Fleischner Society: Glossary of Terms for Thoracic Imaging.

Members of the Fleischner Society have compiled a glossary of terms for thoracic imaging that replaces previous glossaries published in 1984, 1996, and 2008, respectively. The impetus to update the previous version arose from multiple considerations. These include an awareness that new terms and concepts have emerged, others have become obsolete, and the usage of some terms has either changed or become inconsistent to a degree that warranted a new definition. This latest glossary is focused on terms of clinical importance and on those whose meaning may be perceived as vague or ambiguous. As with previous versions, the aim of the present glossary is to establish standardization of terminology for thoracic radiology and, thereby, to facilitate communications between radiologists and clinicians. Moreover, the present glossary aims to contribute to a more stringent use of terminology, increasingly required for structured reporting and accurate searches in large databases. Compared with the previous version, the number of images (chest radiography and CT) in the current version has substantially increased. The authors hope that this will enhance its educational and practical value. All definitions and images are hyperlinked throughout the text. Click on each figure callout to view corresponding image. © RSNA, 2024 Supplemental material is available for this article. See also the editorials by Bhalla and Powell in this issue.

Pulmonary functional imaging (PFI): A historical review and perspective.

PFI Pulmonary Functional Imaging (PFI) refers to visualization and measurement of ventilation, perfusion, gas flow and exchange as well as biomechanics. In this review, we will highlight the historical development of PFI, describing recent advances and listing the various techniques for PFI offered per modality. Challenges PFI is facing and requirements for PFI from a clinical point of view will be pointed out. Hereby the review is meant as an introduction to PFI.

Chest CT Diagnosis and Clinical Management of Drug-related Pneumonitis in Patients Receiving Molecular Targeting Agents and Immune Checkpoint Inhibitors: A Position Paper from the Fleischner Society.

Use of molecular targeting agents and immune checkpoint inhibitors (ICIs) has increased the frequency and broadened the spectrum of lung toxicity, particularly in patients with cancer. The diagnosis of drug-related pneumonitis (DRP) is usually achieved by excluding other potential known causes. Awareness of the incidence and risk factors for DRP is becoming increasingly important. The severity of symptoms associated with DRP may range from mild or none to life-threatening with rapid progression to death. Imaging features of DRP should be assessed in consideration of the distribution of lung parenchymal abnormalities (radiologic pattern approach). The CT patterns reflect acute (diffuse alveolar damage) interstitial pneumonia and transient (simple pulmonary eosinophilia) lung abnormality, subacute interstitial disease (organizing pneumonia and hypersensitivity pneumonitis), and chronic interstitial disease (nonspecific interstitial pneumonia). A single drug can be associated with multiple radiologic patterns. Treatment of a patient suspected of having DRP generally consists of drug discontinuation, immunosuppressive therapy, or both, along with supportive measures eventually including supplemental oxygen and intensive care. In this position paper, the authors provide diagnostic criteria and management recommendations for DRP that should be of interest to radiologists, clinicians, clinical trialists, and trial sponsors, among others. This article is a simultaneous joint publication in Radiology and CHEST. The articles are identical except for stylistic changes in keeping with each journal's style. Either version may be used in citing this article. Published under a CC BY 4.0 license. Online supplemental material is available for this article.

COVID-19 Vaccination-Related Uptake on FDG PET/CT: An Emerging Dilemma and Suggestions for Management.

