Pulmonary embolism in oncologic patients: frequency and embolus burden of symptomatic and unsuspected events.

BACKGROUND: Pulmonary embolism (PE) is a common cause of morbidity and mortality in oncologic patients. Furthermore, PE is an unsuspected finding in many cases. PURPOSE: To determine the frequency and embolus burden of PE in a consecutive oncologic patient group including symptomatic as well as incidental and initially unreported events. MATERIAL AND METHODS: In a retrospective, single-center study from June 2005 to January 2010 all patients with an oncologic disease (ICD-10 code C00 to C96) that received at least one contrast-enhanced computed tomography (CT) examination of the chest were reviewed. The study group included 3270 patients with 6780 examinations. A validated pulmonary artery obstruction index (Mastora score) was used to assess embolus burden. RESULTS: PE was found in 240 of 3270 (7.3%) oncologic patients. The frequency was highly variable among different malignancies ranging from 0% to 25%. In the present study about half of all PE were unsuspected. The mean embolus burden was significantly higher in symptomatic PE than in unsuspected PE (P <0.001). The risk of developing a PE was 1.5 times higher in patients with metastases compared to patients without metastases (P <0.005). Age and sex had no influence on PE risk and embolus burden. CONCLUSION: PE is a frequent unsuspected finding in staging examinations: particularly in patients with malignancies of the ovary, brain, and pancreas, and in patients with metastases. Therefore, the status of the pulmonary vasculature should be assessed in every staging examination that includes the chest. The effect of therapeutic actions on PE events and the unsuspected finding of PE in follow-up CT examinations require further prospective studies.

Imaging findings of gastric diverticula.

INTRODUCTION: Gastric diverticula (GD) are very rare. Computer tomographic findings in GD have been reported only as case reports previously. The aim of this study was to estimate the prevalence of GD on computed tomography (CT) and to analyze their radiological appearances. MATERIALS AND METHODS: From 2006 to 2013, a total of 14,428 patients were examined by abdominal/thoracic CT at our institution. GD were diagnosed in 18 (0.12%) patients (13 women and 5 men, median age, 64 years). In 9 patients, additional endoscopy and in 7 patients upper gastrointestinal investigation with contrast medium were performed. Magnetic resonance imaging (MRI) was available for 3 cases. RESULTS: In all patients GD were diagnosed incidentally during CT examination. The diverticula were located at the posterior wall of the gastric fundus below the esophagogastric junction. On CT, GD presented as cystic lesions with a thin wall and an air fluid level, located behind the stomach between spleen, adrenal gland, and crus of the left diaphragm. CONCLUSION: The prevalence of GD encountered in our CT series is 0.12%. GD demonstrate typical CT appearances, namely, cystic lesions located in the left paravertebral region. The radiologist should be familiar with this finding to avoid possible misinterpretations.

Prevalence and patterns of renal involvement in imaging of malignant lymphoproliferative diseases.

BACKGROUND: Renal involvement in patients with lymphoproliferative disease is an uncommon radiological finding. PURPOSE: To determine its prevalence and radiological appearances in a patient population. MATERIAL AND METHODS: All forms of lymphoproliferative disease (ICD: C81-C96) were considered. From January 2005 to January 2010, 668 consecutive patients with lymphoproliferative disease were identified with the help of the radiological database and patient records. Inclusion criteria were complete staging including appropriate CT scan and/or MRI. All stored images (initial staging and follow-up examinations) were reviewed. RESULTS: Review of all stored images revealed renal infiltration in patients with non-Hodgkin lymphoma (11 of 364 = 3.0%; median age = 65 years, m:f = 6:5) but also multiple myeloma (2 of 162 = 1.2%; median age = 72 years; m:f = 1:1) and leukemia (5 of 101 = 4.9%; median age = 12 years; m:f = 2:3). There were no cases of renal infiltration in 41 patients with Hodgkin's disease. In total there were six patients with solitary lesions, five patients with diffuse renal enlargement, four patients with perirenal lesions, and two patients with direct invasion of the kidney. CONCLUSION: In leukemia the most common imaging pattern is diffuse enlargement. In the other subtypes of lymphoproliferative disease no specific correlation between typical CT patterns and subtype of lymphoproliferative disease can be found. The prevalence of renal involvement is in line with earlier studies. Contrary to earlier reports, multiple lesions were not found to be a common pattern.

