Second primary malignancies in head and neck cancer patients: high prevalence of curable-stage disease.

BACKGROUND AND PURPOSE: Patients treated for squamous cell carcinoma of the head and neck (HNSCC) carry a high risk of second primary malignancies (SPM). Recently, computed tomography (CT) of the chest was shown to significantly decrease the risk of death due to bronchial carcinoma (BC) in a cohort of smokers whose risk of BC is increased but might be lower than that of patients previously treated for HNSCC. Thus, the present study evaluated the potential benefit of CT and other examinations in the detection of SPM in HNSCC patients. PATIENTS AND METHODS: Between July 2008 and November 2011, 118 participants underwent a prospective, systematic examination for SPM (13 women, 105 men, median age 62 years). All patients had been previously treated for HNSCC and showed no recurrence or distant metastases at the time of the study start. CT scans, ear-nose-throat endoscopy, and endoscopy of the esophagus and stomach were performed. RESULTS: Overall, 33 suspicious findings were clarified by additional investigations. In all, 26 SPM were confirmed in 21 of 118 patients (18%; 10 lung, 7 HNSCC, 3 gastrointestinal, 1 renal). Eighteen of these 21 patients (86%) underwent therapy with curative intent. CONCLUSION: The examinations revealed a high prevalence of curable stage SPM in HNSCC patients. Adapting a surveillance scheme including a chest CT is recommended.

Does computer-assisted detection of pulmonary emboli enhance severity assessment and risk stratification in acute pulmonary embolism?

AIM: To prospectively assess the value of computer-aided detection (CAD) for the computed tomography (CT) severity assessment of acute pulmonary embolism (PE). MATERIALS AND METHODS: CT angiographic scans of 58 PE-positive patients (34-89 years, mean 66 years) were analysed by four observers for PE severity using the Mastora index, and by CAD. Patients were stratified to three PE risk groups and results compared to an independent reference standard. Interobserver agreement was tested by Bland and Altman and extended kappa (Ke) statistics. Mastora index changes after CAD data review were tested by Wilcoxon signed ranks. RESULTS: CAD detected 343 out of 1118 emboli within given arterial segments and a total of 155 out of 218 polysegmental emboli (segmental vessel-based sensitivity = 30.7%, embolus-based sensitivity = 71.2% false-positive rate = 4.1/scan). Interobserver agreement on PE severity [95% limits of agreement (LOA) = -19.7-7.5% and-5.5-3% for reader pairs 1 versus 2 and 3 versus 4, respectively was enhanced by consensus with CAD data (LOA = -6.5-5.4% and-3.7-2% for reader pairs 1 versus 2 and 3 versus 4, respectively). Simultaneously, the percentual scoring errors (PSE) were significantly decreased (PSE = 35.4+/-31.8% and 5.1+/-8.9% for readers 1/2 and 2/3, respectively, and PSE=27.6 +/- 31% and 3.8 +/- 6.2%, respectively, after CAD consensus; p < or = 0.005). Misclassifications to PE risk groups occurred in 27.6, 24.1, 5.2, and 5.2% of patients for readers 1-4, respectively, (Ke=0.74) and were corrected by CAD consensus in 56.3, 36, 33.3, and 33.3% of misclassified patients, respectively (Ke = 0.83; p < 0.05). CONCLUSION: Radiologists may benefit from consensus with CAD data that improve PE severity scores and stratification to PE risk groups.

[Radiotherapy : an option for refractory salivary fistulas]. / Radiatio : Therapieoption bei therapierefraktärer Speichelfistel.

A 45-year-old patient presented with refractory salivary fistula, attributed to multiple surgery and Botulinum toxin, following lateral parotidectomy. He underwent fractionated radiotherapy of the remaining parotid gland including the fistula opening (total dose of 30 Gy) at our clinic. In time, fistula secretion could be inhibited completely. Although the indication for radiotherapy for such fistulas is rare since Botulinum toxin has been in use, it should still be considered in refractory disease courses.

