. In addition, we asked respondents to provide information on the availability of support services, personnel, and hardware and software tools that could improve work efficiency and reduce radiologist stress levels thereby mitigating burnout. We found that postpandemic case workload and cardiothoracic radiologists' burnout rates were similarly high compared with prepandemic levels with an overall burnout rate of 88% including a 100% burnout rate among women which had significantly increased. The range of radiologists' workload capacity is broad, although 80% of respondents reported that reading at an average sectional case volume was at or above their capacity, and the perceived capacity correlated with burnout measures. The presence of fellows and computer-aided diagnosis/artificial intelligence tools were each associated with significant decreases in burnout, providing 2 potential strategies that could be employed to address high cardiothoracic radiologist burnout rates.

Pneumocystis jiroveci pneumonia: high-resolution CT findings in patients with and without HIV infection.

OBJECTIVE: The purpose of this essay is to review the spectrum of high-resolution CT findings of Pneumocystis jiroveci pneumonia in immunocompromised patients with and without HIV infection. CONCLUSION: Pneumocystis jiroveci pneumonia is a common opportunistic infection affecting immunosuppressed patients. High-resolution CT may be indicated for evaluation of immunosuppressed patients with suspected pneumonia and normal chest radiographic findings. The most common high-resolution CT finding of Pneumocystis jiroveci pneumonia is diffuse ground-glass opacity. Consolidation, nodules, cysts, and spontaneous pneumothorax also can develop.

Prevalence of Burnout Among Cardiothoracic Radiologists: Stress Factors, Career Satisfaction, and Modality-specific Imaging Volumes.

PURPOSE: We investigated the impact of modality-specific volumes and other potential stressors on burnout and career-choice satisfaction. MATERIALS AND METHODS: An anonymous survey of 36 questions was sent by email to all 875 faculty members of the STR. These included 11 multiple-choice questions, 23 Likert questions, and 2 free-text questions. The Maslach Burnout Index was used to assess the prevalence of the 3 components of burnout (emotional exhaustion, depersonalization, and low professional accomplishment), and we assessed variations among the potential sources of stress with respect to the respondent sex, career stage, and practice setting. Respondents were asked to estimate daily work volume as if interpreting only chest radiographs (CXRs) or only chest/cardiac computed tomography (CT). Statistical analysis was performed using Excel (Microsoft), open-source statistical computing package pandas and SciPy for Python, and Jupyter Notebook, an open-source interactive computing platform. RESULTS: Although financial concerns (49.3%), lack of input into decisions (48.6%), and inadequate staffing (45.2%) were additional stressors, the major sources were work-life balance (67.4%) and workload (66.8%), which were more frequently cited by women than men (78.9% vs. 60.8%, P=0.001). Emotional exhaustion and depersonalization were related to higher CXR volumes. Although 83.2% were satisfied being a diagnostic radiologist, 18.8% had thought of leaving medicine. More than half of all radiologists interpreted ≥150 CXRs daily (51.1% vs. 53.6%); more in private practice read ≥200 CXRs (23.2% vs. 14.7%). Of the academic radiologists, 80.2% interpreted 21 to 49 CTs; twice as many in private practice read ≥50 CTs (25.5% vs. 12.7%). CONCLUSIONS: The contributing factors to cardiothoracic radiologist burnout vary by sex, career stage, and practice setting. Several stressors, especially work-life balance, were associated with higher burnout prevalence. Most respondents expressed career-choice satisfaction. Defining threshold work volumes associated with higher rates of burnout is an important first step in defining burnout prevention guardrails.

Blastomycosis: The Great Pretender.

Blastomycosis is an endemic fungal infection caused by Blastomyces, a soil-dwelling dimorphic fungus found predominantly in North America. In this pictorial essay, we illustrate the varied imaging features of blastomycosis along with a brief description of the epidemiology, clinical aspects, and differential diagnosis, emphasizing clues that can help radiologists arrive at this diagnosis.

Diffuse cystic lung disease at high-resolution CT.

OBJECTIVE: This article will illustrate and describe the spectrum of diseases associated with air cysts at high-resolution CT (HRCT). CONCLUSION: HRCT is an important modality in the evaluation of interstitial lung disease to include cystic lung disease. Although most commonly associated with lymphangioleiomyomatosis or Langerhans cell histiocytosis, cystic lung disease is increasingly being recognized as a feature of other entities. Awareness of the spectrum of HRCT findings associated with these diseases may help the trained observer narrow the differential diagnosis.

