Diagnostic and Imaging Approaches to Chest Wall Lesions.

Chest wall lesions are relatively uncommon and may be challenging once they are encountered on images. Radiologists may detect these lesions incidentally at examinations performed for other indications, or they may be asked specifically to evaluate a suspicious lesion. While many chest wall lesions have characteristic imaging findings that can result in an accurate diagnosis with use of imaging alone, other entities are difficult to distinguish at imaging because there is significant overlap among them. The interpreting radiologist should be familiar with the imaging features of both "do not touch" benign entities (which can be confidently diagnosed with imaging only, with no need for biopsy or resection unless the patient is symptomatic) and lesions that cannot be confidently characterized and thus require further workup. CT and MRI are the main imaging modalities used to assess the chest wall, with each having different benefits and drawbacks. Chest wall lesions can be classified according to their predominant composition: fat, calcification and ossification, soft tissue, or fluid. The identification or predominance of signal intensities or attenuation for these findings, along with the patient age, clinical history, and lesion location, can help establish the appropriate differential diagnosis. In addition, imaging findings in other organs, such as the lungs or upper abdomen, can at times provide clues to the underlying diagnosis. The authors review different chest wall lesions classified on the basis of their composition and highlight the imaging findings that can assist the radiologist in narrowing the differential diagnosis and guiding management. ©RSNA, 2022.

Radiologic Review With Pathology Correlation of E-Cigarette or Vaping Product Use-associated Lung Injury.

More than 2000 cases of vaping-associated lung injury have been reported in a recent outbreak, including >40 deaths. Although chest imaging is integral in the evaluation of these patients and is often abnormal, the spectrum of findings and the role of imaging in the diagnosis are not widely appreciated. The aim of this review is to highlight the imaging findings of vaping-associated lung injury. Basilar-predominant ground-glass opacities and/or consolidations, often with areas of subpleural or lobular sparing, are the most common pattern, and many other patterns are known to occur. Radiologists are encouraged to become familiar with the different imaging patterns of vaping-associated lung injury. The diagnosis should be considered in patients who have vaped within 90 days of onset of symptoms and present with bilateral lung opacities.

Check the chest: review of chest findings on abdominal MRI.

Magnetic resonance imaging (MRI) of the abdomen may include lower chest findings which may be overlooked or misinterpreted due to their location outside the area of main exam focus or lack of familiarity with the image appearance of these findings. This article will review the utility of abdominal MRI sequences to diagnose lower chest pathology while providing a systematic pictorial review of imaging findings in the lungs, pleura, mediastinum and chest wall. We will discuss the MRI appearance of lung nodules and masses, lung infiltrates, pulmonary infarction, pulmonary embolism, empyema, pleural effusions and thickening, mediastinal lesions and lymphadenopathy, cardiac thrombus and masses, and breast lesions. The purpose of this article is to increase awareness to the diagnostic advantages of abdominal MRI sequences for lower chest findings and encourage abdominal MRI readers to meticulous scrutinize the lower chest for concomitant pathology.

Bronchoesophageal fistula: a rare complication of aortic endograft infection.

Endovascular aortic aneurysm repair is an increasingly common approach for aortic aneurysm repair. Infection of the prosthetic is a rare, but devastating complication which may result in the well-known aortoenteric or aortobronchial fistulae. Bronchoesophageal fistula resulting from an infected aortic endograft has not yet been reported in the literature. Early recognition of the symptoms and prompt imaging confirmation are essential for treating an otherwise highly morbid diagnosis.

Medical Applications for 3D Printing: Recent Developments.

This is a review of some of the recent developments in the application of 3D printing to medicine. The topic is introduced with a brief explanation as to how and why 3D is changing practice, teaching, and research in medicine. Then, taking recent examples of progress in the field, we illustrate the current state of the art. This article concludes by evaluating the current limitations of 3D printing for medical applications and suggesting where further progress is likely to be made.

Correction to: Feasibility and Validity of Printing 3D Heart Models from Rotational Angiography.