Comparison of flat-panel-detector-based CT and multidetector-row CT in automated volumetry of pulmonary nodules using an anthropomorphic chest phantom.

This study evaluates the accuracy and reproducibility of an experimental flat-panel-detector-based CT scanner (fp-CT) in comparison with those of a 64-slice multidetector row CT (MDCT) in automated pulmonary nodule volumetry. An anthropomorphic chest phantom with 31 spherical nodules (nodule diameters of 2.94-10.01 mm; volumes of 13.24-524.97 mm(3)) was scanned both with an amorphous silicon-based fp-CT scanner, using various tube current and kilovoltage settings, and with a conventional MDCT scanner. Automated nodule volumetry was performed using dedicated software. CT image data were evaluated twice by two independent radiologists. Intra- and inter-observer variations of volumetric measurements were determined and tested using the Kruskal-Wallis test and analysis of variance (fn-ANOVA). The percentage measurement errors (PME) were calculated and differences tested using Wilcoxon signed ranks and Friedman tests. Intraobserver variation was significantly higher for MDCT than for fp-CT (range: p = 0.043-0.045). The measured nodule volumes were significantly greater on fp-CT than on MDCT scans (p<0.001). The PME was significantly greater in fp-CT than in MDCT scans (PME range, 12.35-13.35% for fp-CT scan protocols and 16.87-19.02% for MDCT scan protocols; p<0.0001). The PME increased significantly with reduction of nodule size, and this increase was significantly higher on MDCT than on fp-CT scans (p = 0.0001). The absolute PME was significantly different for nodules of less than 5 mm in diameter (p = 0.0001-0.0033) than for larger nodules. Flat-panel-detector-based CT has advantages over MDCT in accurately determining the volume of pulmonary nodules below 5 mm in diameter.

Computer-assisted quantification of interstitial lung disease associated with rheumatoid arthritis: preliminary technical validation.

PURPOSE: To validate a threshold-based prototype software application (MeVis PULMO 3D) for quantification of chronic interstitial lung disease (ILD) in patients with rheumatoid arthritis (RA) using variable threshold settings for segmentation of diseased lung areas. METHODS: Twenty-two patients with rheumatoid arthritis were included and underwent thin-section CT (4x1.25mm collimation). CT scans were assessed by two observers for extent of ILD (EoILD), and twice by MeVis PULMO 3D for each protocol. MeVis PULMO 3D used four segmentation threshold (ST) settings (ST=-740, -780, -800 and -840HU). Pulmonary function tests were obtained in all patients. Statistical evaluation used 95% limits of agreement (LoA) and linear regression analysis. RESULTS: There was total concordance between the software measurements. Interobserver agreement was good (LoA=-28.36 to 17.58%). EoILD by readers correlated strongly with DL(CO) (r=-0.702, p<0.0001) and moderately with FVC (r=-0.523, p=0.018). There was close correlation between readers and MeVis PULMO 3D with best results for ST <780HU (EoILD vs. MeVis PULMO 3D: r=0.650 for ST=-800 and -840HU, respectively; p=0.002). MeVis PULMO 3D correlated best with DL(CO) at ST of -800HU (r=-0.44, -0.49, -0.58 and -0.57 for ST=-740, -780, -800 and -840, respectively; p=0.007-0.05) and moderately with FVC (r=-0.44, -0.51, -0.59 and -0.45 for ST=-740, -780, -800 and -840), respectively; p=0.007-0.05). CONCLUSION: The MeVis PULMO 3D system used holds promise to become a valuable instrument for quantification of chronic ILD in patients with RA when using the threshold value of -800HU, with evidence of the closest correlations, both with human observers and physiologic impairment.

Interstitial lung disease associated with collagen vascular disorders: disease quantification using a computer-aided diagnosis tool.