As mass COVID-19 vaccination is underway, radiologists are encountering transient FDG uptake in normal or enlarged axillary, supraclavicular, and cervical lymph nodes after ipsilateral deltoid vaccination. This phenomenon may confound interpretation in patients with cancer undergoing FDG PET/CT. In this article, we present our institutional approach for management of COVID-19 vaccine-related lymphadenopathy on FDG PET/CT according to early experience. We suggest performing PET/CT at least 2 weeks after vaccination in patients with a cancer for which interpretation is anticipated to be potentially impacted by the vaccination but optimally 4-6 weeks after vaccination given increased immunogenicity of mRNA vaccines and potentially longer time for resolution than lymphadenopathy after other vaccines. PET/CT should not be delayed when clinically indicated to be performed sooner. Details regarding vaccination should be collected at the time of PET/CT to facilitate interpretation. Follow-up recommendations for postvaccination lymphadenopathy are provided, considering the lymph node's morphology and likely clinical relevance. Consideration should be given to administering the vaccine in the arm contralateral to a unilateral cancer to avoid confounding FDG uptake on the side of cancer. Our preliminary experience and suggested institutional approach should guide radiologists in management of patients with cancer undergoing PET/CT after COVID-19 vaccination.

The Growth Rate of Subsolid Lung Adenocarcinoma Nodules at Chest CT.

Background Confirming that subsolid adenocarcinomas show exponential growth is important because it would justify using volume doubling time to assess their growth. Purpose To test whether the growth of lung adenocarcinomas manifesting as subsolid nodules at chest CT is accurately represented by an exponential model. Materials and Methods Patients with lung adenocarcinomas manifesting as subsolid nodules surgically resected between January 2005 and May 2018, with three or more longitudinal CT examinations before resection, were retrospectively included. Overall volume (for all nodules) and solid component volume (for part-solid nodules) were measured over time. A linear mixed-effects model was used to identify the growth pattern (linear, exponential, quadratic, or power law) that best represented growth. The interactions between nodule growth and clinical, CT morphologic, and pathologic parameters were studied. Results Sixty-nine patients (mean age, 70 years ± 9 [standard deviation]; 48 women) with 74 lung adenocarcinomas were evaluated. Overall growth and solid component growth were better represented by an exponential model (adjusted R2 = 0.89 and 0.95, respectively) than by a quadratic model (r2 = 0.88 and 0.93, respectively), a linear model (r2 = 0.87 and 0.92, respectively), or a power law model (r2 = 0.82 and 0.93, respectively). Faster overall volume growth was associated with a history of lung cancer (P < .001), a baseline nodule volume less than 500 mm3 (P = .03), and histologic findings of invasive adenocarcinoma (P < .001). The median volume doubling time of noninvasive adenocarcinoma was significantly longer than that of invasive adenocarcinoma (939 days [interquartile range, 588-1563 days] vs 678 days [interquartile range, 392-916 days], respectively; P = .01). Conclusion The overall volume growth of adenocarcinomas manifesting as subsolid nodules at chest CT was best represented by an exponential model compared with the other tested models. This justifies the use of volume doubling time for the growth assessment of these nodules. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Kuriyama and Yanagawa in this issue.

Radiographic pulmonary vessel volume, lung function and airways disease in the Framingham Heart Study.

Radiographic abnormalities of the pulmonary vessels, such as vascular pruning, are common in advanced airways disease, but it is unknown if pulmonary vascular volumes are related to measures of lung health and airways disease in healthier populations.In 2388 participants of the Framingham Heart Study computed tomography (CT) sub-study, we calculated total vessel volumes and the small vessel fraction using automated CT image analysis. We evaluated associations with measures of lung function, airflow obstruction on spirometry and emphysema on CT. We further tested if associations of vascular volumes with lung function were present among those with normal forced expiratory volume in 1 s and forced vital capacity.In fully adjusted linear and logistic models, we found that lower total and small vessel volumes were consistently associated with worse measures of lung health, including lower spirometric volumes, lower diffusing capacity and/or higher odds of airflow obstruction. For example, each standard deviation lower small vessel fraction (indicating more severe pruning) was associated with a 37% greater odds of obstruction (OR 1.37, 95% CI 1.11-1.71, p=0.004). A similar pattern was observed in the subset of participants with normal spirometry.Lower total and small vessel pulmonary vascular volumes were associated with poorer measures of lung health and/or greater odds of airflow obstruction in this cohort of generally healthy adults without high burdens of smoking or airways disease. Our findings suggest that quantitative CT assessment may detect subtle pulmonary vasculopathy that occurs in the setting of subclinical and early pulmonary and airways pathology.

