Consensus Statements on Deployment-Related Respiratory Disease, Inclusive of Constrictive Bronchiolitis: A Modified Delphi Study.

BACKGROUND: The diagnosis of constrictive bronchiolitis (CB) in previously deployed individuals, and evaluation of respiratory symptoms more broadly, presents considerable challenges, including using consistent histopathologic criteria and clinical assessments. RESEARCH QUESTION: What are the recommended diagnostic workup and associated terminology of respiratory symptoms in previously deployed individuals? STUDY DESIGN AND METHODS: Nineteen experts participated in a three-round modified Delphi study, ranking their level of agreement for each statement with an a priori definition of consensus. Additionally, rank-order voting on the recommended diagnostic approach and terminology was performed. RESULTS: Twenty-five of 28 statements reached consensus, including the definition of CB as a histologic pattern of lung injury that occurs in some previously deployed individuals while recognizing the importance of considering alternative diagnoses. Consensus statements also identified a diagnostic approach for the previously deployed individual with respiratory symptoms, distinguishing assessments best performed at a local or specialty referral center. Also, deployment-related respiratory disease (DRRD) was proposed as a broad term to subsume a wide range of potential syndromes and conditions identified through noninvasive evaluation or when surgical lung biopsy reveals evidence of multicompartmental lung injury that may include CB. INTERPRETATION: Using a modified Delphi technique, consensus statements provide a clinical approach to possible CB in previously deployed individuals. Use of DRRD provides a broad descriptor encompassing a range of postdeployment respiratory findings. Additional follow-up of individuals with DRRD is needed to assess disease progression and to define other features of its natural history, which could inform physicians better and lead to evolution in this nosology.

Comprehensive genomic profiling aids in treatment of a metastatic endometrial cancer.

FGFR-TACC fusions, including FGFR3-TACC3, have been identified as potential oncogenic drivers and actionable alterations in a number of different cancer types. The clinical relevance of FGFR3-TACC3 fusions in endometrial cancer has not yet been described. Formalin-fixed, paraffin-embedded metastatic endometrial carcinoma from the spleen and peritoneum were sent for comprehensive genomic profiling (CGP) using the FoundationOne platform as part of a prospective tumor genomic profiling protocol. We report the identification of an FGFR3-TACC3 fusion in a case of metastatic endometrioid endometrial cancer. Other potentially actionable alterations detected in this specimen included PIK3CA T1025S and an uncharacterized rearrangement involving TSC2 The patient initially received an FGFR inhibitor as an investigational agent and experienced stable disease with complete resolution of a pelvic nodule; however, treatment had to be discontinued because of intolerable side effects. A PET/CT scan nearly 3 mo after discontinuation showed disease progression. She subsequently received the mTOR inhibitor, temsirolimus, later accompanied by letrozole, and achieved stable disease. Clinical benefit was attributed to the mTOR inhibitor as tumor stained negative for estrogen receptor. Temsirolimus was discontinued after >17 mo because of disease progression. FGFR inhibitors may have clinical benefit in the treatment of endometrial carcinoma with FGFR3-TACC3 fusions. Additionally, clinical benefit from an mTOR inhibitor may reflect a response to targeting the alteration in PIK3CA or TSC2 More research is needed to understand the activity of FGFR3-TACC3 fusions on tumors and to discover additional therapeutic options for endometrial carcinoma patients with this gene fusion.

ACR CT Accreditation Program and the Lung Cancer Screening Program Designation.

The ACR recognizes that low-dose CT for lung cancer screening has the potential to significantly reduce mortality from lung cancer in the appropriate high-risk population. The ACR supports the recommendations of the US Preventive Services Task Force and the National Comprehensive Cancer Network for screening patients. To be effective, lung cancer screening should be performed at sites providing high-quality low-dose CT examinations overseen and interpreted by qualified physicians using a structured reporting and management system. The ACR has developed a set of tools necessary for radiologists to take the lead on the front lines of lung cancer screening. The ACR Lung Cancer Screening Center designation is built upon the ACR CT accreditation program and requires use of Lung-RADS or a similar structured reporting and management system. This designation provides patients and referring providers with the assurance that they will receive high-quality screening with appropriate follow-up care.

ACR CT accreditation program and the lung cancer screening program designation.

