Malignancies incidentally detected at lung transplantation: radiologic and pathologic features.

OBJECTIVE: The purpose of this study was to assess the CT-pathologic features of cancer incidentally detected at lung transplantation. MATERIALS AND METHODS: Our lung transplant registry was reviewed over 7 years for incidental malignancy. Patient demographics, diffuse lung disease, surgical procedure, histopathology, and chest CT were recorded. We correlated lesion size, morphology, multiplicity, and location with surgical and pathology reports and histopathology. Cancers were pathologically staged. RESULTS: Of 759 lung transplant recipients, cancer was incidentally detected in 22 (2.9%). Half (11 of 258) or 4.3% were detected within the past 2 years. Four patients had a history of treated malignancy, and three had recurrence. Patients had emphysema (chronic obstructive pulmonary disease [COPD]) (n = 10), fibrosis (n = 10), or combined COPD and fibrosis (n = 2). Histopathology revealed 13 solitary lung carcinomas, four multifocal adenocarcinomas, three metastases, and two lymphoproliferative diseases. Lung cancer (n = 17) stages were I or II (n = 13), IIIA (n = 2), or IV (n = 2). Metastases (n = 3) and lymphoproliferative disease (n = 2) represented advanced disease. The interval between CT and surgery was a mean of 4 months. CT-positive cases (n = 10) represented lung cancer (n = 9) and posttrans-plantation lymphoproliferative disease (n = 1). Cases with no CT findings of malignancy (n = 12) included lung cancer (n = 8), metastases (n = 3), and lymphoma (n = 1). Ten cases (45%) had other histologically benign CT abnormalities that mimicked cancer. CONCLUSION: Detection of incidental malignancy at lung transplantation has increased over the past 2 years. Malignancies were typically stage I or II lung cancers that were occult or indeterminate on CT. Diffuse lung disease, multiple CT abnormalities, and a delay between CT and transplantation compromise the preoperative diagnosis of cancer.

Automated segmentation of five different body tissues on computed tomography using deep learning.

PURPOSE: To develop and validate a computer tool for automatic and simultaneous segmentation of five body tissues depicted on computed tomography (CT) scans: visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), intermuscular adipose tissue (IMAT), skeletal muscle (SM), and bone. METHODS: A cohort of 100 CT scans acquired on different subjects were collected from The Cancer Imaging Archive-50 whole-body positron emission tomography-CTs, 25 chest, and 25 abdominal. Five different body tissues (i.e., VAT, SAT, IMAT, SM, and bone) were manually annotated. A training-while-annotating strategy was used to improve the annotation efficiency. The 10-fold cross-validation method was used to develop and validate the performance of several convolutional neural networks (CNNs), including UNet, Recurrent Residual UNet (R2Unet), and UNet++. A grid-based three-dimensional patch sampling operation was used to train the CNN models. The CNN models were also trained and tested separately for each body tissue to see if they could achieve a better performance than segmenting them jointly. The paired sample t-test was used to statistically assess the performance differences among the involved CNN models RESULTS: When segmenting the five body tissues simultaneously, the Dice coefficients ranged from 0.826 to 0.840 for VAT, from 0.901 to 0.908 for SAT, from 0.574 to 0.611 for IMAT, from 0.874 to 0.889 for SM, and from 0.870 to 0.884 for bone, which were significantly higher than the Dice coefficients when segmenting the body tissues separately (p < 0.05), namely, from 0.744 to 0.819 for VAT, from 0.856 to 0.896 for SAT, from 0.433 to 0.590 for IMAT, from 0.838 to 0.871 for SM, and from 0.803 to 0.870 for bone. CONCLUSION: There were no significant differences among the CNN models in segmenting body tissues, but jointly segmenting body tissues achieved a better performance than segmenting them separately.

Automated identification of pulmonary arteries and veins depicted in non-contrast chest CT scans.

We present a novel integrative computerized solution to automatically identify and differentiate pulmonary arteries and veins depicted on chest computed tomography (CT) without iodinated contrast agents. We first identified the central extrapulmonary arteries and veins using a convolutional neural network (CNN) model. Then, a computational differential geometry method was used to automatically identify the tubular-like structures in the lungs with high densities, which we believe are the intrapulmonary vessels. Beginning with the extrapulmonary arteries and veins, we progressively traced the intrapulmonary vessels by following their skeletons and differentiated them into arteries and veins. Instead of manually labeling the numerous arteries and veins in the lungs for machine learning, this integrative strategy limits the manual effort only to the large extrapulmonary vessels. We used a dataset consisting of 120 chest CT scans acquired on different subjects using various protocols to develop, train, and test the algorithms. Our experiments on an independent test set (n = 15) showed promising performance. The computer algorithm achieved a sensitivity of ∼98% in labeling the pulmonary artery and vein branches when compared with a human expert's results, demonstrating the feasibility of our computerized solution in pulmonary artery/vein labeling.