Software-based risk stratification of pulmonary adenocarcinomas manifesting as pure ground glass nodules on computed tomography.

OBJECTIVES: To assess the performance of the "Computer-Aided Nodule Assessment and Risk Yield" (CANARY) software in the differentiation and risk assessment of histological subtypes of lung adenocarcinomas manifesting as pure ground glass nodules on computed tomography (CT). METHODS: 64 surgically resected and histologically proven adenocarcinomas manifesting as pure ground-glass nodules on CT were assessed using CANARY software, which classifies voxel-densities into three risk components (low, intermediate, and high risk). Differences in risk components between histological adenocarcinoma subtypes were analysed. To determine the optimal threshold reflecting the presence of an invasive focus, sensitivity, specificity, negative predictive value, and positive predictive value were calculated. RESULTS: 28/64 (44%) were adenocarcinomas in situ (AIS); 26/64 (41%) were minimally invasive adenocarcinomas (MIA); and 10/64 (16%) were invasive ACs (IAC). The software showed significant differences in risk components between histological subtypes (P<0.001-0.003). A relative volume of 45% or less of low-risk components was associated with histological invasiveness (specificity 100%, positive predictive value 100%). CONCLUSIONS: CANARY-based risk assessment of ACs manifesting as pure ground glass nodules on CT allows the differentiation of their histological subtypes. A threshold of 45% of low-risk components reflects invasiveness in these groups. KEY POINTS: • CANARY-based risk assessment allows the differentiation of their histological subtypes. • 45% or less of low-risk component reflects histological invasiveness. • CANARY has potential role in suspected adenocarcinomas manifesting as pure ground-glass nodules.

Recommendations for Measuring Pulmonary Nodules at CT: A Statement from the Fleischner Society.

These recommendations for measuring pulmonary nodules at computed tomography (CT) are a statement from the Fleischner Society and, as such, incorporate the opinions of a multidisciplinary international group of thoracic radiologists, pulmonologists, surgeons, pathologists, and other specialists. The recommendations address nodule size measurements at CT, which is a topic of importance, given that all available guidelines for nodule management are essentially based on nodule size or changes thereof. The recommendations are organized according to practical questions that commonly arise when nodules are measured in routine clinical practice and are, together with their answers, summarized in a table. The recommendations include technical requirements for accurate nodule measurement, directions on how to accurately measure the size of nodules at the workstation, and directions on how to report nodule size and changes in size. The recommendations are designed to provide practical advice based on the available evidence from the literature; however, areas of uncertainty are also discussed, and topics needing future research are highlighted. © RSNA, 2017 Online supplemental material is available for this article.

Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017.

The Fleischner Society Guidelines for management of solid nodules were published in 2005, and separate guidelines for subsolid nodules were issued in 2013. Since then, new information has become available; therefore, the guidelines have been revised to reflect current thinking on nodule management. The revised guidelines incorporate several substantive changes that reflect current thinking on the management of small nodules. The minimum threshold size for routine follow-up has been increased, and recommended follow-up intervals are now given as a range rather than as a precise time period to give radiologists, clinicians, and patients greater discretion to accommodate individual risk factors and preferences. The guidelines for solid and subsolid nodules have been combined in one simplified table, and specific recommendations have been included for multiple nodules. These guidelines represent the consensus of the Fleischner Society, and as such, they incorporate the opinions of a multidisciplinary international group of thoracic radiologists, pulmonologists, surgeons, pathologists, and other specialists. Changes from the previous guidelines issued by the Fleischner Society are based on new data and accumulated experience. © RSNA, 2017 Online supplemental material is available for this article. An earlier incorrect version of this article appeared online. This article was corrected on March 13, 2017.

