Clinical characteristics of and outcomes for patients with COVID-19 and comorbid lung diseases primarily hospitalized in a conventional pulmonology unit: A retrospective study.

BACKGROUND: Scant data are currently available about a potential link between comorbid chronic lung diseases (CLD) and the risk and severity of the coronavirus disease 2019 (COVID-19) infection. METHODS: To describe the clinical characteristics of and outcomes for patients with COVID-19 infection, including patients with comorbid respiratory diseases, who have been primarily hospitalized in the pulmonology department of Strasbourg University Hospital, France. In this retrospective, single-center study, we included all confirmed cases of COVID-19 from March 3 to April 15, 2020. We then compared the symptoms, biological and radiological findings, and outcomes for patients with and without CLD. RESULTS: Of the 124 patients that were enrolled, the median age was 62 years, and 75 patients (60%) were male. Overall, 40% of patients (n=50) had preexisting CLD, including chronic obstructive pulmonary disease (COPD) (n=15, 12%) and asthma (n=19, 15%). Twenty-eight patients were transferred to the intensive care unit (ICU), and six patients died in our unit. CLD were not predictive of ICU hospitalization, but a significantly higher total mortality was observed (17.6% vs. 5.5%, P<0.05) in these patients. CONCLUSIONS: Our results suggest the lack of an over-representation of CLD in COVID-19, representing 40% of patients in this cohort and even within a pulmonology department. CLD were not a risk factor for ICU management. However, a tendency to higher global mortality was observed in COVID-19 patients with CLD. Further studies are warranted to determine the risk of COVID-19 for patients with comorbid CLD.

Shear-wave elastography of the testicle: potential role of the stiffness value in various common testicular diseases.

AIM: To assess the value and efficacy of real-time shear-wave elastography (SWE) of normal testicular parenchyma and various common testicular diseases in clinical practice. MATERIALS AND METHODS: SWE was undertaken in 338 patients (mean age: 43.2±17.2 years, range 17-78 years) comprising normal testicles (n = 358), testicular microlithiasis (n = 40), and various testicular diseases (n = 208) and the stiffness was recorded. The final diagnosis was correlated with the clinical context, long-term follow-up, or histopathology. Statistical evaluation was performed to provide a stiffness threshold for pathological diagnosis. RESULTS: The mean size of testicular lesions was 2.6±1.5 cm (range: 10-42 mm). The mean Young's modulus value for normal testis was recorded at 4.55±2.54 kPa. Whatever the stage of microlithiasis, a higher statistically significant stiffness value was recorded. For acute orchitis, the mean stiffness value was slightly higher, but not statistically significantly. The testicular tumoural processes presented a median stiffness value of 21.02 kPa with a cut-off of 16.1 kPa. Fibrosis presented the highest median stiffness value of 30.03 kPa with a cut-off of 26.3 kPa. By analysing the distribution of the different pathological groups, the difference was statistically significant between fibrosis and tumoural processes (p = 0.001). CONCLUSION: SWE is a feasible technique in the exploration of the testicular parenchyma. SWE values can be used to differentiate testicular fibrosis from a tumoural process with confidence.

Radiation-induced lung toxicity predictors: Retrospective analysis of 90 patients treated with stereotactic body radiation therapy for stage I non-small-cell lung carcinoma.

BACKGROUND: The main complication after hypofractionated radiotherapy for lung carcinoma is radiation-induced lung toxicity, which can be divided into radiation pneumonitis (acute toxicity, occurring within 6 months) and lung fibrosis (late toxicity, occurring after 6 months). The literature describes several predictive factors related to the patient, to the tumor (volume, central location), to the dosimetry and to biological factors. MATERIALS AND METHODS: This study is a retrospective analysis of 90 patients treated with stereotactic body irradiation for stage I non-small-cell lung carcinoma between December 2010 and May 2015. RESULTS: Radiation pneumonitis was observed in 61.5% of the patients who were mainly asymptomatic (34%). Chronic obstructive pulmonary disease was not predictive of radiation pneumonitis, whereas active smoking was protective. Centrally located tumors were not more likely to result in this complication if the radiation schedule utilized adapted fractionation. In our study, no predictive factor was identified. Whereas the mean lung dose was a predictive factor in 3D radiotherapy, the lung volume irradiated at high doses seemed to be involved in the pathogenesis after hypofractionated radiotherapy. CONCLUSION: The discovery of predictive factors for radiation pneumonitis is difficult due to the rarity of this complication, especially with an 8×7.5Gy schedule. Radiation pneumonitis seems to be correlated with the volume irradiated at high doses, which is in contrast to the known knowledge about the organs in parallel. This finding leads us to raise the hypothesis that vessel damage, organs in series, occurring during hypofractionated radiotherapy could be responsible for this toxicity.

