Management of Pulmonary Nodules in Oncologic Patients: AJR Expert Panel Narrative Review.

Cancer survivors are at higher risk than the general population for development of a new primary malignancy, most commonly lung cancer. Current lung cancer screening guidelines recommend low-dose chest CT for high-risk individuals, including patients with a history of cancer and a qualifying smoking history. However, major lung cancer screening trials have inconsistently included cancer survivors, and few studies have assessed management of lung nodules in this population. This narrative review highlights relevant literature and provides expert opinion for management of pulmonary nodules detected incidentally or by screening in oncologic patients. In patients with previously treated lung cancer, a new nodule most likely represents distant metastasis from the initial lung cancer or a second primary lung cancer; CT features such as nodule size and composition should guide decisions regarding biopsy, PET/CT, and CT surveillance. In patients with extrapulmonary cancers, nodule management requires individualized risk assessment; smoking is associated with increased odds of primary lung cancer, whereas specific primary cancer types are associated with increased odds of pulmonary metastasis. Nonneoplastic causes, such as infection, medication toxicity, and postradiation or postsurgical change, should also be considered. Future prospective studies are warranted to provide evidence-based data to assist clinical decision-making in this context.

The Assessment of Cardiac Masses by Cardiac CT and CMR Including Pre-op 3D Reconstruction and Planning.

PURPOSE OF REVIEW: The purpose of this review is to (1) review the recent evidence examining the use of CT and CMR in the assessment of a suspected cardiac mass, (2) summarize the typical imaging features of the most common cardiac masses, and (3) examine the latest developments in the use of three-dimensional reconstructions and models in the preoperative assessment of a cardiac mass. RECENT FINDINGS: CMR can distinguish between tumors and non-tumor masses and between benign and malignant mass with a high degree of accuracy. CT and CMR are complementary tools in the evaluation of cardiac masses. CMR is the preferred initial imaging modality due to its versatile imaging planes and superior tissue characterization. CT better depicts calcification and has a higher spatial resolution compared with CMR, which is of particular importance in preoperative planning. CT also offers a valuable alternative in those with contraindications to CMR. Three-dimensional reconstructions, particularly of CT datasets, are a valuable adjunct in the preoperative assessment of a cardiac mass and may allow a better appreciation of the margins of the mass and its relationship with surrounding structures. Three-dimensional printing is an emerging technology which may be of additional value in selected patients with a cardiac mass.

How to use MRI in cardiac disease with diastolic dysfunction?

Left ventricular (LV) diastolic dysfunction (DD) is an initially asymptomatic condition that can progress to heart failure, either with preserved or reduced ejection fraction. As such, DD is a growing public health problem. Impaired relaxation, the first stage of DD, is associated with altered LV filling. With progression, reducing LV compliance leads to restrictive cardiomyopathy. While cardiac magnetic resonance (CMR) imaging is the reference for LV systolic function assessment, transthoracic echocardiography (TTE) with Doppler flow measurements remains the standard for diastolic function assessment. Rather than simply replicating TTE measurements, CMR should complement and further advance TTE findings. We provide herein a step-by-step review of CMR findings in DD as well as imaging features which may help identify the underlying cause.

Family-based associations in measures of psychological distress and quality of life in a cardiac screening clinic for inheritable cardiac diseases: a cross-sectional study.

BACKGROUND: Family-based cardiac screening programmes for persons at risk for genetic cardiac diseases are now recommended. However, the psychological wellbeing and health related quality of life (QoL) of such screened patients is poorly understood, especially in younger patients. We sought to examine wellbeing and QoL in a representative group of adults aged 16 and over in a dedicated family cardiac screening clinic. METHODS: Prospective survey of consecutive consenting patients attending a cardiac screening clinic, over a 12 month period. Data were collected using two health measurement tools: the Short Form 12 (version 2) and the Hospital Anxiety and Depression Scale (HADS), along with baseline demographic and screening visit-related data. The HADS and SF-12v.2 outcomes were compared by age group. Associations with a higher HADS score were examined using logistic regression, with multi-level modelling used to account for the family-based structure of the data. RESULTS: There was a study response rate of 86.6%, with n=334 patients providing valid HADS data (valid response rate 79.5%), and data on n=316 retained for analysis. One-fifth of patients were aged under 25 (n=61). Younger patients were less likely than older to describe significant depression on their HADS scale (p<0.0001), although there were overall no difference between the prevalence of a significant HADS score between the younger and older age groups (18.0% vs 20.0%, p=0.73). Significant positive associates of a higher HADS score were having lower educational attainment, being single or separated, and being closely related to the family proband. Between-family variance in anxiety and depression scores was greater than within-family variance. CONCLUSIONS: High levels of anxiety were seen amongst patients attending a family-based cardiac screening clinic.Younger patients also had high rates of clinically significant anxiety. Higher levels of anxiety and depression tends to run in families, and this has implications for family screening and intervention programmes.

Optimal timing of SPECT/CT to demonstrate parathyroid adenomas in 99mTc-sestamibi scintigraphy.

