Predictors and characteristics of Rib fracture following SBRT for lung tumors.

BACKGROUND: The utilization of stereotactic body radiation therapy (SBRT) is increasing for primary and secondary lung neoplasms. Despite encouraging results, SBRT is associated with an increased risk of osteoradionecrosis-induced rib fracture. We aimed to (1) evaluate potential clinical, demographic, and procedure-related risk factors for rib fractures and (2) describe the radiographic features of post-SBRT rib fractures. METHODS: We retrospectively identified 106 patients who received SBRT between 2015 and 2018 for a primary or metastatic lung tumor with at least 12 months of follow up. Exclusion criteria were incomplete records, previous ipsilateral thoracic radiation, or relevant prior trauma. Computed tomography (CT) images were reviewed to identify and characterize rib fractures. Multivariate logistic regression modeling was employed to determine clinical, demographic, and procedural risk factors (e.g., age, sex, race, medical comorbidities, dosage, and tumor location). RESULTS: A total of 106 patients with 111 treated tumors met the inclusion criteria, 35 (32%) of whom developed at least one fractured rib (60 total fractured ribs). The highest number of fractured ribs per patient was five. Multivariate regression identified posterolateral tumor location as the only independent risk factor for rib fracture. On CT, fractures showed discontinuity between healing edges in 77% of affected patients. CONCLUSIONS: Nearly one third of patients receiving SBRT for lung tumors experienced rib fractures, 34% of whom experienced pain. Many patients developed multiple fractures. Post-SBRT fractures demonstrated a unique discontinuity between the healing edges of the rib, a distinct feature of post-SBRT rib fractures. The only independent predictor of rib fracture was tumor location along the posterolateral chest wall. Given its increasing frequency of use, describing the risk profile of SBRT is vital to ensure patient safety and adequately inform patient expectations.

Lung recovery with prolonged ECMO following fibrotic COVID-19 acute respiratory distress syndrome.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus has been associated with acute respiratory distress syndrome (ARDS) and in some cases with pulmonary fibrosis. There is limited information regarding the long-term outcomes of patients who develop severe COVID-19 infection and subsequent pulmonary fibrosis. We present a patient with severe ARDS due to COVID-19 who required prolonged extra-corporeal oxygenation support and eventually recovered significant lung function. This case is unique because the patient survived one of the longest reported runs on extra-corporeal membrane oxygenation without requiring lung transplantation. Further, our patient developed severe parenchymal and airway distortion but ultimately resolved pulmonary fibrosis many months into the hospitalization. In addition to our detailed case discussion, we will provide a focused review on pulmonary fibrosis post COVID-19.

Mitral Annular Disjunction: Review of an Increasingly Recognized Mitral Valve Entity.

Mitral annular disjunction (MAD) refers to atrial displacement of the hinge point of the mitral valve annulus from the ventricular myocardium. MAD leads to paradoxical expansion of the annulus in systole and may often be associated with mitral valve prolapse (MVP), leaflet degeneration, myocardial and papillary muscle fibrosis, and, potentially, malignant cardiac arrhythmias. Patients with MAD and MVP may present similarly, and MAD is potentially the missing link in explaining why some patients with MVP experience adverse outcomes. Patients with a 5 mm or longer MAD distance have an elevated risk of malignant cardiac arrhythmia compared with those with a shorter MAD distance. Evaluation for MAD is an important component of cardiac imaging, especially in patients with MVP and unexplained cardiac arrhythmias. Cardiac MRI is an important diagnostic tool that aids in recognizing and quantifying MAD, MVP, and fibrosis in the papillary muscle and myocardium, which may predict and help improve outcomes following electrophysiology procedures and mitral valve surgery. This article reviews the history, pathophysiology, controversy, prevalence, clinical implications, and imaging considerations of MAD, focusing on cardiac MRI. Keywords: MR-Dynamic Contrast Enhanced, Cardiac, Mitral Valve, Mitral Annular Disjunction, Mitral Valve Prolapse, Floppy Mitral Valve, Cardiac MRI, Arrhythmia, Sudden Cardiac Death, Barlow Valve © RSNA, 2023.

Impact of multidetector computed tomography scan parameters, novel reconstruction settings, and lung nodule characteristics on nodule diameter measurements: A phantom study.