Differentiating between Subsolid and Solid Pulmonary Nodules at CT: Inter- and Intraobserver Agreement between Experienced Thoracic Radiologists.

PURPOSE: To quantify the reproducibility and accuracy of experienced thoracic radiologists in differentiating between subsolid and solid pulmonary nodules at CT. MATERIALS AND METHODS: The institutional review board of Beth Israel Deaconess Medical Center approved this multicenter study. Six thoracic radiologists, with a mean of 21 years of experience in thoracic radiology (range, 17-22 years), selected images of 10 solid and 10 subsolid nodules to create a database of 120 nodules; this selection served as the reference standard. Each radiologist then interpreted 120 randomly ordered nodules in two different sessions that were separated by a minimum of 3 weeks. The radiologists classified whether or not each nodule was subsolid. Inter- and intraobserver agreement was assessed with a κ statistic. The number of correct classifications was calculated and correlated with nodule size by using Bland-Altman plots. The relationship between disagreement and nodule morphologic characteristics was analyzed by calculating the intraclass correlation coefficient. RESULTS: Interobserver agreement (κ) was 0.619 (range, 0.469-0.745; 95% confidence interval (CI): 0.576, 0.663) and 0.670 (range, 0.440-0.839; 95% CI: 0.608, 0.733) for interpretation sessions 1 and 2, respectively. Intraobserver agreement (κ) was 0.792 (95% CI: 0.750, 0.833). Averaged for interpretation sessions, correct classification was achieved by all radiologists for 58% (70 of 120) of nodules. Radiologists agreed with their initial determination (the reference standard) in 77% of cases (range, 45%-100%). Nodule size weakly correlated with correct classification (long axis: Spearman rank correlation coefficient, rs = 0.161 and P = .049; short axis: rs = 0.128 and P = .163). CONCLUSION: The reproducibility and accuracy of thoracic radiologists in classifying whether or not a nodule is subsolid varied in the retrospective study. This inconsistency may affect surveillance recommendations and prognostic determinations.

Normal spectrum of pulmonary parametric response map to differentiate lung collapsibility: distribution of densitometric classifications in healthy adult volunteers.

OBJECTIVES: Pulmonary parametric response map (PRM) was proposed for quantitative densitometric phenotypization of chronic obstructive pulmonary disease. However, little is known about this technique in healthy subjects. The purpose of this study was to describe the normal spectrum of densitometric classification of pulmonary PRM in a group of healthy adults. METHODS: 15 healthy volunteers underwent spirometrically monitored chest CT at total lung capacity (TLC) and functional residual capacity (FRC). The paired CT scans were analyzed by PRM for voxel-by-voxel characterization of lung parenchyma according to 4 densitometric classifications: normal lung (TLC ≥ -950 HU, FRC ≥ -856 HU); expiratory low attenuation area (LAA) (TLC ≥ -950 HU, FRC < -856 HU); dual LAA (TLC<-950 HU, FRC < -856 HU); uncharacterized (TLC < -950 HU, FRC ≥ -856 HU). RESULTS: PRM spectrum was 78 % ± 10 % normal lung, 20 % ± 8 % expiratory LAA, and 1 % ± 1 % dual LAA. PRM was similar between genders, there was moderate correlation between dual LAA and spirometrically assessed TLC (R = 0.531; p = 0.042), and between expiratory LAA and VolExp/Insp ratio (R = -0.572; p = 0.026). CONCLUSIONS: PRM reflects the predominance of normal lung parenchyma in a group of healthy volunteers. However, PRM also confirms the presence of physiological expiratory LAA seemingly related to air trapping and a minimal amount of dual LAA likely reflecting emphysema. KEY POINTS: • Co-registration of inspiratory and expiratory computed tomography allows dual-phase densitometry. • Dual-phase co-registered densitometry reflects heterogeneous regional changes in lung function. • Quantification of lung in healthy subjects is needed to set reference values. • Expiratory low attenuation areas <30 % could be considered within normal range.