Dental Trauma on whole Body Trauma CT-An underreported finding.

BACKGROUND: The prevalence of dental injuries (DI) in polytrauma patients is unknown. The purpose of our study was to identify the frequency of dental injuries on whole body CTs acquired in a trauma setting and to estimate how often they are correctly reported by the radiologist. METHODS: In the time period between 2006 and 2018 the radiological database of one university hospital was screened for whole-body trauma CTs. A total of 994 CTs were identified and re-evaluated. RESULTS: Dental injuries were identified in 127 patients (12.8% of patients). There were 27 women (21.3%) and 100 men (78.7%) with a mean age of 51.0 ± 18.9 years (range 10-96 years). Regarding localization, most findings involved the molars (n = 107, 37.4%), followed by the incisors (n = 81, 28.3%), premolars (n = 59, 20.6%) and canines (n = 39, 13.7%). Most common findings were as follows: luxations (n = 49, 45.8%), followed by crown fractures (n = 46, 43%), root fractures (n = 10, 9.3%), extrusions (n = 1, 0.9%), and intrusions (n = 1, 0.9%). Only 15 findings (11.8% of all patients with dental injuries) were described in the original radiological reports. CONCLUSION: DI had a high occurrence in polytrauma patients. A high frequency of underreported dental trauma findings was identified. Radiologists reporting whole-body trauma CT should be aware of possible dental trauma to report the findings adequately.

Time to threshold as a new indicator of circulatory state and prognosis in patients with pulmonary embolism.

BACKGROUND: Bolus tracking is commonly applied in computed tomography pulmonary angiography. The time that it takes for contrast to reach a predefined threshold in the pulmonary artery is called time to threshold (TTT). TTT could be associated with the circulatory state, and ultimately with prognosis in patients with PE. AIM: The purpose of the present study was to examine the correlation of TTT with embolus burden, radiological and clinical parameters of circulatory state, and ultimately with 30-day mortality. METHODS: In a single-center, retrospective study 50 patients with pulmonary embolism and contrast administration via central venous line were included. The Mastora score was used to quantify embolus burden. Radiological parameters of circulatory state were the ratio of the short axes of the right and left ventricle diameter and the reflux of contrast medium into the inferior vena cava. Clinical parameters of circulatory state were arterial pH, systolic blood pressure, heart rate, and the Acute Physiology and Chronic Health Evaluation II: APACHE II. Survival was defined as surviving the following 30days after the PE diagnosis. RESULTS: TTT was significantly correlated with all radiological and clinical parameters of circulatory state and with 30-day mortality. However, TTT is dependent on device specific and protocol specific factors. CONCLUSIONS: Higher TTT is associated with worse prognosis in patients with pulmonary embolism.

Renal incidental findings on computed tomography: Frequency and distribution in a large non selected cohort.

Renal incidental findings (IFs) are common. However, previous reports investigated renal IFs were limited to patient selection. The purpose of this study was to estimate the prevalence and distribution of all renal IFs on computed tomography (CT) in a large patient collective.All patients, who underwent CT investigations of the abdominal region at our institution in the time period between January 2006 and February 2014 were included in this study. Inclusion criteria were as follows: no previous history of renal diseases and well image quality. Patients with known kidney disorders were excluded from the study. Overall, 7365 patients meet the inclusion criteria were identified. There were 2924 (39.7%) women and 4441 men (60.3%) with a mean age of 59.8 ±â€Š16.7 years. All CTs were retrospectively analyzed in consensus by 2 radiologists. Collected data were evaluated by means of descriptive statistics.Overall, 2756 patients (37.42% of all included patients) showed 3425 different renal IFs (1.24 findings per patient). Of all renal IFs, 123 (3.6%) findings were clinically relevant, 259 (7.6%) were categorized as possibly clinically relevant, and 3043 (88.8%) were clinically non relevant.Different renal IFs can be detected on CT. The present study provides a real prevalence and proportion of them in daily clinical routine. Kidneys should be thoroughly evaluated because of the fact that incidental renal findings occur frequently.