Estimating 3-D whole-body composition from a chest CT scan.

BACKGROUND: Estimating whole-body composition from limited region-computed tomography (CT) scans has many potential applications in clinical medicine; however, it is challenging. PURPOSE: To investigate if whole-body composition based on several tissue types (visceral adipose tissue [VAT], subcutaneous adipose tissue [SAT], intermuscular adipose tissue [IMAT], skeletal muscle [SM], and bone) can be reliably estimated from a chest CT scan only. METHODS: A cohort of 97 lung cancer subjects who underwent both chest CT scans and whole-body positron emission tomography-CT scans at our institution were collected. We used our in-house software to automatically segment and quantify VAT, SAT, IMAT, SM, and bone on the CT images. The field-of-views of the chest CT scans and the whole-body CT scans were standardized, namely, from vertebra T1 to L1 and from C1 to the bottom of the pelvis, respectively. Multivariate linear regression was used to develop the computer models for estimating the volumes of whole-body tissues from chest CT scans. Subject demographics (e.g., gender and age) and lung volume were included in the modeling analysis. Ten-fold cross-validation was used to validate the performance of the prediction models. Mean absolute difference (MAD) and R-squared (R2 ) were used as the performance metrics to assess the model performance. RESULTS: The R2 values when estimating volumes of whole-body SAT, VAT, IMAT, total fat, SM, and bone from the regular chest CT scans were 0.901, 0.929, 0.900, 0.933, 0.928, and 0.918, respectively. The corresponding MADs (percentage difference) were 1.44 ± 1.21 L (12.21% ± 11.70%), 0.63 ± 0.49 L (29.68% ± 61.99%), 0.12 ± 0.09 L (16.20% ± 18.42%), 1.65 ± 1.40 L (10.43% ± 10.79%), 0.71 ± 0.68 L (5.14% ± 4.75%), and 0.17 ± 0.15 L (4.32% ± 3.38%), respectively. CONCLUSION: Our algorithm shows promise in its ability to estimate whole-body compositions from chest CT scans. Body composition measures based on chest CT scans are more accurate than those based on vertebra third lumbar.

Rasamsonia argillacea species complex myocarditis in a patient with chronic granulomatous disease.

Herein, we present a case of successfully treated biopsy-proven Rasamsonia argillacea species complex myocarditis, pericarditis, and pulmonary infection in a 35-year-old male with a history of chronic granulomatous disease. Computed tomography of the chest demonstrated numerous pulmonary nodules and mass-like pulmonary lesions, and subsequent cardiac magnetic resonance imaging demonstrated an infiltrating mass-like lesion within the interventricular septum and pericarditis. Endobronchial, thoracoscopic, and eventual myocardial biopsies with cultures were ultimately reported as positive for R. argillacea species and the patient was treated with tailored antifungal therapy resulting in a significant therapeutic response upon short interval follow-up. This case stresses the importance of recognizing unusual thoracic imaging manifestations of an atypical fungal infection in immunocompromised individuals in order to expedite treatment of an otherwise potentially fatal disease.

Pulmonary veno-occlusive disease is highly prevalent in scleroderma patients undergoing lung transplantation.

There is an unexpectedly high incidence of PVOD in patients with SSc-PH-ILD. Presence of PVOD may be an unrecognised contributor to the dismal prognosis of these patients. Early transplant referral should be considered for those with SSc-PH-ILD. http://ow.ly/vPvc30neJZV.

Innovative and Contemporary Interventional Therapies for Esophageal Diseases.