PURPOSE: Novel CT reconstruction techniques strive to maintain image quality and processing efficiency. The purpose of this study is to investigate the impact of a newer hybrid iterative reconstruction technique, Adaptive Statistical Iterative Reconstruction-V (ASIR-V), in combination with various CT scan parameters on the semi-automated quantification using various lung nodules. METHODS: A chest phantom embedded with eight spherical objects was scanned using varying CT parameters such as tube current and ASIR-V levels. We calculated absolute percentage error (APE) and mean APE (MAPE) using differences between the semi-automated measured diameters and known dimensions. Predictive variables were assessed using a multivariable general linear model. The linear regression slope coefficients (ß) were reported to demonstrate effect size and directionality. RESULTS: The APE of the semi-automated measured diameters was higher in ground-glass than solid nodules (ß = 9.000, p < 0.001). APE had an inverse relationship with nodule diameter (mm; ß = -3.499, p < 0.001) and tube current (mA; ß = -0.006, p < 0.001). MAPE did not vary based on the ASIR-V level (range: 5.7%-13.1%). CONCLUSION: Error is dominated by nodule characteristics with a small effect of tube current. Regardless of phantom size, nodule size accuracy is not affected by tube voltage or ASIR-V level, maintaining accuracy while maximizing radiation dose reduction.

Frequency of Statin Prescription Among Individuals with Coronary Artery Calcifications Detected Through Lung Cancer Screening.

Individuals eligible for lung cancer screening (LCS) are at risk for atherosclerotic cardiovascular disease (ASCVD) due to smoking history. Coronary artery calcifications (CAC), a common incidental finding on low-dose CT (LDCT) for LCS, is a predictor of cardiovascular events. Despite findings of high ASCVD risk and CAC, a substantial proportion of LCS patients are not prescribed primary preventive statin therapy for ASCVD. We assessed the frequency of statin prescription in LCS patients with moderate levels of CAC. Among 259 individuals with moderate CAC, 95% had ASCVD risk ≥ 7.5%. Despite this, 27% of patients were statin-free prior to LDCT and 21.2% remained statin-free after LDCT showing moderate CAC. Illustratively, while a substantial proportion of LCS patients are statin-eligible, many lack a statin prescription, even after findings of CAC burden. CAC reporting should be standardized, and interdisciplinary communication should be optimized to ensure that LCS patients are placed on appropriate preventive therapy.

Validating deep learning inference during chest X-ray classification for COVID-19 screening.

The new coronavirus unleashed a worldwide pandemic in early 2020, and a fatality rate several times that of the flu. As the number of infections soared, and capabilities for testing lagged behind, chest X-ray (CXR) imaging became more relevant in the early diagnosis and treatment planning for patients with suspected or confirmed COVID-19 infection. In a few weeks, proposed new methods for lung screening using deep learning rapidly appeared, while quality assurance discussions lagged behind. This paper proposes a set of protocols to validate deep learning algorithms, including our ROI Hide-and-Seek protocol, which emphasizes or hides key regions of interest from CXR data. Our protocol allows assessing the classification performance for anomaly detection and its correlation to radiological signatures, an important issue overlooked in several deep learning approaches proposed so far. By running a set of systematic tests over CXR representations using public image datasets, we demonstrate the weaknesses of current techniques and offer perspectives on the advantages and limitations of automated radiography analysis when using heterogeneous data sources.

Racial disparities in COVID-19 associated pulmonary embolism: A multicenter cohort study.

BACKGROUND: Thromboembolism is a recognized component of severe coronavirus disease 2019 (COVID-19) disease. However, research into racial disparities in COVID-19-related pulmonary embolism is limited. MATERIALS AND METHODS: In this retrospective cohort study, we examined adults diagnosed with COVID-19 between January 20 and September 30, 2020, using a multicenter electronic health record dataset of over 73 million patients (TriNetX), mostly in the USA. The main study outcomes were development of pulmonary embolism or mortality within 30 days of COVID-19 diagnosis. Secondary outcome analysis included hospitalization, mechanical ventilation, and ICU admission within 30 days of diagnosis, as well as lab values within 0-1 days of diagnosis. Sociodemographic and clinical variables were used to create balanced cohorts via propensity matching. RESULTS: 346,953 patients were identified, with 56.0% non-Hispanic white and 14.7% non-Hispanic black; the mean age was 47.6 years. 3879 patients developed PE, with 2036 (1.30% of 157,049) white and 1088 (2.16% of 50,376) black patients. After propensity matching, black race was associated with higher mortality (risk ratio 1.890 [95% CI 1.727-2.067]) and PE (RR 1.537 [1.380-1.711]; p < 0.0001). Both races had higher mortality with COVID-associated PE than COVID or PE alone (RR 1.575-1.627 and 3.000-5.389 respectively; p < 0.0001). Black patients with COVID-19 and PE had a higher rate of mortality compared to white patients (RR 1.397 [1.059-1.844]; p = 0.0174). INTERPRETATION: Black race was associated with higher risk of pulmonary embolism and mortality after COVID-19. Additionally, black patients with COVID-19 and PE had a higher mortality compared to white patients.

