Frequency and Severity of Pulmonary Hemorrhage in Patients Undergoing Percutaneous CT-guided Transthoracic Lung Biopsy: Single-Institution Experience of 1175 Cases.

PURPOSE: To evaluate the frequency and severity of pulmonary hemorrhage after transthoracic needle lung biopsy (TTLB) and assess possible factors associated with pulmonary hemorrhage. MATERIALS AND METHODS: This retrospective study was approved by the institutional review board. The requirement to obtain informed consent was waived. Records from 1113 patients who underwent 1175 TTLBs between January 2008 and April 2013 were retrospectively reviewed. Primary outcomes were pulmonary hemorrhage, documented hemoptysis, and bleeding complications necessitating intervention. Pulmonary hemorrhage was graded as follows: 0, none; 1, less than or equal to 2 cm around the needle; 2, more than 2 cm and sublobar; 3, at least lobar; and 4, hemothorax. Patient, technique, and lesion-related variables were evaluated as predictors of pulmonary hemorrhage. Patient-related variables included main pulmonary artery diameter (mPAD) at computed tomography (CT), pulmonary artery pressures at echocardiography and right-sided heart catheterization, medications, chronic lung disease, bleeding diathesis, and immunodeficiency. Technique- and lesion-related variables included needle gauge, number of passes, pleura-needle angle, lesion size and morphologic characteristics, and distance to pleura. Univariate analysis was performed with χ(2), Fisher exact, and Student t tests. RESULTS: Pulmonary hemorrhage occurred in 483 of the 1175 TTLBs (41.1%); hemoptysis was documented in 21 of the 1175 TTLBs (1.8%). Higher-grade hemorrhage (grade 2 or higher) occurred in 201 of the 1175 TTLBs (17.1%); five of the 1175 TTLBs (0.4%) necessitated hemorrhage-related admission. Higher-grade hemorrhage was more likely to occur with female sex (P = .001), older age (P = .003), emphysema (P = .004), coaxial technique (P = .025), nonsubpleural location (P < .001), lesion size of 3 cm or smaller (P < .001), and subsolid lesions (P = .028). Enlarged mPAD at CT (≥2.95 cm) was not significantly associated with higher-grade hemorrhage (P = .430). CONCLUSION: Pulmonary hemorrhage after TTLB is common but rarely requires intervention. An enlarged mPAD at CT may not be a risk factor for higher-grade hemorrhage.

Hypervascular mediastinal masses: action points for radiologists.

Hypervascular mediastinal masses are a distinct group of rare diseases that include a subset of benign and malignant entities. Characteristic features and known association with syndromes and genetic mutations assist in achieving a diagnosis. Imaging allows an understanding of the vascularity of the lesion and should alert the radiologist and clinician to potential hemorrhagic complications and avoid percutaneous CT guided biopsies. In such cases, pre-procedure embolization and surgical biopsy maybe considered for better control of post procedure hemorrhage. The purpose of this article is to describe and illustrate the clinical features and radiologic spectrum of hypervascular mediastinal masses, and discuss the associated clinical and genetic syndromes. We will present an imaging algorithm to determine further evaluation and subsequently guide treatment.

Congenital lung disease in the adult: guide to the evaluation and management.

A high index of suspicion is required to consider the diagnosis of adult congenital lung disease because of the rarity of presentation in adulthood. The purpose of this article is to provide a framework for evaluation of these lesions and a guide to management. Adults may be asymptomatic, and the abnormality identified as an incidental imaging finding or the individual may present with symptoms of cough, hemoptysis, or recurrent pneumonia. The diagnosis may be readily apparent on computed tomography imaging because of a characteristic appearance, or the abnormality may require further evaluation for diagnosis with supplemental magnetic resonance imaging. Surgical resection provides a definitive diagnosis. The congenital lung malformation may be a solitary lesion or part of a complex group of abnormalities. A detailed review of all the components of the thorax is required to identify additional lesions. Management is typically surgical resection because of the propensity of these lesions to enlarge and to become infected as well as the potential risk for malignant transformation. Computed tomography surveillance may be appropriate for small asymptomatic lesions or lesions with either no or very low risk for developing malignancy.