The original version of this article unfortunately contained a mistake.

Feasibility and Validity of Printing 3D Heart Models from Rotational Angiography.

Rotational angiography (RA) has proven to be an excellent method for evaluating congenital disease (CHD) in the cardiac cath lab, permitting acquisition of 3D datasets with superior spatial resolution. This technique has not been routinely implemented for 3D printing in CHD. We describe our case series of models printed from RA and validate our technique. All patients with models printed from RA were selected. RA acquisitions from a Toshiba Infinix-I system were postprocessed and printed with a Stratasys Eden 260. Two independent observers measured 5-10 points of interest on both the RA and the 3D model. Bland Altman plot was used to compare the measurements on rotational angiography to the printed model. Models were printed from RA in 5 patients (age 2 months-1 year). Diagnoses included (a) coronary artery aneurysm, (b) Glenn shunt, (c) coarctation of the aorta, (d) tetralogy of Fallot with MAPCAs, and (e) pulmonary artery stenosis. There was no significant measurement difference between RA and the printed model (r = 0.990, p < 0.01, Bland Altman p = 0.987). There was also no significant inter-observer variability. The MAPCAs model was referenced by the surgeon intraoperatively and was accurate. Rotational angiography can generate highly accurate 3D models in congenital heart disease, including in small vascular structures. These models can be extremely useful in patient evaluation and management.

Proposed clinical internal carotid artery classification system.

INTRODUCTION: Numerical classification systems for the internal carotid artery (ICA) are available, but modifications have added confusion to the numerical systems. Furthermore, previous classifications may not be applicable uniformly to microsurgical and endoscopic procedures. The purpose of this study was to develop a clinically useful classification system. MATERIALS AND METHODS: We performed cadaver dissections of the ICA in 5 heads (10 sides) and evaluated 648 internal carotid arteries with computed tomography angiography. We identified specific anatomic landmarks to define the beginning and end of each ICA segment. RESULTS: The ICA was classified into eight segments based on the cadaver and imaging findings: (1) Cervical segment; (2) cochlear segment (ascending segment of the ICA in the temporal bone) (relation of the start of this segment to the base of the styloid process: Above, 425 sides [80%]; below, 2 sides [0.4%]; at same level, 107 sides [20%]; P < 0.0001) (relation of cochlea to ICA: Posterior, 501 sides [85%]; posteromedial, 84 sides [14%]; P < 0.0001); (3) petrous segment (horizontal segment of ICA in the temporal bone) starting at the crossing of the eustachian tube superolateral to the ICA turn in all 10 samples; (4) Gasserian-Clival segment (ascending segment of ICA in the cavernous sinus) starting at the petrolingual ligament (PLL) (relation to vidian canal on imaging: At same level, 360 sides [63%]; below, 154 sides [27%]; above, 53 sides [9%]; P < 0.0001); in this segment, the ICA projected medially toward the clivus in 275 sides (52%) or parallel to the clivus with no deviation in 256 sides (48%; P < 0.0001); (5) sellar segment (medial loop of ICA in the cavernous sinus) starting at the takeoff of the meningeal hypophyseal trunk (ICA was medial into the sella in 271 cases [46%], lateral without touching the sella in 127 cases [23%], and abutting the sella in 182 cases [31%]; P < 0.0001); (6) sphenoid segment (lateral loop of ICA within the cavernous sinus) starting at the crossing of the fourth cranial nerve on the lateral aspect of the cavernous ICA and located directly lateral to the sphenoid sinus; (7) ring segment (ICA between the 2 dural rings) starting at the crossing of the third cranial nerve on the lateral aspect of the ICA; (8) cisternal segment starting at the distal dural ring. CONCLUSIONS: The classification may be applied uniformly to all skull base surgical approaches including lateral microsurgical and ventral endoscopic approaches, obviating the need for 2 separate classification systems. The classification allows extrapolation of relevant clinical information because each named segment may indicate potential surgical risk to specific structures.