BACKGROUND: Accurate preoperative localisation of the parathyroid adenoma is essential to achieve a minimally invasive parathyroidectomy. The purpose of this study was to validate and improve our single-isotope dual-phase parathyroid imaging protocol utilising 99mTechnetium-Sestamibi ([99mTc]MIBI). There has been no accepted gold standard evidence-based protocol regarding timing of single-photon emission computed tomography/computed tomography (SPECT/CT) acquisition in parathyroid imaging with resultant variation between centres. We sought to determine the optimum timing of SPECT/CT post administration of [99mTc]MIBI in the identification of parathyroid adenomas. We aimed to evaluate the efficacy of early and late SPECT/CT and to establish whether SPECT/CT demonstrates increased sensitivity over planar imaging. MATERIAL AND METHODS: A sample of 36 patients with primary hyperparathyroidism underwent planar and SPECT/CT acquisition 15 minutes (early) and two hours (late) post [99mTc]MIBI administration. Two radionuclide radiologists reviewed the images and Fisher's exact Chi-squared statistic was used to evaluate the diagnostic performances of early versus late SPECT/CT acquisition and SPECT/CT versus planar imaging. RESULTS: Twenty-one likely parathyroid adenomas were identified with a statistically superior diagnosis rate in the late SPECT/CT acquisition compared with both early SPECT/CT and planar imaging (p < 0.05). All adenomas diagnosed on early SPECT/CT acquisition were also identified on late SPECT/CT images. CONCLUSIONS: Single late phase SPECT/CT is significantly superior to early SPECT/CT in the identification of parathyroid adenomas. Late SPECT/CT improves diagnostic accuracy over planar acquisition. Imaging protocols should be revised to include late SPECT/CT acquisition. Early SPECT/CT acquisition can be eliminated from scan protocols with associated implications regarding reduced scan time and increased patient throughput.

CT-determined sarcopenia as a predictor of post-operative outcomes in patients undergoing an emergency laparotomy.

PURPOSE: Emergency laparotomy has a high reported thirty-day mortality, ranging from 11 to 15%. Current peri-operative risk assessment tools may poorly estimate the risk of perioperative mortality. We sought to determine if CT-determined sarcopenia may be a useful predictor of post-operative outcomes in patients undergoing an emergency laparotomy. METHODS: A retrospective review of a prospectively maintained database of consecutive adult patients who underwent an emergency laparotomy at our institution was performed. Post-operative mortality (90-day mortality), admission to HDU or ICU and APACHE-II scores were recorded for these patients. Sarcopenia was calculated by determining psoas area and density at the level of the third lumbar vertebra. The lowest quartile was determined to be sarcopenic. Univariate statistical analysis investigated associations between sarcopenia and these outcome measures. RESULTS: Eighty patients were included in the study following application of exclusion criteria. Thirty-eight were male. The 90-day mortality rate was 11%. Compared to their non-sarcopenic counterparts, sarcopenic patients were significantly more likely to have died by 90 days post-operatively (χ2 = 9.51, p = 0.002) and to require admission to either the HDU or ICU in the post-operative period (χ2 = 10.62, p = 0.001). CONCLUSIONS: CT determined sarcopenia is significantly associated with 90-day mortality and post-operative admission to HDU or ICU in patients undergoing an emergency laparotomy. The future development of a validated scoring tool incorporating sarcopenia could help to better select out those patients who will require higher levels of post-operative care as well as identifying those for whom surgery may not confer a survival benefit and be deemed futile.

Colorectal intussusception secondary to primary rectal melanoma: A novel case report.

INTRODUCTION: Intussusception in adults is a rare condition, accounting for just 5% of all cases. Approximately 50% of cases of large intestine intussusception occur due to a malignant neoplasm. We present here a novel case report of colo-rectal intussusception arising secondary to a primary rectal melanoma. PRESENTATION OF CASE: We present the case of an 85 year-old patient, who underwent a colonoscopy for investigation of weight loss and altered bowel habit. At colonoscopy, a pigmented polypoid mass was visualised in the upper third of the rectum. The lesion was causing colo-rectal intussusception. Initial biopsies of the specimen stained positive for S-100. The patient had an MRI (magnetic resonance imaging) pelvis, which demonstrated a mass at the rectosigmoid junction, which was diffusely high signal on the fat sat T1 weighted sequence. The patient proceeded to a laparoscopic anterior resection and had an uncomplicated post-operative course. The resected specimen was sent for pathological analysis. The morphological and immunohistochemical profile was consistent with malignant melanoma. There was no evidence of cutaneous melanoma following a full skin examination. DISCUSSION: Rectal melanoma is a rare condition. We present a novel case report of colo-rectal intussusception arising secondary to rectal melanoma. CONCLUSION: This is a rare entity. This patient's pre-operative MRI and biopsy samples suggested this lesion was a rectal melanoma, which was subsequently confirmed on analysis of the resected specimen. Surgical resection of such neoplasms should be attempted where possible.