Cystic lung disease: achieving a radiologic diagnosis.

Diffuse cystic lung disease represents a diverse group of uncommon disorders with characteristic appearance on high resolution CT imaging. The combination of imaging appearance with clinical features and genetic testing where appropriate permits a confident and accurate diagnosis in the majority of the diseases without recourse for open lung biopsy. The mechanism of cyst development disease is unclear but in some disorders appears to be related to small airways obstruction. These diseases are incurable, with the exception of Langerhans cell histiocytosis which may spontaneously remit or resolve on smoking cessation. Disease progression is unpredictable; in general older patients have a more benign disease, while young patients may progress rapidly to respiratory failure. An understanding of the complications of cystic lung disease and the appearance of disease progression is essential for the management of these patients. A number of these disorders are associated with malignancy, recognition of the potential tumors permits appropriate imaging surveillance. Due to the widespread use of CT, pulmonary cysts are increasingly discovered incidentally in an asymptomatic individual. The diagnostic challenge is to determine whether these cysts represent an early feature of a progressive disease or have no clinical significance. In the elderly population the cysts are unlikely to represent a progressive disease. In individuals <50 years further evaluation is recommended.

The spectrum of Castleman's disease: mimics, radiologic pathologic correlation and role of imaging in patient management.

Castleman's disease (CD) is a rare benign lymphoid disorder with variable clinical course. The two principal histologic subtypes of CD are hyaline-vascular and plasma cell variants and the major clinicoradiological entities are unicentric and multicentric CD. Management of CD is tailored to clinicoradiologic subtype. In this review, we describe the CT, MR and PET/CT findings in Castleman's disease which can help suggest a diagnosis of CD as well as emphasize role of imaging in management of patients with CD.

Radiology of chest wall masses.

OBJECTIVE: The purpose of this article is to highlight the role of radiography, CT, PET/CT, and MRI in the diagnosis and management of chest wall lesions. Chest wall masses are caused by a spectrum of clinical entities. The lesions highlighted in this selection of case scenarios include neoplastic, inflammatory, and vascular lesions. CONCLUSION: Imaging evaluation with radiography, CT, MRI, and PET/CT plays an important role in the accurate diagnosis of chest wall lesions. It can also facilitate percutaneous biopsy, when it is indicated. Imaging enables accurate staging and is a key component of treatment planning for chest wall masses.

FDG PET/CT patterns of treatment failure of malignant pleural mesothelioma: relationship to histologic type, treatment algorithm, and survival.

PURPOSE: This study investigated the diagnostic performance and prognostic value of fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT in suspected malignant pleural mesothelioma (MPM) recurrence, in the context of patterns and intensity of FDG uptake, histologic type, and treatment algorithm. METHODS: Fifty patients with MPM underwent FDG PET/CT for restaging 11 ± 6 months after therapy. Tumor relapse was confirmed by histopathology, and by clinical evolution and subsequent imaging. Progression-free survival was defined as the time between treatment and the earliest clinical evidence of recurrence. Survival after FDG PET/CT was defined as the time between the scan and death or last follow-up. Overall survival was defined as the time between initial treatment and death or last follow-up date. RESULTS: Treatment failure was confirmed in 42 patients (30 epithelial and 12 non-epithelial MPM). Sensitivity, specificity, accuracy, negative predictive value, and positive predictive value for FDG PET/CT were 97.6, 75, 94, 86, and 95.3%, respectively. FDG PET/CT evidence of single site of recurrence was observed in the ipsilateral hemithorax in 18 patients (44%), contralaterally in 2 (5%), and in the abdomen in 1 patient (2%). Bilateral thoracic relapse was detected in three patients (7%). Simultaneous recurrence in the ipsilateral hemithorax and abdomen was observed in ten (24%) patients and in seven (17%) in all three cavities. Unsuspected distant metastases were detected in 11 patients (26%). Four patterns of uptake were observed in recurrent disease: focal, linear, mixed (focal/linear), and encasing, with a significant difference between the intensity of uptake in malignant lesions compared to benign post-therapeutic changes. Lesion uptake was lower in patients previously treated with more aggressive therapy and higher in intrathoracic lesions of patients with distant metastases. FDG PET/CT helped in the selection of 12 patients (29%) who benefited from additional previously unplanned treatment at the time of failure. Multivariate analysis showed that histologic type remained the only independent predictor of progression-free survival. Survival after relapse was independently predicted by the pattern of FDG uptake and PET nodal status, and overall survival by the maximum standard uptake value. CONCLUSION: FDG PET/CT is an accurate modality to diagnose and to estimate the extent of locoregional and distant MPM recurrence, and it carries independent prognostic value. Once the disease recurs, survival outcomes seem to be independent of histologic type and highly dependent on the intensity of lesion uptake and on the pattern of metabolically active disease in FDG PET/CT. Our observations should be considered limited to patients treated surgically with or without perioperative therapies and should not be extrapolated to those unresectable cases treated with chemotherapy alone.