Imaging approach to COVID-19 associated pulmonary embolism.

The novel coronavirus disease-2019 (COVID-19) illness and deaths, caused by the severe acute respiratory syndrome coronavirus-2, continue to increase. Multiple reports highlight the thromboembolic complications, such as pulmonary embolism (PE), in COVID-19. Imaging plays an essential role in the diagnosis and management of COVID-19 patients with PE. There continues to be a rapid evolution of knowledge related to COVID-19 associated PE. This review summarises the current understanding of prevalence, pathophysiology, role of diagnostic imaging modalities, and management, including catheter-directed therapy for COVID-19 associated PE. It also describes infection control considerations for the radiology department while providing care for patients with COVID-19 associated PE.

Performance of a Severity Score on Admission Chest Radiography in Predicting Clinical Outcomes in Hospitalized Patients With Coronavirus Disease (COVID-19).

BACKGROUND. Chest radiographs (CXRs) are typically obtained early in patients admitted with coronavirus disease (COVID-19) and may help guide prognosis and initial management decisions. OBJECTIVE. The purpose of this study was to assess the performance of an admission CXR severity scoring system in predicting hospital outcomes in patients admitted with COVID-19. METHODS. This retrospective study included 240 patients (142 men, 98 women; median age, 65 [range, 50-80] years) admitted to the hospital from March 16 to April 13, 2020, with COVID-19 confirmed by real-time reverse-transcriptase polymerase chain reaction who underwent chest radiography within 24 hours of admission. Three attending chest radiologists and three radiology residents independently scored patients' admission CXRs using a 0- to 24-point composite scale (sum of scores that range from 0 to 3 for extent and severity of disease in upper and lower zones of left and right lungs). Interrater reliability of the score was assessed using the Kendall W coefficient. The mean score was obtained from the six readers' scores for further analyses. Demographic variables, clinical characteristics, and admission laboratory values were collected from electronic medical records. ROC analysis was performed to assess the association between CXR severity and mortality. Additional univariable and multivariable logistic regression models incorporating patient characteristics and laboratory values were tested for associations between CXR severity and clinical outcomes. RESULTS. Interrater reliability of CXR scores ranged from 0.687 to 0.737 for attending radiologists, from 0.653 to 0.762 for residents, and from 0.575 to 0.666 for all readers. A composite CXR score of 10 or higher on admission achieved 53.0% (35/66) sensitivity and 75.3% (131/174) specificity for predicting hospital mortality. Hospital mortality occurred in 44.9% (35/78) of patients with a high-risk admission CXR score (≥ 10) versus 19.1% (31/162) of patients with a low-risk CXR score (< 10) (p < .001). Admission composite CXR score was an independent predictor of death (odds ratio [OR], 1.17; 95% CI, 1.10-1.24; p < .001). composite CXR score was a univariable predictor of intubation (OR, 1.23; 95% CI, 1.12-1.34; p < .001) and continuous renal replacement therapy (CRRT) (OR, 1.15; 95% CI, 1.04-1.27; p = .007) but was not associated with these in multivariable models (p > .05). CONCLUSION. For patients admitted with COVID-19, an admission CXR severity score may help predict hospital mortality, intubation, and CRRT. CLINICAL IMPACT. CXR may assist risk assessment and clinical decision-making early in the course of COVID-19.

Elevated Cardiac Troponin T in Patients with Lupus Myositis Presenting with Noncardiac Chest Pain.

Patients with systemic lupus erythematosus (SLE) presenting with chest pain pose a unique diagnostic challenge, with causes ranging from cardiopulmonary disease to esophageal disorders and musculoskeletal chest wall pain. The most common biomarkers for myocardial injury are cardiac troponin T and I (cTnT and cTnI) due to their high sensitivity for the early detection of myocardial infarction. In the idiopathic inflammatory myopathies, cTnT is commonly elevated, and this reflects skeletal muscle breakdown rather than myocardial damage. Similar observations have not been reported in SLE myositis to date. We present two cases of patients with SLE and associated myositis who presented with chest pain and elevated cTnT. Both patients had a normal cTnI, transthoracic echocardiogram, and cardiac magnetic resonance imaging, likely indicating noncardiac chest pain. Clinicians should be aware that the specificity of cTnT might be lower in SLE myositis and that cTnI elevation may be more specific in detecting myocardial insult.