The ACR recognizes that low-dose CT for lung cancer screening has the potential to significantly reduce mortality from lung cancer in the appropriate high-risk population. The ACR supports the recommendations of the US Preventive Services Task Force and the National Comprehensive Cancer Network for screening patients. To be effective, lung cancer screening should be performed at sites providing high-quality low-dose CT examinations overseen and interpreted by qualified physicians using a structured reporting and management system. The ACR has developed a set of tools necessary for radiologists to take the lead on the front lines of lung cancer screening. The ACR Lung Cancer Screening Center designation is built upon the ACR CT accreditation program and requires use of Lung-RADS or a similar structured reporting and management system. This designation provides patients and referring providers with the assurance that they will receive high-quality screening with appropriate follow-up care.

ACR appropriateness criteria(®)acute respiratory illness in immunocompromised patients.

The respiratory system is often affected by complications of immunodeficiency, typically manifesting clinically as acute respiratory illness. Ongoing literature reviews regarding the appropriateness of imaging in these patients are critical, as advanced medical therapies such as stem cell transplantation, chemotherapy, and immunosuppressive therapies for autoimmune disease continue to keep high the population of immunosuppressed patients in our health care system today. This ACR Appropriateness Criteria(®) topic describes clinical scenarios of acute respiratory illness in immunocompromised patients with cough, dyspnea, chest pain, and fever; in those with negative, equivocal, or nonspecific findings on chest radiography; in those with diffuse or confluent opacities on chest radiography; and in those in whom noninfectious disease is suspected. The use of chest radiography, chest CT, transthoracic needle biopsy, and nuclear medicine imaging are all discussed in the contexts of these clinical scenarios. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

ACR Appropriateness Criteria® screening for pulmonary metastases.

Screening for pulmonary metastatic disease is an important step for staging a patient with a known or recently discovered malignancy. Here we present our recommendations for screening for metastatic disease based on recommendations from the literature and experiences of pulmonary radiologists. In short, chest computed tomographic (CT) screening is the most appropriate tool for evaluation of pulmonary metastasis in the majority of cases. Chest computed tomographic screening is also recommended for follow-up and to determine response to therapy. Other modalities such as chest radiography, magnetic resonance imaging, and scintigraphy will also be discussed. Please note that this study is a summary of the complete version of this topic, which is available on the ACR website at www.acr.org. Practitioners are encouraged to refer to the complete version.

ACR Appropriateness Criteria hemoptysis.

Hemoptysis is defined as the expectoration of blood originating from the tracheobronchial tree or pulmonary parenchyma, ranging from 100 mL to 1 L in volume over a 24-hour period. This article reviews the literature on the indications and usefulness of radiologic studies for the evaluation of hemoptysis. The following recommendations are the result of evidence-based consensus by the American College of Radiology Appropriateness Criteria Expert Panel on Thoracic Radiology: (1) Initial evaluation of patients with hemoptysis should include a chest radiograph; (2) Patients at high risk for malignancy (>40 y old, >40 pack-year smoking history) with negative chest radiograph, computed tomography (CT) scan, and bronchoscopy can be followed with observation for the following 3 years. Radiography and CT are recommended imaging modalities for follow-up. Bronchoscopy may complement imaging during the period of observation; (3) In patients who are at high risk for malignancy and have suspicious chest radiograph findings, CT is suggested for initial evaluation; CT should also be considered in patients who are active or exsmokers, despite a negative chest radiograph; and (4) Massive hemoptysis can be effectively treated with either surgery or percutaneous embolization. Contrast-enhanced multidetector CT before embolization or surgery can define the source of hemoptysis as bronchial systemic, nonbronchial systemic, and/or pulmonary arterial. Percutaneous embolization may be used initially to halt the hemorrhage before definitive surgery.

Imaging the pregnant patient for nonobstetric conditions: algorithms and radiation dose considerations.

Use of diagnostic imaging studies for evaluation of pregnant patients with medical conditions not related to pregnancy poses a persistent and recurring dilemma. Although a theoretical risk of carcinogenesis exists, there are no known risks for development of congenital malformations or mental retardation in a fetus exposed to ionizing radiation at the levels typically used for diagnostic imaging. An understanding of the effects of ionizing radiation on the fetus at different gestational stages and the estimated exposure dose received by the fetus from various imaging modalities facilitates appropriate choices for diagnostic imaging of pregnant patients with nonobstetric conditions. Other aspects of imaging besides radiation (ie, contrast agents) also carry potential for fetal injury and must be taken into consideration. Imaging algorithms based on a review of the current literature have been developed for specific nonobstetric conditions: pulmonary embolism, acute appendicitis, urolithiasis, biliary disease, and trauma. Imaging modalities that do not use ionizing radiation (ie, ultrasonography and magnetic resonance imaging) are preferred for pregnant patients. If ionizing radiation is used, one must adhere to the principle of using a dose that is as low as reasonably achievable after a discussion of risks versus benefits with the patient.