Secondary hypertrophic osteoarthropathy caused by non-pleural or pulmonary tumors.

Hypertrophic osteoarthropathy (HOA) is a rare paraneoplastic syndrome characterized by digital clubbing, periosteal reaction, polyarthralgia, arthritis, and synovitis. Herein, we report a case series of patients with secondary HOA caused by non-pleural or pulmonary tumors.The radiologic databases of 2 tertiary university hospitals were retrospectively screened for secondary HOA patients. In addition, a systemic review of the published case reports. Only HOA cases with non-pleural or pulmonary malignancies were involved into the study. HOA in primary pleural or pulmonary malignant or benign disorders, as well in inflammatory diseases were excluded. In all cases, plain radiography was performed and clinical signs were documented.In our databases, 6 patients with secondary HOA were identified. In addition, the systemic review yielded 24 eligible patients. The most prevalent primary tumors were nasopharyngeal carcinoma and esophageal cancer in 6 patients (20%), respectively. In 17 patients, (56.7%) HOA was associated with lung metastases, and in 10 patients (33.3%), no lung metastases were detected. In 14 patients (46.7%), HOA was symptomatically before a tumor diagnosis was made. Plain radiography displayed typically features with periostal enlargement in every case.This study is the first report about secondary HOA caused by non-pleural or pulmonary tumors. Various primary tumors were identified, including several rare tumors such as sarcomas. HOA is a rare disorder with typically radiologically findings, which is not only associated with lung cancer or pleural mesothelioma and can even occur in tumor patients without lung metastasis.

Cardiovascular findings on computed tomography in patients with unclear finding situation and trauma of unknown origin.

Incidental cardiovascular findings are common and can be found in up to 70% of patients. Previously, several reports about incidental findings (IFs) on whole body computed tomography (CT) were published. However, no previous study investigated cardiovascular IFs in patients with unclear finding situation and trauma of unknown origin on whole body CT.The radiological database of 2 university hospitals was screened for patients with trauma of unknown origin and unclear finding situation investigated by whole body CT. The images were retrospectively analyzed by 2 radiologists in consensus. The findings were classified according to their clinical relevance. Clinically nonrelevant findings like valvular sclerosis, aortic sclerosis, or anatomic variants were excluded from this study. Moreover, the radiology reports were analyzed to assess initial reporting by the radiologist.Overall, we identified 60 patients with a mean age of 63 years. A total of 98 clinically relevant cardiovascular IFs (CRCIF) were identified in 60 (75%) patients (1.6 CRCIF per patient). The most prevalent finding was cardiomegaly in 23 patients, followed by coronary sclerosis in 21 patients and aortic ectasia in 11 patients; other findings were rarer. Sixty-one findings were reported (62.2%) and 37 were nonreported (37.8%). Thirty patients (50%) showed no traumatic event on whole body CT.CRCIFs are common in patients with unclear finding situation and trauma of unknown origin. Despite initial indication for trauma detection, the whole body CT should carefully be evaluated for CRCIF because of the high prevalence of clinically relevant findings. Notably, 37.76% of the findings were not reported by the radiologist.

Clinically Relevant Cardiovascular Findings Detected on Staging Computed Tomography in Patients with Several Malignancies.

We evaluated the frequency and subtypes of clinically relevant cardiovascular (CV) findings identified on staging computed tomography (CT) in a large sample. Patients (n = 5026) with different malignant diseases were staged by CT. Clinically relevant CV findings (CRCFs) were included into the study. The CRCFs were defined as cardiac aneurysm, cardiac thrombus, venous thrombosis, arterial thrombosis, arterial dissection, pulmonary thromboembolism, arterial dissection, and dislocation of venous ports/central venous catheters. The CRCFs were identified in 342 patients (6.8% of all patients). Overall, 491 CRCFs were identified in the patients (1.4 per patient). In 203 (59.4%) patients, 1 CRCF; in 129, 2 (37.7%) CRCFs; and in 10 (2.9%) cases, 3 CRCFs were detected. There were incidental venous thrombosis (n = 298, 60.7% of all CRCFs), pulmonary thromboembolism (n = 84, 17.1%), arterial aneurysms (n = 44, 8.9%), arterial thrombosis (n = 43, 8.8%), heart thrombus (n = 15, 3.1%), arterial dissection (n = 3, 0.6%), heart aneurysms (n = 2, 0.4%), and port catheter dislocation (n = 2, 0.4%). The identified CRCF can be associated with potential hazardous complications. The CV system should be carefully evaluated in staging CT investigations.