CT findings of pulmonary nocardiosis.

OBJECTIVE: Nocardiosis is an opportunistic infection that primarily affects the lungs. Most infected patients have deficits in cell-mediated immunity such as those with AIDS, transplant recipients, and those receiving corticosteroid therapy. We review the various CT appearances of pulmonary nocardiosis and discuss the differential diagnosis. CONCLUSION: Common CT findings include lung consolidation and nodules and masses. Cavitation may occur. Chest wall involvement develops in a small number of patients.

Put your back into it: pathologic conditions of the spine at chest CT.

It is common to encounter pathologic processes of the lower cervical, thoracic, or upper lumbar spine in the course of routine computed tomography (CT) of the chest. Although magnetic resonance (MR) is the imaging modality of choice for evaluating known spinal disease, evaluation of the spine is an integral part of interpreting a chest CT study. Spinal diseases often have a characteristic CT appearance that allows the radiologist to make the diagnosis or provide a structured differential diagnosis. Pathologic conditions of the spine that can be identified at chest CT are categorized into benign or incidental findings, congenital anomalies, traumatic injuries, infectious spondylitis, primary or secondary neoplastic involvement, and associations with systemic disease. CT also provides information about bone mineralization and lesion calcification that complements the superior soft-tissue imaging capability of MR. In addition, chest CT data may be reformatted to create volumetric or multiplanar images of the spine to facilitate management decisions about spinal stabilization in symptomatic patients.

Beyond skin deep: thoracic manifestations of systemic disorders affecting the skin.

A variety of systemic disorders--infections, noninfectious inflammatory diseases, collagen vascular diseases, hereditary diseases, and acquired immune deficiency diseases--may affect both the skin and the lung. The findings in one organ system can help establish the diagnosis or limit the differential diagnosis. Cutaneous manifestations of many conditions (eg, Kaposi sarcoma) precede thoracic manifestations and sometimes have prognostic implications for respiratory disease; in other conditions (eg, organizing pneumonia in polymyositis and dermatomyositis), thoracic manifestations precede cutaneous ones. When skin and thoracic manifestations develop simultaneously, as occurs in the acute form of sarcoidosis known as Löfgren syndrome, the diagnosis is often readily established. Familiarity with the appearances of skin lesions that are commonly associated with systemic lung disease, especially those that are disease specific, may allow the radiologist to pinpoint a diagnosis even when thoracic imaging findings are nonspecific.

Prevalence of Burnout Among Cardiothoracic Radiologists.

PURPOSE: Burnout is a psychological syndrome in response to chronic occupational stressors. The prevalence of burnout among medical professionals has been increasing, and recent studies have shown that radiologists are among those affected. We investigated the prevalence of burnout and assessed associated factors among cardiothoracic radiologists. MATERIALS AND METHODS: Society of Thoracic Radiology members were invited to complete an anonymous cross-sectional survey that included an adapted Maslach Burnout Inventory and questions about demographics, work place characteristics, and stressors. RESULTS: The survey response rate was 33.1% (290/874). Per-item response rate ranged from 94% to 100% with a median of 99%. The prevalence of emotional exhaustion was 66.8% (186/283), depersonalization was 79% (223/283), and low personal accomplishment was 23% (65/280). There were no statistically significant differences between academic and private practice. There was a trend toward worse burnout in women, but this was not statistically significant. Being in early career (0 to 10 y since fellowship) was associated with low personal accomplishment [odds ratio (OR): 2.07, 95% confidence interval (CI): 1.08-3.99]. Those working fewer than 51 hours per week were significantly less likely to report emotional exhaustion (OR: 0.55, 95% CI: 0.33-0.90). The odds of emotional exhaustion for those producing fewer than 7500 work relative value units per year were approximately half of those exceeding that number (OR: 0.46, 95% CI: 0.22-0.95). CONCLUSIONS: The prevalence of burnout among cardiothoracic radiologists is comparable to that reported for radiologists in other subspecialties such as musculoskeletal and interventional radiology. High work relative value unit productivity and longer work hours are associated with higher prevalence of burnout.