Organ-based tube current modulation: are women's breasts positioned in the reduced-dose zone?

PURPOSE: To retrospectively determine the potential of organ-based tube current modulation ( OBTCM organ-based tube current modulation ) to reduce the radiation dose delivered to breast tissue by computed tomography (CT) by determining breast angular position in relation to the zones of decreased versus increased radiation. MATERIALS AND METHODS: The authors obtained institutional review board approval for this study and patients' written informed consent. In two academic centers (center A: Beth Israel Deaconess Medical Center, Boston, Mass; and center B: Hôpital André Vésale, Montignies-le-Tilleul, Belgium), data were collected from clinical thoracic CT examinations performed in 498 women (mean age, 60 years; age range, 18-95 years) in the supine position and 34 women (mean age, 53 years; age range, 18-84 years) in the prone position. One radiologist in each center determined breast tissue location and measured its inner and outer boundaries with respect to the isocenter of the CT examination. The percentages of women with breast tissue within and those with breast tissue outside the zone of decreased radiation delivered by OBTCM organ-based tube current modulation were determined. The location of breast tissue was correlated with patient age and with sagittal and coronal diameters of the thorax by using the Student t test, Fisher exact test, and Pearson correlation. RESULTS: None of the women lying in the supine position had the entirety of the breast tissue located within the reduced-dose zone. Breast tissue was located in the increased-dose zone in 99% of women lying supine and in 82% of women lying prone. CONCLUSION: The breast angular position of almost all women was higher than the angular limit of the reduced versus the increased dose in OBTCM organ-based tube current modulation . No woman, regardless of supine or prone position, had all breast tissue within the reduced-dose zone.

Observer Variability for Classification of Pulmonary Nodules on Low-Dose CT Images and Its Effect on Nodule Management.

PURPOSE: To examine the factors that affect inter- and intraobserver agreement for pulmonary nodule type classification on low-radiation-dose computed tomographic (CT) images, and their potential effect on patient management. MATERIALS AND METHODS: Nodules (n = 160) were randomly selected from the Dutch-Belgian Lung Cancer Screening Trial cohort, with equal numbers of nodule types and similar sizes. Nodules were scored by eight radiologists by using morphologic categories proposed by the Fleischner Society guidelines for management of pulmonary nodules as solid, part solid with a solid component smaller than 5 mm, part solid with a solid component 5 mm or larger, or pure ground glass. Inter- and intraobserver agreement was analyzed by using Cohen κ statistics. Multivariate analysis of variance was performed to assess the effect of nodule characteristics and image quality on observer disagreement. Effect on nodule management was estimated by differentiating CT follow-up for ground-glass nodules, solid nodules 8 mm or smaller, and part-solid nodules smaller than 5 mm from immediate diagnostic work-up for solid nodules larger than 8 mm and part-solid nodules 5 mm or greater. RESULTS: Pair-wise inter- and intraobserver agreement was moderate (mean κ, 0.51 [95% confidence interval, 0.30, 0.68] and 0.57 [95% confidence interval, 0.47, 0.71]). Categorization as part-solid nodules and location in the upper lobe significantly reduced observer agreement (P = .012 and P < .001, respectively). By considering all possible reading pairs (28 possible combinations of observer pairs × 160 nodules = 4480 possible agreements or disagreements), a discordant nodule classification was found in 36.4% (1630 of 4480), related to presence or size of a solid component in 88.7% (1446 of 1630). Two-thirds of these discrepant readings (1061 of 1630) would have potentially resulted in different nodule management. CONCLUSION: There is moderate inter- and intraobserver agreement for nodule classification by using current recommendations for low-radiation-dose CT examinations of the chest. Discrepancies in nodule categorization were mainly caused by disagreement on the size and presence of a solid component, which may lead to different management in the majority of cases with such discrepancies. (©) RSNA, 2015.