Case 227: Endobronchial Carcinoid Tumor with Incidental Metastatic Breast Cancer Detected with Somatostatin Receptor Scintigraphy ((111)In Pentreotide).

HISTORY: A 30-year-old woman with polycystic ovarian syndrome who was undergoing hormone replacement therapy presented with a 6-month history of a nonproductive cough and a 1-day history of hemoptysis (approximately 20 mL). Intravenous contrast material-enhanced (100 mL of Omnipaque 350; GE Healthcare, Princeton, NJ) computed tomographic (CT) pulmonary angiography was performed to evaluate for pulmonary embolism. On the basis of the CT pulmonary angiographic findings, chromogranin A and 5-hydroxyindoleacetic acid levels were measured and were 7 nmol/L (343 µg/L) (high) and 2.9 mg per 24 hours (15.167 µmol/d) (normal), respectively. This patient underwent bronchoscopy and biopsy. After these tests, she was referred for whole-body scintigraphy, which revealed an unexpected finding that was further investigated with fluorine 18 ((18)F) flurodeoxyglucose (FDG) positron emission tomography (PET) and CT.

Sjögren Syndrome Complicated by Mucosa-Associated Lymphoid Tissue Lymphoma and Lymphocytic Interstitial Pneumonia.

Sjögren syndrome (SS) is an autoimmune disease with exocrine glands dysfunction and multiorgan involvement. It is associated with increased risk of lymphoproliferative disorders, especially B-cell marginal zone lymphoma. While the role of F-18 Fluorodeoxyglucose position emission tomography/computed tomography (F-18 FDG PET/CT) for evaluation of lymphoma has been established, its use in patients with a chronic history of SS to evaluate for possible lymphoproliferative disorders or multiorgan involvement is limited. We present a case of chronic SS in which F-18 FDG PET/CT demonstrated FDG avid intraparotid and cervical lymph nodes pathologically proven to be mucosa-associated lymphoid tissue lymphoma. In addition, the patient had bibasilar cystic changes consistent with lymphocytic interstitial pneumonia.

Detection of Metastatic Disease in Cardiophrenic Lymph Nodes: FDG PET/CT Versus Contrast-Enhanced CT and Implications for Staging and Treatment of Disease.

OBJECTIVE: To determine whether FDG PET/CT was more sensitive than CT in detecting metastatic disease in the cardiophrenic space and whether the presence of disease in this location would change the staging and clinical management. MATERIALS AND METHODS: About 1200 PET/CT scans were retrospectively reviewed over 20 months for the presence of FDG-avid cardiophrenic lymph nodes. The SUVmax was used to quantify the metabolic activity in each of the lymph nodes. The radiographic data was used for correlation. A retrospective review of diagnostic CT reports performed within a 1-month period of time of the PET/CT in the same subset of patients determined whether cardiophrenic lymph nodes were mentioned. RESULTS: About 9 (0.8%) of the 1200 studies were found to have FDG-avid cardiophrenic lymph nodes (four males and five females with a mean age of 55 years; range 7-69, median 59). The mean SUVmax was 2.4 (range 1.2-7.9; median 1.9). Only three of the patients were found to have suspicious lymph nodes on CT. The presence of cardiophrenic lymph nodes had the potential to change the staging and/or management in three of the patients. CONCLUSION: PET/CT is more accurate in the detection of pathologic cardiophrenic lymph nodes than CT, especially when they are subcentimeter in size. When present, staging and/or management was potentially affected in 33%. Therefore, these nodes should be included in the TNM staging classification.

Does ¹8F-FDG uptake by respiratory muscles on PET/CT correlate with chronic obstructive pulmonary disease?