[Skull base meningioma: Clinical and radiological efficacy based on a quantitative volumetric analysis]. / Méningiomes de la base du crâne : efficacité clinique et radiologique basée sur une analyse volumétrique quantitative.

PURPOSE: To date, no correlation has been found between clinical and radiological efficacy after irradiation of skull base meningiomas. However, the evaluation of the radiological response was most often made by questionable methods that may have underestimated the radiological effectiveness of radiotherapy. The objective of this work is to verify this hypothesis by quantitative volumetric analysis. MATERIAL AND METHODS: Data from 35 patients treated with either helical tomotherapy (45.7%) or fractionated stereotactic radiotherapy (54.3%) were retrospectively analysed. These were mainly women (94%) aged 59 (43-81) with lesions mainly of the cavernous sinus (60%). There was a median of 2 (1-4) symptoms and the main symptoms were visual impairment (39%), cranial nerve deficits (23.4%) and headaches (17.2%). RESULTS: Median tumour volume decreased significantly (P<0.05) from 9.6mL (0.3-36.6) to 6.8mL (0.1-26.5) after median follow-up of 44 months (24-77). Sixty-three percent of patients had an improvement of at least one symptom. In univariate analysis, clinical efficacy (P<0.05), radiotherapy technique (P<0.05), tumor topography (P<0.05) and initial tumor volume (P<0.05) were predictive factors for radiological response. In multivariate analysis, only the inverse correlation between radiological response and initial tumor volume remained significant (ρ: -0.47 95% CI -3.2 to 5.7; P<0.05). CONCLUSION: The quantitative volumetric monitoring demonstrates a major radiological efficiency of radiotherapy. However, no clear correlation between clinical and radiological efficacy was found.

Ultra-low-dose unenhanced chest CT: Prospective comparison of high kV/low mA versus low kV/high mA protocols.

PURPOSE: To qualitatively and quantitatively compare unenhanced ultra-low-dose chest computed tomography (ULD-CT) acquired at 80kVp and 135kVp. MATERIALS AND METHODS: Fifty-one patients referred for unenhanced chest CT were prospectively included. There were 29 men and 22 women, with a mean age of 64.7±11.6 (SD) years (range: 35-91 years) and a mean body mass index of 26.2±6.3 (SD) (range: 17-54.9). All patients underwent two different ULD-CT protocols (80kVp-40mA and 135kVp-10mA). Image quality of both ULD-CT examinations using a 5-level scale as well as assessability of 6 predetermined lung parenchyma lesions were blindly evaluated by three radiologists and compared using a logistic regression model. Image noise of the two protocols was compared with Wilcoxon signed-rank test. RESULTS: The mean dose-length product at 80kVp and at 135kVp were 14.7±1.8 (SD) mGy.cm and 15.6±1.9 (SD) mGy.cm, respectively (P<0.001). Image noise was significantly lower at 135kVp (58.9±12.4) than at 80kVp (74.7±14.5) (P<0.001). For all readers and for all examinations, the 135kVp protocol yielded better image quality than 80kVp protocol, with a mean qualitative score of 4.5±0.7 versus 3.9±0.8 (P<0.001). The 135kVp protocol was significantly more often of diagnostic quality than the 80kvp protocol (92.3% versus 77.8%, respectively) (P<0.001) and was less prone to image quality deterioration in obese patients. Parenchymal lesions were never better depicted on the 80kVp protocol than with the 135kVp protocol. CONCLUSION: Unenhanced chest ULD-CT should be acquired at a high kilovoltage and low current, such as 135kVp-10mA, over a low kilovoltage and high current protocol.

Wide volume versus helical acquisition using 320-detector row computed tomography for computed tomography urography in adults.