Contrast opacification using a reduced volume of iodinated contrast material and low peak kilovoltage in pulmonary CT angiography: Objective and subjective evaluation.

OBJECTIVE: The purpose of our study was to evaluate whether a reduced volume of iodinated contrast material for pulmonary CT angiography (CTA) using a low peak kilovoltage (kVp) technique yields equivalent opacification in all vessels. MATERIALS AND METHODS: Four hundred fifty-two consecutive pulmonary CTA patients (265 women and 187 men; age range, 18-91 years; mean age, 56.2 years) were retrospectively evaluated. Patients were grouped into those receiving 125 mL (n = 229) and 75 mL (n = 223) of 370 mg I/mL iodinated contrast material. Low kVp was used in all patients. Hounsfield units were measured at lobar, posterobasal segment, posterobasal ramus, and medial basal subsegmental ramus in the left lower lobe. Three thoracic radiologists blinded to contrast dose independently and randomly evaluated the quality of enhancement using a 3-point scale at the same levels. The two-sample Student's t test was used to compare contrast opacification between groups; Spearman's correlation and the C-statistic were used to assess objective and subjective measurements. Interreader agreement was measured using Kendall's coefficient. RESULTS: Mean contrast opacification differences between 125 mL versus 75 mL were not statistically significant (p > 0.21) at the lobar, segmental, and posterior basal rami, although the mean trended (p = 0.07) toward higher opacification of the medial basal ramus among 75 mL patients. Across all four pulmonary artery segments, there was good concordance between subjective and objective measurements, significantly higher than the null value of 0.50 (p > 0.05). For subsegmental arteries, concordance between objective and subjective measures was greater for the 75 mL group (p < 0.05). There was good interreader concordance, with a concordance coefficient of 0.70 (95% CI, 0.66-0.74). CONCLUSION: Both objective and subjective measures of contrast opacification support a reduction from 125 to 75 mL of contrast medium required for pulmonary CTA.

Vascular enhancement and image quality of MDCT pulmonary angiography in 400 cases: comparison of standard and low kilovoltage settings.