A Comprehensive Review of Manifestations of Novel Coronaviruses in the Context of Deadly COVID-19 Global Pandemic.

Since December 2019, the global pandemic caused by the highly infectious novel coronavirus 2019-nCoV (COVID-19) has been rapidly spreading. As of April 2020, the outbreak has spread to over 210 countries, with over 2,400,000 confirmed cases and over 170,000 deaths.1 COVID-19 causes a severe pneumonia characterized by fever, cough and shortness of breath. Similar coronavirus outbreaks have occurred in the past causing severe pneumonia like COVID-19, most recently, severe acute respiratory syndrome coronavirus (SARS-CoV) and middle east respiratory syndrome coronavirus (MERS-CoV). However, over time, SARS-CoV and MERS-CoV were shown to cause extrapulmonary signs and symptoms including hepatitis, acute renal failure, encephalitis, myositis and gastroenteritis. Similarly, sporadic reports of COVID-19 related extrapulmonary manifestations emerge. Unfortunately, there is no comprehensive summary of the multiorgan manifestations of COVID-19, making it difficult for clinicians to quickly educate themselves about this highly contagious and deadly pathogen. What is more, is that SARS-CoV and MERS-CoV are the closest humanity has come to combating something similar to COVID-19, however, there exists no comparison between the manifestations of any of these novel coronaviruses. In this review, we summarize the current knowledge of the manifestations of the novel coronaviruses SARS-CoV, MERS-CoV and COVID-19, with a particular focus on the latter, and highlight their differences and similarities.

Outpatient facility-based order variation in combined imaging.

OBJECTIVE: Combined computed tomography (CT) occurs when one anatomical area is simultaneously imaged both without and with contrast, or two overlapping anatomical areas are imaged concurrently. While this has been studied in a Traditional Medicare population, it has not been studied in other populations subject to prior authorization. This study explores between-facility variation in ordering and receiving orders to render combined CT in a mixed commercial and Medicare Advantage population. METHODS: Orders for CT abdomen (without/with contrast), CT thorax (without/with contrast), and concurrent CT brain and sinus authorized by a prior authorization company from 2013-2017, pertaining to patients with commercial or Medicare Advantage health plans from one national insurer, were extracted. Orders were issued and rendered by both hospitals and nonhospitals. The analysis was performed separately for each anatomical area in two ways: orders were grouped by ordering facility, and by designated rendering facility. For each facility, the ratio of combined to total orders was calculated, and analysis of variance was used to determine whether there were significant differences in this rate by year. The association between health plan type and combined imaging rates was assessed. RESULTS: Combined rates [ratio±standard deviation] for abdomen, thorax, and brain/sinus were 0.306±0.246, 0.089±0.142, and 0.002±0.01 respectively when the analysis was conducted according to ordering facility, and 0.311±0.178, 0.096±0.113, and 0.001±0.006 when the analysis was conducted according to designated rendering facility. Combined CT abdomen and CT thorax rates decreased monotonically from 2013 to 2017, decreases that were significant (P < .01) regardless of whether orders were grouped by ordering or rendering facility. Combined CT abdomen and CT thorax rates significantly differed between orders pertaining to people with commercial and Medicare Advantage plans. DISCUSSION: Variability was greater when orders were grouped by ordering facility, rather than rendering facility. Health plan type may influence whether a patient receives combined CT.

The Case for Patient Navigation in Lung Cancer Screening in Vulnerable Populations: A Systematic Review.

Patient navigation has been proposed to combat cancer disparities in vulnerable populations. Vulnerable populations often have poorer cancer outcomes and lower levels of screening, adherence, and treatment. Navigation has been studied in various cancers, but few studies have assessed navigation in lung cancer. Additionally, there is a lack of consistency in metrics to assess the quality of navigation programs. The authors conducted a systematic review of published cancer screening studies to identify quality metrics used in navigation programs, as well as to recommend standardized metrics to define excellence in lung cancer navigation. The authors included 26 studies evaluating navigation metrics in breast, cervical, colorectal, prostate, and lung cancer. After reviewing the literature, the authors propose the following navigation metrics for lung cancer screening programs: (1) screening rate, (2) compliance with follow-up, (3) time to treatment initiation, (4) patient satisfaction, (5) quality of life, (6) biopsy complications, and (7) cultural competency.

Clinical characteristics of patients with pulmonary infarction - A retrospective review.