Esophageal surgery has become quite specialized, and both dedicated diagnostic and refined surgical techniques are required to deliver state-of-the-art care. The field has evolved to include endoscopic mucosal resection and radiofrequency ablation for early-stage esophageal cancer and minimally invasive esophagectomy with the reconstruction of a gastric conduit for carefully selected patients with esophageal cancer or those with "end-stage" esophagus from benign diseases. Reoperative esophageal surgery after esophagectomy deserves special mention given that these patients, with improved survival, are presenting years after esophagectomy with functional and anatomic disorders that sometimes require surgical intervention. Different diagnostic modalities are essential for assessing patients and planning surgical treatment. Recognizing early and late postoperative complications on imaging may expedite and improve patient outcomes. Finally, endoscopic management of achalasia with peroral endoscopic myotomy and the use of the LINX device for gastroesophageal reflux disease are highly effective and minimally invasive treatments that may reduce complications, costs, and length of hospital stay.

Innovative and Contemporary Interventions of Diaphragmatic Disorders.

The diaphragm is an inconspicuous fibromuscular septum, and disorders may result in respiratory impairment and morbidity and mortality when untreated. Radiologists need to accurately diagnose diaphragmatic disorders, understand the surgical approaches to diaphragmatic incisions/repairs, and recognize postoperative changes and complications. Diaphragmatic defects violate the boundary between the chest and abdomen, with the risk of herniation and strangulation of abdominal contents. In our surgical practice, patients with diaphragmatic hernias present acutely with incarceration and/or strangulation. Bochdalek hernias are commonly diagnosed in asymptomatic older adults on computed tomography; however, when viscera or a large amount of fat herniates into the chest, surgical intervention is strongly advocated. Morgagni hernias are rare in adults and typically manifest acutely with bowel obstruction. Patients with traumatic diaphragm injury may have an acute, latent, or delayed presentation, and radiologists should be vigilant in inspecting the diaphragm on the initial and all subsequent thoracoabdominal imaging studies. Almost all traumatic diaphragm injury are surgically repaired. Finally, with porous diaphragm syndrome, fluid, air, and tissue from the abdomen may communicate with the pleural space through diaphragmatic fenestrations and result in a catamenial pneumothorax or large pleural effusion. When the underlying disorder cannot be effectively treated, the goal of surgical intervention is to establish the diagnosis, incite pleural adhesions, and close diaphragmatic defects. Diaphragmatic plication may be helpful in patients with eventration or acquired injuries of the phrenic nerve, as it can stabilize the affected diaphragm. Phrenic nerve pacing may improve respiratory function in select patients with high cervical cord injury or central hypoventilation syndrome.

Patient selection determines the prostate cancer yield of dynamic contrast-enhanced magnetic resonance imaging-guided transrectal biopsies in a closed 3-Tesla scanner.

OBJECTIVE: To evaluate the cancer yield of transrectal prostate biopsies in a 3-T magnetic resonance imaging (MRI) scanner in patients with elevated prostate specific antigen (PSA) levels and recent negative transrectal ultrasonography (TRUS)-guided prostate biopsies. PATIENTS AND METHODS: Between July 2004 and November 2005, patients with at least one previous negative prostate biopsy within the previous 12 months had MRI-guided biopsy of the prostate in a 3-T MRI scanner. Patients with previous positive biopsies for cancer were excluded. Target selection was based on T2-weighted imaging and dynamic contrast-enhanced (DCE) imaging studies. RESULTS: Thirteen patients were eligible; their median (range) age was 61 (47-74) years and PSA value 4.90 (1.3-12.3) ng/mL. Most patients had one previous negative biopsy (range 1-4). Four patients had a family history of prostate cancer. There were 37 distinct targets based on T2-weighted imaging. Fifteen of 16 distinct DCE abnormalities were co-localized with a target based on T2-weighted imaging. Despite this correlation, only one of 13 patients had a directed biopsy positive for cancer. Including systematic biopsies, two of 13 patients had a biopsy positive for prostate cancer. One patient had prostate intraepithelial neoplasia and one had atypical glands in the specimen. CONCLUSION: The prostate-cancer yield of transrectal biopsies in a 3-T MRI scanner, among patients with recent negative TRUS-guided prostate biopsies, is similar to repeat systematic TRUS-guided biopsy. DCE correlates with T2-imaging but does not appear to improve prostate cancer yield in this population.

CT angiography findings of the left atrium and right ventricle in patients with massive pulmonary embolism.

OBJECTIVE: The purpose of this study was to show the imaging findings of the left atrium and right ventricle on CT angiography in patients with massive pulmonary embolism. CONCLUSION: Massive pulmonary embolism can cause abrupt acute pulmonary arterial hypertension, right ventricular dysfunction, and decrease in left ventricular preload. Patients with these findings on CT angiography can have a poorer prognosis than those without these imaging findings. Consequently, recognizing anatomic changes such as right ventricular dilation or septal bowing, decrease in size of left atrium and pulmonary veins (a manifestation of decreased pulmonary venous return) would be useful for risk stratification at the time of massive pulmonary embolism.