UNLABELLED: (18)F-FDG muscle uptake is evident in some benign physiologic processes as seen in the respiratory muscles of patients with chronic obstructive pulmonary disease (COPD) and labored breathing. The purpose of this study was to correlate the presence of COPD with the patterns of (18)F-FDG uptake by muscles as demonstrated by PET/CT scans. METHODS: (18)F-FDG PET/CT scans and pulmonary function tests (PFTs) were performed for 63 consecutive patients with newly diagnosed or highly suspected lung cancer. Presurgical pulmonary function tests by way of spirometry examinations were performed as the standard of care. Patients were grouped into those with normal spirometry findings and those with mild to very severe COPD. The guidelines of the Global Initiative for Chronic Obstructive Lung Disease were used for staging COPD and obstructive impairment. A nuclear medicine physician and 2 residents who did not know the COPD status retrospectively reviewed PET/CT scans and kept a log for cases of increased (18)F-FDG uptake in the respiratory muscles (diaphragm, intercostal muscles, and scalene muscles). The χ(2) test and Cramer V were used to evaluate the correlation between increased (18)F-FDG uptake by muscles and the presence of COPD. RESULTS: Sixty-three patients underwent both (18)F-FDG PET/CT and PFT within 1 mo of each another without interval therapy. Of the 63 patients, 26 (41%) had no spirometric obstruction and 37 (59%) had spirometric obstruction. Of these, 30 (81%) had a previously established diagnosis of COPD (1 mild, 26 moderate, 9 severe, and 1 very severe). Excessive (18)F-FDG uptake was seen in at least 2 of the 3 muscles (diaphragm and intercostal muscles) in 27 (73%) of the 37 patients with COPD and obstructive ventilatory impairment. The severity of COPD and obstruction showed a significant correlation with the presence of abnormal (18)F-FDG uptake by any of the 3 muscle types, particularly when 2 groups of muscles were involved (Cramer V = 0.60, χ(2) P < 0.001). CONCLUSION: Our study revealed a strong correlation between increased (18)F-FDG uptake by respiratory muscles and the presence of COPD.

Impact of allogenic packed red blood cell transfusion on nosocomial infection rates in the critically ill patient.

OBJECTIVE: To determine whether critically ill patients who receive allogenic packed red blood cell transfusions are at increased risk of developing nosocomial infections during hospitalization. DESIGN: Retrospective database study utilizing Project IMPACT. SETTING: A 40-bed medical-surgical-trauma intensive care unit in an 825-bed tertiary referral teaching hospital. PATIENTS: One thousand seven hundred and seventeen patients admitted to the medical-surgical-trauma intensive care unit. MEASUREMENTS AND MAIN RESULTS: Data were collected by using the Project IMPACT database. Nosocomial infection rates were compared among three groups: the entire cohort, the transfusion group, and the nontransfusion group. We determined the nosocomial infection rates in these groups while adjusting for probability of survival by using Mortality Prediction Model (MPM-0) scores, age, gender, and number of units of packed red blood cells transfused. The average number of units transfused per patient was 4.0. The nosocomial infection rate for the entire cohort was 5.94%. The nosocomial infection rates for the transfusion group (n = 416) and the nontransfusion group (n = 1301) were 15.38% and 2.92%, respectively (p <.005 chi-square). Transfusion of packed red blood cells was related to the occurrence of nosocomial infection, and there was a dose-response pattern (the more units of packed red blood cells transfused, the greater the chance of nosocomial infection; p< 0.0001 chi-square). The transfusion group was six times more likely to develop nosocomial infection compared with the nontransfusion group. In addition, for each unit of packed red blood cells transfused, the odds of developing nosocomial infection were increased by a factor of 1.5. A subgroup analysis of nosocomial infection rates adjusted for probability of survival by using MPM-0 scores showed nosocomial infection to occur at consistently higher rates in transfused patients vs. nontransfused patients. A second subgroup analysis adjusted for patient age showed a statistically significant increase in rates of nosocomial infection for transfused patients regardless of age. CONCLUSIONS: Transfusion of packed red blood cells is associated with nosocomial infection. This association continues to exist when adjusted for probability of survival and age. In addition, mortality rates and length of intensive care unit and hospital stay are significantly increased in transfused patients.