PURPOSE: To evaluate the best collimation used in wide volume (WV) mode to cover the abdomen in computed tomography (CT) urography in terms of radiation dose and image quality. MATERIALS AND METHODS: This study was performed on a 320×0.5mm detector row CT unit. The first part identified the lowest volume CT dose index (CTDIvol) by using the topograms data of 25 medium size patients (13 men and 12 women; mean age: 52±9 [SD] years; age range: 46-68 years) using different collimations on WV from 6cm to 16cm and the one of the helical mode for the same coverage length. The second part consisted of a clinical evaluation of this result including 45 medium size patients (32 men and 13 women; mean age: 68±14 [SD] years; age range: 45-72 years). The qualitative evaluation included several items based on a 5-point Likert scale. RESULTS: The first part of the study indicated that a collimation of 10cm (200×0.5mm) in WV mode with 5 volumes had the lowest CTDIvol (2.78±0.35mGy; range: 2.35-3.21mGy) compared to helical mode (4.38±0.48mGy, range: 3.75-4.95mGy). In the second part, the mean radiation dose reduction by comparison with helical mode was 44.03%±0.36% (P<0.001) and 51.16%±1.22% (P<0.005) for CTDIvol and DLP, respectively. CONCLUSION: Wide volume mode of the abdomen can be performed with a significant radiation dose reduction with a collimation of 10cm (200×0.5mm) and five volumes.

[Base of the skull meningioma: Efficacy, clinical tolerance and radiological evaluation after radiotherapy]. / Méningiomes de la base du crâne : efficacité et tolérance clinique, efficacité radiologique et cinétique tumorale après radiothérapie.

Skull base meningioma leads to functional disturbances, which can significantly alter the quality of life. The optimal management of these lesions, whose goals are neurological preservation and tumour local control, is not yet clearly established. It is widely recognized that the goal of a radical excision should be abandoned despite the advances in the field of microsurgery of skull base lesions. Although less morbid, partial tumour excision would be associated with increased risk of local tumour recurrence. Although discussed both exclusive and adjuvant have proven to be highly successful in terms of clinical improvement and local control. Various radiation techniques have demonstrated their efficacy in the management of this pathology. However, high rates of clinical improvement are in contrast with low rates of radiological improvement. The notion of clinical and radiological dissociation appeared. However, in most of these studies, the analysis of the radiological response could be subject of legitimate criticism. This work proposes to review the local control, the efficacy and the clinical tolerance and the radiological response of the various radiation techniques for the meningioma of the base of the skull and to demonstrate the interest of quantitative volumetric analyses in the follow-up of meningioma after radiotherapy.

Single source dual energy CT: What is the optimal monochromatic energy level for the analysis of the lung parenchyma?

OBJECTIVE: To determine the optimal monochromatic energy level for lung parenchyma analysis in spectral CT. METHODS: All 50 examinations (58% men, 64.8±16yo) from an IRB-approved prospective study on single-source dual energy chest CT were retrospectively included and analyzed. Monochromatic images in lung window reconstructed every 5keV from 40 to 140keV were independently assessed by two chest radiologists. Based on the overall image quality and the depiction/conspicuity of parenchymal lesions, each reader had to designate for every patient the keV level providing the best diagnostic and image quality. RESULTS: 72% of the examinations exhibited parenchymal lesions. Reader 1 picked the 55keV monochromatic reconstruction in 52% of cases, 50 in 30% and 60 in 18%. Reader 2 chose 50keV in 52% cases, 55 in 40%, 60 in 6% and 40 in 2%. The 50 and 55keV levels were chosen by at least one reader in 64% and 76% of all patients, respectively. Merging 50 and 55keV into one category results in an optimal setting selected by reader 1 in 82% of patients and by reader 2 in 92%, with a 74% concomitant agreement. CONCLUSION: The best image quality for lung parenchyma in spectral CT is obtained with the 50-55keV monochromatic reconstructions.

[What future for chest x-ray against ultra-low-dose computed tomography?] / Quel avenir pour la radiographie thoracique face au scanner ultra-low dose ?

Technological improvements, with iterative reconstruction at the foreground, have lowered the radiation dose of a chest CT close to that of a PA and lateral chest x-ray. This ultra-low dose chest CT (ULD-CT) has an image quality that is degraded on purpose, yet remains diagnostic in many clinical indications. Thus, its effectiveness is already validated for the detection and the monitoring of solid parenchymal nodules, for the diagnosis and monitoring of infectious lung diseases and for the screening of pleural lesions secondary to asbestos exposure. Its limitations are the analysis of the mediastinal structures, the severe obesity (BMI>35) and the detection of interstitial lesions. If it can replace the standard chest CT in these indications, all the more in situations where radiation dose is a major problem (young patients, repeated exams, screening), it progressively emerges as a first line alternative for chest radiograph, providing more data at a similar radiation cost.

[Pre- and postoperative imaging of type B aortic dissection]. / Imagerie de la dissection aortique de type B : ce que veut savoir le chirurgien avant et après l'intervention.