The purpose of this study was to evaluate a computer-aided diagnosis (CAD) tool compared to human observers in quantification of interstitial lung disease (ILD) in patients with collagen-vascular disorders. A total of 52 patients with rheumatoid arthritis (n=24), scleroderma (n=14) and systemic lupus erythematosus (n=14) underwent thin-section CT. Two independent observers assessed the extent of ILD (EoILD), reticulation (EoRet) and ground-glass opacity (EoGGO). CAD assessed EoILD twice. Pulmonary function tests were obtained. Statistical evaluation used 95% limits of agreement and linear regression analysis. CAD correlated well with diffusing capacity (DL(CO)) (R= -0.531, P<0.0001) and moderately with forced vital capacity (FVC) (R= -0.483, P=0.0008). There was close correlation between CAD and the readers (EoILD vs. CAD: R=0.716, P<0.0001; EoRet vs. CAD: R=0.69, P<0.0001). Subgroup analysis including patients with minimal EoGGO (<15%) strengthened the correlations between CAD and the readers, readers and PFT, and CAD and PFT. EoILD by readers correlated strongly with DL(CO) (R= -0.705, P<0.0001) and moderately with FVC (R= -0.559, P=0.0002). EoRet correlated closely with DL(CO) and moderately with FVC (DL(CO): R= -0.663; FVC: R = -0.436; P

[Multidetector-row CT in severe pulmonary embolism: radiologists' help in risk stratification]. / Multislice-CT bei akuter Lungenembolie: Beitrag des Radiologen zur Prognoseabschätzung.

Multidetector-row computed tomographic (CT) angiography of pulmonary arteries is the first-line imaging technique in patients suspected of having pulmonary embolism (PE). Patient risk stratification is important because optimal management, monitoring, and therapeutic strategies depend on the patient's prognosis. Acute right-sided heart failure is known to be responsible for circulatory collapse and death in patients with severe PE. Acute right-sided heart failure can be assessed on CT pulmonary angiography by measuring the dimensions of the right-sided heart cavities or systemic veins. The magnitude of PE can be calculated on CT pulmonary angiography by applying dedicated CT scores or angiographic scores adapted. This article reviews and discusses the various CT-based methods for risk stratification of patients with acute PE.

[Acute pulmonary embolism: prediction of cor pulmonale and short-term patient survival from assessment of cardiac dimensions in routine multidetector-row CT]. / Mehrschicht-Spiral-CT bei vermuteter und inzidenteller akuter Lungenembolie: prognostischer Wert morphologischer Herzparameter.

PURPOSE: Evaluation of the prognostic value of morphological cardiac parameters in patients with suspected and incidental acute pulmonary embolism (PE) using multidetector-row chest CT (MSCT). MATERIALS AND METHODS: 2335 consecutive MSCT scans were evaluated for the presence of PE. The arterial enhancement and analysability of pulmonary arteries and the heart were assessed as parameters of the scan quality. The diastolic right and left ventricular short axes (RV (D), LV (D)) and the interventricular septal deviation (ISD) were measured in all PE-positive patients and the echocardiography reports were reviewed. The clinical data assessment included cardio-respiratory and other co-morbidities, systemic anticoagulant therapy (ACT), and the 30-day outcome. Predictors of acute cor pulmonale and the short-term outcome were calculated by univariate and multivariate logistic regressions including odds ratios (OR) and ROC analyses using positive (PPV) and negative predictive values (NPV). RESULTS: 90 patients with acute PE were included (36 with clinically suspected PE, 54 with incidental PE). 26 patients had cardio-respiratory co-morbidities. Four patients underwent systemic thrombolysis, 43 underwent anticoagulation in therapeutic doses, 19 underwent anticoagulation in prophylactic doses, and 24 patients did not undergo ACT. 15 of 41 patients had echocardiographic evidence of acute cor pulmonale. 8 patients died within 30 days. The RV (D) was the best independent predictor of acute cor pulmonale (p = 0,002, OR = 9.16, PPV = 0.68, NPV = 1 at 4.49 cm cut off) and short-term outcome (p = 0,0005, OR = 2.82, PPV = 0.23, NPV = 0.98 at 4.75 cm cut off). The RV (D)/LV (D) ratio had a PPV of 0.85 for cor pulmonale. CONCLUSION: The RV (D) and RV (D)/LV (D) ratio were suitable for identifying patients with acute cor pulmonale and for benign short-term prognosis. Further studies should prospectively address the combined use of CT-morphological and clinical parameters for the prediction of patient outcome.