Thrombotic events as incidental finding on computed tomography in intensive care unit patients.

INTRODUCTION: Intensive care unit (ICU) patients are a risk group to develop thrombosis and/or thromboembolism. The purpose of this study was to analyze the frequency and localization of clinically silent thrombotic events (TE) detected on CT. MATERIALS AND METHODS: From 2006 to 2013 a total of 370 patients from the ICU of our university clinic were investigated by postcontrast CT. In all cases CT was performed for detecting septic foci. There were 135 women and 235 men. CT scans included cervical, thoracic, abdominal, and pelvic regions. CT images of all patients were re-interpreted by 2 radiologists by consensus. Only thromboses detected for the first time on CT were included into the analysis. Collected data were evaluated by means of descriptive statistics. Frequencies and localizations of TE in surgical and non surgical patients were analyzed by Chi-square test. Significance level was p<0.05. RESULTS: In 31.9% several TE were diagnosed. There were venous thrombosis (89.8%), cardiac thrombus (2.6%), and pulmonary embolism (7.6%). More often jugular veins were affected followed by brachiocephalic veins, and iliac veins. The frequency of TE in surgical patients was 31.1%, and 32.1% in non surgical patients. Patients after surgery had more often thrombosis of extremities veins in comparison to non surgical patients. In 61.9% of all TE the identified thrombotic complications were not diagnosed at the time of CT investigations. CONCLUSION: TE can be identified in 31.9% of ICU patients as incidental finding on CT. There were venous thromboses, pulmonary embolism, and cardiac thrombus. Most frequently neck and thoracic veins were affected. 61.9% of all TE were not diagnosed at the time of CT investigations. Radiologists should check carefully CT scans for presence of different TE.

[Frequency, cause, and awareness of pulmonary embolism in oncologic patients]. / Die Lungenarterienembolie bei onkologischen Erkrankungen: Häufigkeit, Ursachen und Wahrnehmung.

The frequency of pulmonary embolism (PE) in oncologic patients ranges from 1.1 % to 7.3 % depending on whether not only symptomatic findings but also incidental and initially overseen events are considered. The frequency of PE is tumor-specific. Most frequently PE occurs in patients with malignancy of the ovary (25 %), pancreas, brain, uterus, and multiple myeloma. Most rarely is PE found in patients with malignancy of the testis.The tumor-specific frequency shows that the association of malignancy and PE is not equally true for alle malignancies. A number of arguments that support the above association are also valid in non-oncologic patients.The awareness of the diagnosing radiologist and the thrombus mass decide whether or not an unexpected PE is detected. An increased awareness is suggested in patients with malignancies with high PE frequency and in patients with advanced oncologic disease.

30-Day Mortality in Acute Pulmonary Embolism: Prognostic Value of Clinical Scores and Anamnestic Features.

PURPOSE: Identification of high-risk patients with pulmonary embolism is vital. The aim of the present study was to examine clinical scores, their single items, and anamnestic features in their ability to predict 30-day mortality. MATERIALS AND METHODS: A retrospective, single-center study from 06/2005 to 01/2010 was performed. Inclusion criteria were presence of pulmonary embolism, availability of patient records and 30-day follow-up. The following clinical scores were calculated: Acute Physiology and Chronic Health Evaluation II, original and simplified pulmonary embolism severity index, Glasgow Coma Scale, and euroSCORE II. RESULTS: In the study group of 365 patients 39 patients (10.7%) died within 30 days due to pulmonary embolism. From all examined scores and parameters the best predictor of 30-day mortality were the Glasgow Coma scale (≤ 10) and parameters of the circulatory system including presence of mechanical ventilation, arterial pH (< 7.335), and systolic blood pressure (< 99 mm Hg). CONCLUSIONS: Easy to ascertain circulatory parameters have the same or higher prognostic value than the clinical scores that were applied in this study. From all clinical scores studied the Glasgow Coma Scale was the most time- and cost-efficient one.