CT-Definable Subtypes of Chronic Obstructive Pulmonary Disease: A Statement of the Fleischner Society.

The purpose of this statement is to describe and define the phenotypic abnormalities that can be identified on visual and quantitative evaluation of computed tomographic (CT) images in subjects with chronic obstructive pulmonary disease (COPD), with the goal of contributing to a personalized approach to the treatment of patients with COPD. Quantitative CT is useful for identifying and sequentially evaluating the extent of emphysematous lung destruction, changes in airway walls, and expiratory air trapping. However, visual assessment of CT scans remains important to describe patterns of altered lung structure in COPD. The classification system proposed and illustrated in this article provides a structured approach to visual and quantitative assessment of COPD. Emphysema is classified as centrilobular (subclassified as trace, mild, moderate, confluent, and advanced destructive emphysema), panlobular, and paraseptal (subclassified as mild or substantial). Additional important visual features include airway wall thickening, inflammatory small airways disease, tracheal abnormalities, interstitial lung abnormalities, pulmonary arterial enlargement, and bronchiectasis.

Comparison of four software packages for CT lung volumetry in healthy individuals.

OBJECTIVES: To compare CT lung volumetry (CTLV) measurements provided by different software packages, and to provide normative data for lung densitometric measurements in healthy individuals. METHODS: This retrospective study included 51 chest CTs of 17 volunteers (eight men and nine women; mean age, 30 ± 6 years), who underwent spirometrically monitored CT at total lung capacity (TLC), functional residual capacity (FRC), and mean inspiratory capacity (MIC). Volumetric differences assessed by four commercial software packages were compared with analysis of variance (ANOVA) for repeated measurements and benchmarked against the threshold for acceptable variability between spirometric measurements. Mean lung density (MLD) and parenchymal heterogeneity (MLD-SD) were also compared with ANOVA. RESULTS: Volumetric differences ranged from 12 to 213 ml (0.20 % to 6.45 %). Although 16/18 comparisons (among four software packages at TLC, MIC, and FRC) were statistically significant (P < 0.001 to P = 0.004), only 3/18 comparisons, one at MIC and two at FRC, exceeded the spirometry variability threshold. MLD and MLD-SD significantly increased with decreasing volumes, and were significantly larger in lower compared to upper lobes (P < 0.001). CONCLUSIONS: Lung volumetric differences provided by different software packages are small. These differences should not be interpreted based on statistical significance alone, but together with absolute volumetric differences. KEY POINTS: • Volumetric differences, assessed by different CTLV software, are small but statistically significant. • Volumetric differences are smaller at TLC than at MIC and FRC. • Volumetric differences rarely exceed spirometric repeatability thresholds at MIC and FRC. • Differences between CTLV measurements should be interpreted based on comparison of absolute differences. • MLD increases with decreasing volumes, and is larger in lower compared to upper lobes.

Imaging of Large Airways Disorders.

OBJECTIVE: Recent technical advances, including the routine use of CT thin sections and techniques such as 2D minimum-intensity-projection and 3D volume images, have increased our ability to detect large airways diseases. Furthermore, dedicated CT protocols allow the evaluation of dynamic airway dysfunction. CONCLUSION: With diseases of the large airways more commonly seen in daily practice, it is important that radiologists be familiar with the appearances, differential diagnosis, and clinical implications of these entities.

Honorary authorship in radiologic research articles: do geographic factors influence the frequency?