Type B aortic dissections are serious diseases with a 60 to 80 % 5-year survival rate. Although typically managed with a medical treatment, surgery may be necessary in the acute/subacute or the chronic phase if significant complications are encountered. For these patients, CT angiography is the first-line imaging modality, used for indicating and preparing the surgical procedure as well as for follow-up. Physicians in charge of these patients should be familiar with the key reading points. Visceral malperfusion is the most common acute complication, while aneurysmal dilatation of the false lumen is the most common chronic complication, with surgical management generally indicated when the axial diameter of the aorta exceeds 55mm. Endovascular treatment tends to replace open surgery: it requires precise measurements and identification of the entry tear (contribution of 4D-MRA).

[Reversible posterior encephalopathy syndrome and cardiomyopathy after bevacizumab therapy]. / Syndrome d'encéphalopathie postérieure et atteinte cardiaque réversibles sous bévacizumab.

INTRODUCTION: Bevacizumab is an antibody directed against VEGF-A. It is approved for the treatment of many cancer diseases. Its side effects are currently not well known by physicians. CASE REPORT: A 70-year-old female with metastatic colonic adenocarcinoma was admitted in the intensive care unit because of a coma, four days after having received a combined monthly chemotherapy containing bevacizumab, oxaliplatine, 5 fluorouracil, and folinic acid for the fourth time. On clinical examination, she presented with lower limbs spasticity and hypertension. Etiologic investigations, including cerebral tomodensitometry, cerebrospinal fluid examination, psychotropic drugs urinary testing, and electroencephalogram, were negative. Consciousness improved without any other treatment than nicardipine and urapidil, but the patient was initially confused. Cerebral magnetic resonance imaging showed changes suggestive of posterior reversible encephalopathy syndrome, but also involving frontal lobes. There were additional biological and echocardiographic changes suggestive of cardiac involvement. The patient recovered completely of both cardiac and neurologic manifestations 10 days later. CONCLUSION: Physicians should be aware of cardiovascular adverse effects of bevacizumab. High blood pressure must be treated to avoid more severe complications. When a posterior reversible encephalopathy syndrome occurs, cardiac involvement should be investigated.

Iterative reconstruction in single source dual-energy CT pulmonary angiography: Is it sufficient to achieve a radiation dose as low as state-of-the-art single-energy CTPA?

OBJECTIVE: Dual-energy (DE) brings numerous significant improvements in pulmonary CT angiography (CTPA), but is associated with a 15-50% increase in radiation dose that prevents its widespread use. We hypothesize that thanks to iterative reconstruction (IR), single source DE-CTPA acquired at the same radiation dose that a single-energy examination will maintain an equivalent quantitative and qualitative image quality, allowing a more extensive use of the DE technique in the clinical routine. MATERIAL AND METHODS: Fifty patients (58% men, mean age 64.8yo ± 16.2, mean BMI 25.6 ± 4.5) were prospectively included and underwent single source DE-CTPA with acquisition parameters (275 mA fixed tube current, 50% IR) tweaked to target a radiation dose similar to a 100 kV single-energy CTPA (SE-CTPA), i.e., a DLP of 260 mGy cm. Thirty patients (47% men, 64.4yo ± 18.6, BMI 26.2 ± 4.6) from a previous prospective study on DE-CTPA (375 mA fixed tube current, reconstruction with filtered-back projection) were used as the reference group. Thirty-five consecutive patients (57% men, 65.8yo ± 15.5, BMI 25.7 ± 4.4) who underwent SE-CTPA on the same scanner (automated tube current modulation, 50% IR) served as a comparison. Subjective image quality was scored by two radiologists using a 5-level scale and compared with a Kruskal-Wallis nonparametric test. Density measurements on the 65 keV monochromatic reconstructions were used to calculate signal-to-noise (SNR) and contrast-to-noise (CNR) ratios that were compared using a Student's t test. Correlations between image quality, SNR, CNR and BMI were sought using a Pearson's test. p<0.05 was considered significant. RESULTS: All examinations were of diagnostic quality (score ≥ 3). In comparison with the reference DE-CTPA and the SE-CTPA protocols, the DE-IR group exhibited a non-inferior image quality (p=0.95 and p=0.21, respectively) and a significantly lower mean image noise (p<0.01 and p=0.01) thus slightly improving the SNR (p=0.09 and p=0.47) and the CNR (p=0.12 and p=0.51). There was a strong negative relationship between BMI and SNR/CNR (ρ=-0.59 and -0.55 respectively), but only a moderate negative relationship between BMI and image quality (ρ=-0.27). CONCLUSION: With iterative reconstruction, objective and subjective image quality of single source DE-CTPA are preserved even though the radiation dose is lowered to that of a single-energy examination, overcoming a major limitation of the DE technique and allowing a widespread use in the clinical routine.