BACKGROUND: Pulmonary infarction is an infrequent complication of pulmonary embolism. Traditionally, it has been regarded as a sign of worse outcome because ischemia can only occur by the simultaneous failure of all oxygenation sources to the area of infarct, but supporting evidence is limited. METHODS: We identified 74 cases of pulmonary infarction over 5 years at a single academic center via review of radiographic reports. Contrast-enhanced chest CT scans were examined to confirm evidence of pulmonary infarction, and patient clinical characteristics and imaging results were studied. RESULTS: Survival to discharge was high (97%). Patients most commonly presented with dyspnea (69%), chest pain (46%), and swelling or pain in the lower extremities (31%), while underlying risk factors included history of malignancy (41%) and surgery within 30 days (24%). Many patients had concurrent cardiovascular (59%) and pulmonary disease (22%). Infarction disproportionately affected the lower lobes. CONCLUSIONS: Survival after diagnosis of pulmonary infarction is comparable to uncomplicated pulmonary embolism, suggesting that outcome is not worse. While emboli occurred in multiple lobar sites, pulmonary infarction occurred most commonly in the lower lobes, suggesting unique underlying physiological mechanisms in pulmonary infarction development.

Lung Cancer Screening Guidelines: How Readable Are Internet-Based Patient Education Resources?

OBJECTIVE: Following the findings of the National Lung Screening Trial, several national societies from multiple disciplines have endorsed the use of low-dose chest CT to screen for lung cancer. Online patient education materials are an important tool to disseminate information to the general public regarding the proven health benefits of lung cancer screening. This study aims to evaluate the reading level at which these materials related to lung cancer screening are written. MATERIALS AND METHODS: The four terms "pulmonary nodule," "radiation," "low-dose CT," and "lung cancer screening" were searched on Google, and the first 20 online resources for each term were downloaded, converted into plain text, and analyzed using 10 well-established readability scales. If the websites were not written specifically for patients, they were excluded. RESULTS: The 80 articles were written at a 12.6 ± 2.7 (mean ± SD) grade level, with grade levels ranging from 4.0 to 19.0. Of the 80 articles, 62.5% required a high school education to comprehend, and 22.6% required a college degree or higher (≥ 16th grade) to comprehend. Only 2.5% of the analyzed articles adhered to the recommendations of the National Institutes of Health and American Medical Association that patient education materials be written at a 3rd- to 7th-grade reading level. CONCLUSION: Commonly visited online lung cancer screening-related patient education materials are written at a level beyond the general patient population's ability to comprehend and may be contributing to a knowledge gap that is inhibiting patients from improving their health literacy.

Molecular Testing Guideline for the Selection of Patients With Lung Cancer for Treatment With Targeted Tyrosine Kinase Inhibitors: American Society of Clinical Oncology Endorsement of the College of American Pathologists/International Association for the Study of Lung Cancer/Association for Molecular Pathology Clinical Practice Guideline Update.

Purpose In response to advances in the field, the College of American Pathologists (CAP), the International Association for the Study of Lung Cancer (IASLC), and the Association for Molecular Pathology (AMP) recently updated their recommendations for molecular testing for the selection of patients with lung cancer for treatment with targeted tyrosine kinase inhibitors. ASCO has a policy and set of procedures for endorsing clinical practice guidelines that have been developed by other professional organizations. Methods The molecular testing guideline was reviewed for developmental rigor by methodologists. Then an ASCO Expert Panel reviewed the content and the recommendations. Results The ASCO Expert Panel determined that the recommendations from the CAP/IASLC/AMP molecular testing guideline are clear, thorough, and based upon the most relevant scientific evidence. ASCO endorsed the guideline with minor modifications. Recommendations This update clarifies that any sample with adequate cellularity and preservation may be tested and that analytical methods must be able to detect mutation in a sample with as little as 20% cancer cells. It strongly recommends against evaluating epidermal growth factor receptor (EGFR) expression by immunohistochemistry for selection of patients for EGFR-targeted therapy. New for 2018 are recommendations for stand-alone ROS1 testing with additional confirmation testing in all patients with advanced lung adenocarcinoma, and RET, ERBB2 (HER2), KRAS, and MET testing as part of larger panels. ASCO also recommends stand-alone BRAF testing in patients with advanced lung adenocarcinoma. Recommendations are also provided for testing methods for lung cancers that have a nonadenocarcinoma non-small-cell component, for patients with targetable mutations who have relapsed on targeted therapy, and for testing the presence of circulating cell-free DNA. Additional information is available at www.asco.org/thoracic-cancer-guidelines and www.asco.org/guidelineswiki .