PURPOSE: To quantify the potential effect of geographic factors on the frequency of honorary authorship in four major radiology journals. MATERIALS AND METHODS: In this institutional review board-approved study, an electronic survey was sent to first authors of all original research articles published in American Journal of Roentgenology, European Radiology, Journal of Magnetic Resonance Imaging, and Radiology during 2 years (July 2009 through June 2011). Questions addressed guidelines used for determining authorship, perception of honorary authorship, and demographic information. Univariate analysis was performed by using χ(2) tests. Multiple-variable logistic regression models were used to assess independent factors associated with the perception of honorary authorship. RESULTS: Of 1398 first authors, 328 (23.5%) responded. Of these, 91 (27.7%) perceived that at least one coauthor did not make sufficient contributions to merit authorship, and 165 (50.3%) stated that one or more coauthors performed only "nonauthor" tasks according to International Committee of Medical Journal Editors (ICMJE) criteria. The perception of honorary authorship was significantly higher (P ≤ .0001) among respondents from Asia and Europe than from North America and in institutions where a section or department head was automatically listed as coauthor. A significantly lower (P ≤ .0001) perception of honorary authorship was associated with adherence to ICMJE criteria and with policies providing lectures or courses on publication ethics. CONCLUSION: Perceived honorary authorship was substantially higher among respondents from Asia and Europe than from North America. Perceived honorary authorship was lower with adherence to the ICMJE guidelines and policies providing lectures or courses on publication ethics.

Dose reduction in cardiothoracic CT: review of currently available methods.

Radiation exposure from computed tomography (CT) has received much attention lately in the medical literature and the media, given the relatively high radiation dose that characterizes a CT examination. Although there are a variety of possible strategies for reducing radiation exposure from CT in an individual patient, optimal CT image acquisition requires that the radiologist understand new scanner technology and how to implement the most effective means of dose reduction while maintaining image quality. The authors describe a practical approach to dose reduction in cardiothoracic radiology, discussing CT radiation dose metrics (eg, CT dose index, dose-length product, effective diameter, and size-specific dose estimate) as well as CT scanner parameters that directly or indirectly influence radiation dose (eg, scan length, x-ray tube output, tube current modulation, pitch, image reconstruction techniques [including iterative reconstruction], and noise reduction). These variables are discussed in terms of their relative importance to image quality and the implications of parametric changes for image quality and diagnostic content, and practical recommendations are made for their immediate implementation in the clinical setting. Taken together, the principles of physics and key parameters involved in reducing radiation dose while maintaining image quality can serve as a "survival guide" for a diagnostic radiology practice.

Integrated cardio-thoracic imaging curriculum for residents: Design, implementation, and analysis of test and evaluation results.

As the field of cardiac imaging has demonstrated exceptional growth over the past several decades, radiology departments and residency programs have struggled to integrate cardiac imaging instruction into training curricula. PURPOSE: To create an integrated cardio-thoracic teaching and lecture curriculum and resident rotation in accordance with AGGME and Society of Thoracic Radiology (STR) guidelines. MATERIALS AND METHODS: Consecutive PGY-2 to PGY-4 residents (n = 14) rotating through our Cardiothoracic Imaging (CTI) section from 1/1/2021 to 04/18/2022 were give pre- and post- rotation tests of knowledge and feedback evaluations. Attending feedback of the curriculum was obtained at 3-months and 9-months post curriculum implementation. A Wilcxon test was used to evaluate differences in improvement between pre- and post- rotation resident feedback scores, test scores for thoracic and cardiac test questions in addition to attending feedback scores at 3 and 9-months post curriculum implementation. RESULTS: The overall post-rotation scores in addition to thoracic only and cardiac only scores improved, with the difference between improved versus stable or decreased scores being statistically significant overall (P = 0.039) and for cardiac scores (P = 0.003), but not for thoracic scores (P = 0.22). The overall (P = 0.002), thoracic (P = 0.027), and cardiac (P = 0.026) resident feedback scores were significantly improved post-rotation. Similarly, the overall attending feedback scores significantly improved over time (P = 0.021). CONCLUSION: An integrated Cardio-thoracic Imaging teaching curriculum was well received by both residents and attendings with significant improvement in post rotation feedback scores by both groups. Moreover, residents demonstrated improved scores on knowledge tests post rotation.