Suspected and incidental pulmonary embolism on multidetector-row CT: analysis of technical and morphological factors influencing the diagnosis in a cross-sectional cancer centre patient cohort.

AIM: To assess technical and computed tomography (CT) predictors of true-positive (TP) and false-negative (FN) radiological diagnoses in a retrospective patient cohort with pulmonary embolism (PE) in the setting of a cancer centre. MATERIALS AND METHODS: Two thousand, four hundred and twelve consecutive chest multidetector-row CT images from 1869 patients were reviewed for presence of PE. CT protocols and TP and FN radiological reports were determined and the clinical files reviewed for suspicion of PE. The severity of PE was assessed by an arterial obstruction index. Ancillary pulmonary findings were scored qualitatively and on a lobar basis. Statistical tests included analysis of variance and univariate and multivariate logistic regressions. RESULTS: Ninety-one out of a total of 111 PE-positive images were included. Thirty-five patients had clinically suspected PE; 56 were not suspected of having PE. Forty-eight patients had TP diagnoses; 43 (39 of whom were not suspected of having PE) had FN radiological diagnoses. FN diagnoses were most frequent in oesophageal (17/19; 89.5%) and standard chest CT (19/35; 54.3%). Pulmonary CT angiography was associated with TP diagnosis (p<0.0001), whereas oesophageal CT was associated with FN diagnosis (p=0.001). Artefacts and arterial attenuation did not influence PE detection (p=0.017 and 0.066 for artefacts and arterial attenuation, respectively). However, the arterial obstruction index strongly predicted PE diagnosis (p=0.001). This was confirmed on multivariate analysis (p=0.041, 0.027 and 0.020 for pulmonary CT angiography, oesophageal protocols and arterial obstruction index, respectively). When stratified for clinically unsuspected cases, the arterial obstruction index remained the only predictor of PE diagnosis (p=0.009). CONCLUSION: Predictors of PE diagnosis were PE severity and technical factors; the latter were linked to clinical suspicion of PE. Arterial enhancement appears unlikely to contribute to missed diagnoses, if judged adequate for diagnosis of PE, and ancillary chest findings are unlikely to improve embolus detection.

Case report: Fatal acute exacerbation of usual interstitial pneumonia in ulcerative colitis.

Pulmonary involvement in ulcerative colitis may manifest as a variety of disorders. Ulcerative colitis-related interstitial lung disease is exceedingly rare and has been reported to be steroid-responsive. We describe the first case of a patient with acute exacerbation of ulcerative colitis-induced usual interstitial pneumonia, who did not respond to corticosteroid therapy and died 12 weeks after the onset of pulmonary symptoms. Early recognition of pulmonary disease in patients with ulcerative colitis is necessary to initiate further diagnostic work-up and may aid treatment decisions.

[Computer-aided diagnosis and volumetry of pulmonary nodules: current concepts and future perspectives]. / Computerassistierter Nachweis und automatisierte Volumetrie pulmonaler Rundherde in der Multislice-CT: Aktueller Stand und Perspektiven.

For computer-aided detection (CAD) and volumetry of small pulmonary nodules, a number of algorithms have been developed for multislice CT data sets in recent years, with the goal of improving the diagnostic work-up and the follow-up of findings. Recent data show that the detection of small lesions may improve with CAD, suggesting that especially experienced readers may benefit from using CAD systems. This has lead to the recommendation of CAD as a replacement of the second reader in clinical practice. Furthermore, computer-aided volumetry of pulmonary nodules allows a precise determination of nodular growth rates as a prerequisite for a better classification of nodules as benign or malignant. In this article, we review recent developments of CAD and volumetry tools for pulmonary nodules, and address open questions regarding the use of these software tools in clinical routine.