Herniation of Packing Material into a Bronchopleural Fistula after Right Pneumonectomy and Clagett Window.

Diagnosis of a bronchopleural fistula (BPF) can be challenging in patients after pneumonectomy and Clagett window. Herein, we present a case of pneumonectomy for advanced lung cancer complicated by a BPF. Herniation of packing material from the open-chest cavity into the fistula and airways on computed tomography was an important clue to making the diagnosis.

Design and rationale of a randomized trial comparing standard versus ultrasound-assisted thrombolysis for submassive pulmonary embolism.

BACKGROUND: Catheter-directed interventions for the treatment of patients with submassive pulmonary embolism (sPE) have shown promise in rapidly improving right-sided heart strain and preventing decompensation to massive pulmonary embolism. Among various catheter interventions, ultrasound-assisted thrombolysis (USAT) has attracted interest as potentially having more efficient lytic effect that could achieve thrombolysis faster and with a reduced lytic dose. However, based on clinical evidence, it is unclear whether USAT is superior to standard catheter-directed thrombolysis (SCDT). We herein describe the study design of the Standard vs UltrasouNd-assiSted CathEter Thrombolysis for Submassive Pulmonary Embolism (SUNSET sPE) trial, an ongoing randomized clinical trial designed to address this question. METHODS: Adults with sPE presenting or referred to our institution are considered for enrollment in the trial. At the discretion of the treatment team, all patients undergo a catheter-directed intervention plus concomitant therapeutic anticoagulation. Participants are randomized 1:1 to a USAT catheter or an SCDT catheter. Study assessors are blinded to treatment group. The primary outcome is clearance of pulmonary thrombus burden, assessed by postprocedure computed tomography angiography. Secondary outcomes include resolution of right ventricular strain by echocardiography; improvement in pulmonary artery pressures; and 3- and 12-month improvement in echocardiographic, functional capacity, and quality of life measures. The study is powered to detect a 50% improvement in pulmonary artery thrombus clearance. Our enrollment target is 40 patients per treatment arm. CONCLUSIONS: SUNSET sPE is an ongoing randomized, head-to-head, single-blinded clinical trial with the goal of assessing whether USAT results in superior thrombus clearance compared with SCDT in patients with sPE. We expect the results of our study to inform future guidelines on choice of thrombolysis modality in this population of challenging patients.

The biologic basis of in vivo angiogenesis imaging.

Knowledge of the different physiology and endothelial markers present in tumor vessels is essential to enable both the development of new anti-angiogenic chemotherapeutic agents and of more specific imaging techniques. Tumor blood vessels are disorganized, irregular in caliber, tortuous, and do not have specialized features of normal arterioles, capillaries or venules. Neo-angiogenic tumor vessels have large gaps between or through cells, loose pericytes, and discontinuities or redundant layers within the basement membrane, rendering these vessels hyper-permeable. Furthermore, the endothelia of tumor vessels may express unique markers on their surface. Imaging is becoming increasingly important in the evaluation of angiogenesis. Clinical imaging is minimally invasive and enables sampling of the whole tumor in a nondestructive manner. The patterns of increased permeability seen on Dynamic contrast-enhanced Magnetic Resonance Imaging (DCE-MRI) mirror the known ultrastructural defects associated with angiogenic vessels. Conventional low-molecular weight contrast agents are currently in clinical use for DCE-MRI studies and have proven successful in detecting changes related to novel angiogenic inhibitors. However, they are relatively non-specific. Macromolecular contrast media may be more suitable for imaging tumor vessels. It is hoped that imaging modalities can be adapted to specifically target markers expressed on the endothelium of tumor vessels. The number of cell surface markers of angiogenesis is relatively low, and only small amounts of contrast agents can bind to these receptors; currently only Positron Emission Tomography (PET) and Single Photon Emission Computed Tomography (SPECT) tracers have sufficient sensitivity to allow detection at this low level. Despite limitations in their spatial resolution, PET and SPECT imaging are more likely to enter the clinic as targeted angiogenesis imaging methods. The quest for selective targets on the tumor vasculature continues, currently the integrin family of receptors offer the most promise but other targets are being pursued by investigators. Serial analysis of gene expression or in vivo phage display may help identify new, more selective, markers that can be utilized for the targeted imaging and treatment of angiogenesis.