Timing of pulmonary embolism diagnosis in the emergency department.

BACKGROUND: Patients with pulmonary embolism(PE) benefit from rapid diagnosis and treatment. The aim of the present study is to examine factors that contribute to the time between admission at the emergency department and diagnosis of PE (=time to diagnosis TTD). METHODS: This retrospective study included 241 patients with symptomatic PE that were admitted at the emergency department. Patient records were reviewed to obtain the relevant clinical information. Patients were assigned in one of three groups according to their TTD: short TTD ≤ 2 h; intermediate TTD N 2 h and ≤ 12 h; and prolonged TTD N 12 h. The groups were compared for differences in clinical factors. Furthermore multiple linear regression analyses based on TTD was performed. RESULTS: Factor that significantly contribute to a very short TTD b 2 h are tachycardia and a high embolus burden. Factors that significantly contribute to a diagnosis b12 h are embolus burden, no COPD present, patient admitted at day shift, and a less pathologic ratio of ventricle axis. Multiple regression analyses identified increased age and low embolus burden as the strongest, independent factors for prolonged TTD. CONCLUSIONS: Patients with higher embolus load or signs of severe PE including tachycardia were most likely diagnosed within 2 h after presentation.More effort should be put in a faster diagnostic process in older patients and in patients with COPD.

CT pulmonary angiography findings that predict 30-day mortality in patients with acute pulmonary embolism.

PURPOSE: Standard computed tomography pulmonary angiography (CTPA) can be used to diagnose acute pulmonary embolism. In addition, multiple findings at CTPA have been proposed as potential tools for risk stratification. Therefore, the aim of the present study is to examine the prognostic value of (I) thrombus distribution, (II) morphometric parameters of right ventricular dysfunction, and (III) contrast reflux in inferior vena cava on 30-day mortality. MATERIAL AND METHODS: In a retrospective, single-center study from 06/2005 to 01/2010 365 consecutive patients were included. Inclusion criteria were: presence of acute pulmonary embolism, and availability of 30-day follow-up. A review of patient charts and images was performed. RESULTS: There were no significant differences between the group of 326 survivors and 39 non-survivors in (I) thrombus distribution, and (II) morphometric measurements of right ventricular dysfunction. However, (III) contrast reflux in inferior vena cava was significantly stronger in non-survivors (odds ratio 3.29; p<0.001). Results were independent from comorbidities like heart insufficiency and pulmonary hypertension. CONCLUSION: Measurement of contrast reflux is a new and robust method for predicting 30-day mortality in patients with acute pulmonary embolism. Obstruction scores and morphometric measurements of right ventricular dysfunction perform poor as risk stratification tools.

Imaging characteristics and embolus burden of unreported pulmonary embolism in oncologic patients.

The present study sought to estimate the frequency of overseen and unreported (i.e., false negative) pulmonary embolism (PE) events in oncologic patients. In a retrospective analysis, 3270 patients (6780 computed tomography examinations) were reviewed. Unreported PE was found in 74 patients (2.3%). It was particularly frequent in follow-up staging examinations in patients with metastasized malignancies of the lung and kidney. The present data support the thesis that the search error (thrombus was never fixed by the eyes of the reviewer) was the most common reason why PE was overseen.

Muscle metastases: comparison of features in different primary tumours.

BACKGROUND: Muscle metastases (MM) from solid tumours are rare. The aim of this study was to describe radiological features of MM, and to compare their patterns in different malignancies. METHODS: A retrospective search in the statistical database of our institution revealed 61 cases of MM. Additionally, a retrospective search in Pubmed database was performed. Together with our cases the present analysis comprises 461 patients (682 MM). RESULTS: MM derived from the following malignancies: lung cancer (25.1%), gastrointestinal tumours (21.0%), and urological tumours (13.2%). Other neoplasias with MM were rare. MM were localised most frequently in the thigh muscles, the extraocular musculature, and the gluteal and paravertebral muscles. The localisation of MM was different in several primary malignancies. CONCLUSION: MM present with a broad spectrum of radiological features. Different CT imaging findings of MM were observed in different primary tumours. The localisation of MM also varies with different primary malignancies.