Computer-aided detection of pulmonary nodules: influence of nodule characteristics on detection performance.

AIM: To evaluate prospectively the influence of pulmonary nodule characteristics on detection performances of a computer-aided diagnosis (CAD) tool and experienced chest radiologists using multislice CT (MSCT). MATERIALS AND METHODS: MSCT scans of 20 consecutive patients were evaluated by a CAD system and two independent chest radiologists for presence of pulmonary nodules. Nodule size, position, margin, matrix characteristics, vascular and pleural attachments and reader confidence were recorded and data compared with an independent standard of reference. Statistical analysis for predictors influencing nodule detection or reader performance included chi-squared, retrograde stepwise conditional logistic regression with odds ratios and nodule detection proportion estimates (DPE), and ROC analysis. RESULTS: For 135 nodules, detection rates for CAD and readers were 76.3, 52.6 and 52.6%, respectively; false-positive rates were 0.55, 0.25 and 0.15 per examination, respectively. In consensus with CAD the reader detection rate increased to 93.3%, and the false-positive rate dropped to 0.1/scan. DPEs for nodules < or = 5 mm were significantly higher for ICAD than for the readers (p < 0.05). Absence of vascular attachment was the only significant predictor of nodule detection by CAD (p = 0.0006-0.008). There were no predictors of nodule detection for reader consensus with CAD. In contrast, vascular attachment predicted nodule detection by the readers (p = 0.0001-0.003). Reader sensitivity was higher for nodules with vascular attachment than for unattached nodules (sensitivities 0.768 and 0.369; 95% confidence intervals = 0.651-0.861 and 0.253-0.498, respectively). CONCLUSION: CAD increases nodule detection rates, decreases false-positive rates and compensates for deficient reader performance in detection of smallest lesions and of nodules without vascular attachment.

Electrocardiographic assistance in multidetector CT of thoracic disorders.

ECG-synchronized multislice spiral CT (MSCT) allows a significant reduction of cardiac motion artefacts and as a result a virtually artefact-free display of intrathoracic structures. With their advantages in imaging geometry and continuous spiral image acquisition multislice CT scanners provide superior image quality and spatial resolution in these patients. Possible clinical applications for ECG assistance in MSCT include CT angiography of the coronary arteries, functional cardiac CT imaging and imaging of the cardiac valves, CT angiography of the aorta or pulmonary vascular tree as well as ECG-gated imaging of the lung parenchyma. Prospective ECG triggering and retrospectively ECG-gated image reconstruction comprise the technical corsage for reduction of pulsation artefacts in cardiac and other thoracic CT applications. In addition the development of time-optimised reconstruction algorithms for retrospective cardiac gating in 8- and 16 slice spiral CT scanners have enabled further improvements in temporal resolution. This overview describes the technique, its clinical indications and the merits of electrocardiographic assistance in MSCT of chest disorders.

The CT halo: a new sign in active pulmonary sarcoidosis.

A case of pulmonary sarcoidosis is presented characterized by multiple coalescent nodules and peripheral ground glass halos, which were fully reversible under repeat systemic glucocorticoid treatment. The differential diagnostic aspects of the pulmonary CT halo sign and its potential for indicating active reversible disease in patients with sarcoidosis is discussed.

Pulmonary haemangiosarcoma with main pulmonary artery thrombosis imitating subacute pulmonary embolism with infarction.

We report a patient with subacute pulmonary hypertension caused by unilateral massive pulmonary artery thrombosis due to a pulmonary haemangiosarcoma of the lower lobe with pulmonary arterial and bronchial invasion. The patient was misdiagnosed as having subacute pulmonary embolism and underwent thrombolytic therapy complicated by severe pulmonary haemorrhage. The imaging features of pulmonary artery thrombosis with underlying malignancy and their differential diagnosis are discussed.