Dynamic contrast-enhanced MRI of prostate cancer at 3 T: a study of pharmacokinetic parameters.

OBJECTIVE: The objectives of our study were to determine whether dynamic contrast-enhanced MRI performed at 3 T and analyzed using a pharmacokinetic model improves the diagnostic performance of MRI for the detection of prostate cancer compared with conventional T2-weighted imaging, and to determine which pharmacokinetic parameters are useful in diagnosing prostate cancer. SUBJECTS AND METHODS: This prospective study included 50 consecutive patients with biopsy-proven prostate cancer who underwent imaging of the prostate on a 3-T scanner with a combination of a sensitivity-encoding (SENSE) cardiac coil and an endorectal coil. Scans were obtained at least 5 weeks after biopsy. T2-weighted turbo spin-echo images were obtained in three planes, and dynamic contrast-enhanced images were acquired during a single-dose bolus injection of gadopentetate dimeglumine (0.1 mmol/kg). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were estimated for T2-weighted and dynamic contrast-enhanced MRI. The following pharmacokinetic modeling parameters were determined and compared for cancer, inflammation, and healthy peripheral zone: K(trans) (forward volume transfer constant), k(ep) (reverse reflux rate constant between extracellular space and plasma), v(e) (the fractional volume of extracellular space per unit volume of tissue), and the area under the gadolinium concentration curve (AUGC) in the first 90 seconds after injection. RESULTS: Pathologically confirmed cancers in the peripheral zone of the prostate were characterized by their low signal intensity on T2-weighted scans and by their early enhancement, early washout, or both on dynamic contrast-enhanced MR images. The overall sensitivity, specificity, PPV, and NPV of T2-weighted imaging were 94%, 37%, 50%, and 89%, respectively. The sensitivity, specificity, PPV, and NPV of dynamic contrast-enhanced MRI were 73%, 88%, 75%, and 75%, respectively. K(trans), k(ep), and AUGC were significantly higher (p < 0.001) in cancer than in normal peripheral zone. The ve parameter was not significantly associated with prostate cancer. CONCLUSION: MRI of the prostate performed at 3 T using an endorectal coil produces high-quality T2-weighted images; however, specificity for prostate cancer is improved by also performing dynamic contrast-enhanced MRI and using pharmacokinetic parameters, particularly K(trans) and k(ep), for analysis. These results are comparable to published results at 1.5 T.

Delayed recurrence of ulcerative colitis manifested by tracheobronchitis, bronchiolitis, and bronchiolectasis.

Ulcerative colitis can cause inflammation of small and large airways, characterized by mucosal inflammation, tracheobronchial stenosis, bronchiestasis, and bronchiolitis. We present a case of tracheobronchitis and bronchiolitis associated with ulcerative colitis in a 58-year-old nonsmoking man, 17 years after the total colectomy and complete resolution of intestinal findings. Computed tomography demonstrated wall thickening of trachea and left main stem bronchus, and multiple bronchi around the both hilum with mild to moderate stenosis. Fiberoptic bronchial biopsy showed inflammation of the airways, similar to histologic findings of ulcerative colitis within colon.

[Pneumatosis intestinalis mimicking free intraabdominal air: a case report]. / Karin içinde serbest hava görünümü veren Pnömatozis intestinalis: Olgu sunumu.

A 47-year-old male patient had undergone endoscopic balloon dilatation six times due to pyloric stenosis however the result was not satisfying. Surgical treatment was considered. Chest X-ray revealed free sub-diaphragmatic air but there were no acute abdomen signs clinically. In abdominal computerized tomography, there were small intestinal loops anterior to the liver and there was gas collection, which can not be differentiated exactly between an extraluminal free air and the one in the bowel wall of adjacent small bowel segments. In the emergency surgery cysts filled with gas in the wall of distal ileal segments were seen. Pneumatosis intestinalis should be kept in mind in the differential diagnosis of free intraabdominal air.

Fractured Ribs and the CT Funky Fat Sign of Diaphragmatic Rupture.

Traumatic diaphragmatic rupture remains a diagnostic challenge for both radiologists and surgeons. In recent years, multidetector CT has markedly improved the diagnosis of diaphragmatic injury in polytrauma patients. Herein, we describe two cases of subacute presentation of traumatic diaphragmatic rupture from a penetrating rib fracture and subsequent intrathoracic herniation of omental fat, representing the CT "funky fat" sign.