Case 287: Intrathoracic Migration of a Breast Implant after Video-assisted Thoracoscopic Surgery for Right Upper Lobectomy.

History A 60-year-old woman was diagnosed with a new right upper lobe stage I lung adenocarcinoma and underwent video-assisted thoracoscopic surgery (VATS) for right upper lobectomy. Her postoperative course was complicated by a large pneumothorax after chest tube removal on postoperative day 3. This was managed with repeat right-sided chest tube placement on the same day. The second chest tube was removed on postoperative day 8 without complications. A 2-week postoperative clinic visit was unremarkable. Postoperative chest radiographs on postoperative days 1, 3, and 8 are provided. Subsequently, chest CT scanning was performed as part of routine 6-month postsurgical lung cancer surveillance follow-up. The patient had no clinical complaints at routine follow-up. Physical examination revealed well-healed VATS scars in the chest wall. Laboratory results were within normal limits, including a normal white blood cell count of 6400/mL. Her surgical history included prior left upper lobectomy for remote left upper lobe stage IIIA adenocarcinoma and prior bilateral breast implantation for cosmesis. On the basis of chest CT findings, the patient was transferred from an outside institution.

Comparison of Baseline, Bone-Subtracted, and Enhanced Chest Radiographs for Detection of Pneumothorax.

PURPOSE: To assess and compare detectability of pneumothorax on unprocessed baseline, single-energy, bone-subtracted, and enhanced frontal chest radiographs (chest X-ray, CXR). METHOD AND MATERIALS: Our retrospective institutional review board-approved study included 202 patients (mean age 53 ± 24 years; 132 men, 70 women) who underwent frontal CXR and had trace, moderate, large, or tension pneumothorax. All patients (except those with tension pneumothorax) had concurrent chest computed tomography (CT). Two radiologists reviewed the CXR and chest CT for pneumothorax on baseline CXR (ground truth). All baseline CXR were processed to generate bone-subtracted and enhanced images (ClearRead X-ray). Four radiologists (R1-R4) assessed the baseline, bone-subtracted, and enhanced images and recorded the presence of pneumothorax (side, size, and confidence for detection) for each image type. Area under the curve (AUC) was calculated with receiver operating characteristic analyses to determine the accuracy of pneumothorax detection. RESULTS: Bone-subtracted images (AUC: 0.89-0.97) had the lowest accuracy for detection of pneumothorax compared to the baseline (AUC: 0.94-0.97) and enhanced (AUC: 0.96-0.99) radiographs (P < .01). Most false-positive and false-negative pneumothoraces were detected on the bone-subtracted images and the least numbers on the enhanced radiographs. Highest detection rates and confidence were noted for the enhanced images (empiric AUC for R1-R4 0.96-0.99). CONCLUSION: Enhanced CXRs are superior to bone-subtracted and unprocessed radiographs for detection of pneumothorax. CLINICAL RELEVANCE/APPLICATION: Enhanced CXRs improve detection of pneumothorax over unprocessed images; bone-subtracted images must be cautiously reviewed to avoid false negatives.

Case 287.

History A 60-year-old woman was diagnosed with a new right upper lobe stage I lung adenocarcinoma and underwent video-assisted thoracoscopic surgery (VATS) for right upper lobectomy. Her postoperative course was complicated by a large pneumothorax after chest tube removal on postoperative day 3. This was managed with repeat right-sided chest tube placement on the same day. The second chest tube was removed on postoperative day 8 without complications. A 2-week postoperative clinic visit was unremarkable. Postoperative chest radiographs on postoperative days 1, 3, and 8 (Fig 1a-1c) are provided. Subsequently, chest CT scanning was performed as part of routine 6-month postsurgical lung cancer surveillance follow-up (Figs 2, 3). The patient had no clinical complaints at routine follow-up. Physical examination revealed well-healed VATS scars in the chest wall. Laboratory results were within normal limits, including a normal white blood cell count of 6400/µL. Her surgical history included prior left upper lobectomy for remote left upper lobe stage IIIA adenocarcinoma and prior bilateral breast implantation for cosmesis. On the basis of chest CT findings, the patient was transferred from an outside institution.