Imaging before and after catheter ablation of atrial fibrillation.

Catheter ablation of arrhythmogenic triggers has been validated for the treatment of atrial fibrillation that is refractory to anti-arrhythmic medication. Imaging plays an important role in guiding the procedure as well as in planning and follow-up. The goal of pre-procedural imaging is to obtain a detailed anatomical description of the pulmonary veins, to eliminate a thrombus of the left atrium and to define the prognostic factors. MDCT angiography effectively and simply meets nearly all of these needs. Thus, a precise description of the left atrium anatomy before the procedure is a key factor to success and left atrium volume is a reliable prognostic factor of recurrence. Radiologists should be aware of early and late complications, sometimes severe such as pulmonary vein stenosis, cardiac tamponade or atrial-esophageal fistula, whose positive diagnosis is based on imaging.

Current optimal morphological evaluation of peripheral arterial diseases.

Imaging plays a central role in the management of peripheral arterial diseases (PAD), emphasized by the continuously increasing use of modern cross-sectional imaging and the corresponding decline of digital subtraction angiography (DSA) in the diagnostic setting. Imaging is sometimes used as a screening tool in high-risk individuals. In symptomatic patients, imaging is mandatory to make an accurate positive diagnosis, grade the severity and the extent of the abnormalities, carefully choose and plan the best therapeutic option and provide adequate follow-up. Non-invasive diagnosis of PAD can be made by Doppler ultrasonography, magnetic resonance angiography (MRA) and computed tomography angiography (CTA). Given the major technological breakouts over the last decade, MRA and especially CTA are nowadays mature and precise enough to properly answer all the questions raised in symptomatic patients. This review article aims at describing state-of-the-art non-invasive imaging of PAD, its involvement in the decision-making for the vascular surgeon and the future trends and developments expected in the coming years.

Thoracic dual energy CT: acquisition protocols, current applications and future developments.

Thanks to a simultaneous acquisition at high and low kilovoltage, dual energy computed tomography (DECT) can achieve material-based decomposition (iodine, water, calcium, etc.) and reconstruct images at different energy levels (40 to 140keV). Post-processing uses this potential to maximise iodine detection, which elicits demonstrated added value for chest imaging in acute and chronic embolic diseases (increases the quality of the examination and identifies perfusion defects), follow-up of aortic endografts and detection of contrast uptake in oncology. In CT angiography, these unique features are taken advantage of to reduce the iodine load by more than half. This review article aims to set out the physical basis for the technology, the acquisition and post-processing protocols used, its proven advantages in chest pathologies, and to present future developments.

Imaging of lung transplant complications.

Since the late 1980s, lung transplantation has emerged as a valid treatment option for some patients with advanced non-neoplastic lung disease. Long-term survival of lung transplant recipients, however, is lower than that of patients with other types of transplantation, because of numerous specific postoperative complications. Thanks to X-ray and CT, radiologists can guide clinicians, helped in this diagnostic approach by the time between the date of injury and date of transplantation. We will detail in this pictorial review the immediate and late surgical complications, the immunological complications, the infectious complications and other late complications.

MR urography (MRU) of non-dilated ureter with diuretic administration: Static fluid 2D FSE T2-weighted versus 3D gadolinium T1-weighted GE excretory MR.

OBJECTIVE: The goal of this prospective study was to compare the efficiency of two types of MRU after diuretic administration to identify the non-dilated ureter. METHODS: MR pelvic examinations were performed in 126 patients after receiving furosemide. Each patient underwent in addition to their protocol for context, two types of MRU: 2D T2-weighted FSE (T2w-MRU) and 3D Gd T1-weighted GE (CE-MRU). Four segments were checked for each ureter. For the first part of the analysis, readers evaluated the whole image quality using a four points subjective scale and for the second part, they were asked to score separately each ureteral segment as present or absent. RESULTS: 1008 ureteral segments were checked. For the image quality, readers did not find any significant difference (3.8 ± 0.5 vs 3.6 ± 0.7, p value: 0.13) between MRU methods. The interobserver agreement was excellent with a κ correlation coefficient as high as 0.89 for T2w-MRU and 0.92 for CE-MRU, respectively. For the detection of the segments and considering the 9 rotations for the T2W MRU, there were no statistically significant differences between the two groups. CONCLUSION: T2-weighted MRU with multiple orientations and diuretic is sufficient to identify the non-dilated ureter. It offers information on ureteral peristaltism. It can be suggested that this sequence is able to detect an initial obstruction before hydronephrosis occurs.