Stereotactic Body Radiation Therapy for Early-Stage Non-Small Cell Lung Cancer: A Primer for Radiologists.

The past 2 decades have seen a rapid growth in use of stereotactic body radiation therapy (SBRT) for the management of non-small cell lung cancer (NSCLC). Not only is SBRT the reference standard for treatment of early-stage node-negative NSCLC in medically inoperable patients, it is also currently challenging the role of surgery for early-stage operable disease. SBRT is also used to treat recurrent disease and has a role in the management of multiple synchronous lung cancers. Imaging changes after SBRT differ from the changes after conventional radiation therapy in many ways, the knowledge of which is pertinent for accurate image interpretation. Posttreatment response assessment and detection of recurrent disease are heavily reliant on radiologic assessment, and often the decision to treat recurrent disease is based on the imaging findings themselves. This article provides a comprehensive review of the concepts of SBRT and the current indications for its use in the treatment of early-stage NSCLC, as well as a discussion of the CT findings seen after SBRT compared with the changes after conventional radiation therapy. Radiologic findings that are suggestive of recurrent disease and the imaging pitfalls are also highlighted. Finally, the rare complications after SBRT are described. SBRT is a major component of the changing treatment paradigms for early- and late-stage NSCLC. The imaging findings after SBRT often determine the next steps in a patient's clinical management. Therefore, radiologists must be familiar with the uses of this therapy and its radiologic appearance to be able to effectively contribute to the care of patients with NSCLC. ©RSNA, 2018.

Congenital heart disease in adults: Quantitative and qualitative evaluation of IR FLASH and IR SSFP MRA techniques using a blood pool contrast agent in the steady state and comparison to first pass MRA.

OBJECTIVES: To evaluate magnetic resonance angiography sequences during the contrast steady-state (SS-MRA) using inversion recovery (IR) with fast low-angle shot (IR-FLASH) or steady-state free precession (IR-SSFP) read-outs, following the injection of a blood-pool contrast agent, and compare them to first-pass MR angiography (FP-MRA) in adults with congenital heart disease (CHD). MATERIALS AND METHODS: Twenty-three adult patients with CHD who underwent both SS-MRA and FP-MRA using a 1.5-T scanner were retrospectively identified. Signal-to-noise and contrast-to-noise ratios were obtained at eight locations within the aorta and pulmonary vessels.. Image quality and the presence of artifacts were subjectively assessed by two radiologists. The presence of pathology was noted and given a confidence score. RESULTS: There was no difference in vessel dimensions among the sequences. IR-SSFP showed better image quality and fewer artifacts than IR-FLASH and FP-MRA. Confidence scores were significantly higher for SS-MRA compared to FP-MRA. Seven cases (30.4%) had findings detected at SS-MRA that were not detected at FP-MRA, and 2 cases (8.7%) had findings detected by IR-SSFP only. CONCLUSION: SS-MRA of the thoracic vasculature using a blood pool contrast agent offers superior image quality and reveals more abnormalities compared to standard FP-MRA in adults with CHD, and it is best achieved with an IR-SSFP sequence. These sequences could lead to increased detection rates of abnormalities and provide a simpler protocol image acquisition.

Dynamic analysis of BMP-responsive smad activity in live zebrafish embryos.

Bone morphogenetic proteins (BMPs) are critical players in development and disease, regulating such diverse processes as dorsoventral patterning, palate formation, and ossification. These ligands are classically considered to signal via BMP receptor-specific Smad proteins 1, 5, and 8. To determine the spatiotemporal pattern of Smad1/5/8 activity and thus canonical BMP signaling in the developing zebrafish embryo, we generated a transgenic line expressing EGFP under the control of a BMP-responsive element. EGFP is expressed in many established BMP signaling domains and is responsive to alterations in BMP type I receptor activity and smad1 and smad5 expression. This transgenic Smad1/5/8 reporter line will be useful for determining ligand and receptor requirements for specific domains of BMP activity, as well as for genetic and pharmacological screens aimed at identifying enhancers or suppressors of canonical BMP signaling.