OBJECTIVE: The purpose of this study was to investigate the vascular enhancement and image quality of pulmonary CT angiography performed with lower peak kilovoltage settings in a large patient sample. MATERIALS AND METHODS: This retrospective study was approved by our institutional review board, which waived the requirement for informed consent. Four hundred patients believed to have a pulmonary embolism were studied. All patients underwent 16- or 64-MDCT with automatic tube current modulation. The 200 patients in the standard peak kilovoltage group (mean age, 57 years; range, 22-95 years) underwent MDCT at 130 or 120 kVp. The 200 patients in the low peak kilovoltage group (mean age, 56 years; range, 21-92 years) underwent MDCT at 110 or 100 kVp. Vascular enhancement was evaluated by measurement of the attenuation value in the main pulmonary artery and segmental and subsegmental arteries. Image noise was quantified by measurement of the SD of the attenuation value in the main pulmonary artery. One blinded radiologist assessed image quality using visual scores. Wilcoxon's rank test was used to evaluate differences between the groups. RESULTS: Mean vascular enhancement in the main pulmonary artery had significantly higher attenuation values in the low peak kilovoltage group (376.1 +/- 102.9 HU) than in the standard peak kilovoltage group (309.2 +/- 94.8 HU) (p < 0.0001). Mean attenuation values in all measured segmental and subsegmental arteries were significantly higher in the low peak kilovoltage group than in the standard peak kilovoltage group (p < 0.0001). Image noise in the low peak kilovoltage group was significantly higher than in the standard peak kilovoltage group (p < 0.0001). There was no significant difference in the image quality scores of the two groups (p = 0.116). CONCLUSION: Lowering kilovoltage improved vascular enhancement without deterioration of image quality. The results of our study confirm previously reported preliminary findings.

MR imaging of benign and malignant pleural disease.

MR imaging serves as a problem-solving tool in the diagnosis of inflammatory and infectious pleural diseases and primary and secondary pleural malignancies. Knowledge of MR imaging appearance of pleural diseases, including pleural effusions and empyema, benign and malignant pleural tumors, and especially mesothelioma, helps guide treatment decisions and surgical planning.

Routine pelvic and lower extremity CT venography in patients undergoing pulmonary CT angiography.

OBJECTIVE: The purpose of our study was to assess the utility of performing routine pelvic and lower extremity CT venography (CTV) along with pulmonary CT angiography (CTA) in all patients evaluated for pulmonary embolism. MATERIALS AND METHODS: Eight hundred twenty-nine consecutive patients (281 men and 548 women) underwent CTA-CTV for pulmonary embolism. Reports were evaluated as follows: positive or negative for pulmonary embolism with or without deep venous thrombosis (DVT) or with nondiagnostic CTV. Coexisting factors of malignancy, previous venous thromboembolism (VTE), recent surgery, and cardiovascular disease comprised the high-risk group of 446 patients. The remaining 383 patients formed the low-risk group. Statistical analysis included four binary predictors (previous VTE, malignancy, cardiovascular disease, and surgery) and three binary outcome variables (pulmonary embolism, DVT, and VTE). Chi-square test and univariate and multivariate regression analyses were performed. RESULTS: VTE, pulmonary embolism, and DVT occurred in 152 (18.3%), 124 (15.0%), and 61 (7.3%) of 829 patients, respectively. Between the high-risk and low-risk groups, prevalence of VTE was 114 (25.6%) of 446 and 38 (9.9%) of 383 patients, respectively (p < 0.001); prevalence of pulmonary embolism was 92 (20.6%) of 446 and 32 (8.3%) of 383 patients, respectively (p < 0.001). Isolated DVT was found in 28 (3.4%) of 829 patients. The incremental value of CTV for the entire cohort was 3.4%, 0.72% in the low-risk group (six of 829) and 2.6% (22 of 829) in the high-risk group. For outcome variable VTE, malignancy and previous VTE were statistically significant (p = 0.04 and p < 0.001, respectively); for pulmonary embolism, malignancy and previous VTE were statistically significant (p = 0.03 and p = 0.005, respectively); for DVT, only previous VTE was statistically significant (p < 0.001). CONCLUSION: CTV should not be performed routinely in all patients evaluated for pulmonary embolism and may only be useful in patients with a high probability of pulmonary embolism, including those with a history of VTE and possible malignancy.

Radiology in the intensive care unit (part 2).

This review of intensive care unit (ICU) radiology has been divided into two sections. In Part 1, previously published, the discussion focused on the role of the portable radiograph in the evaluation of the critically ill patient and the impact of the introduction of digital radiography and picture-archiving communications systems on patient care. Part 2 of this review will emphasize the role of computed tomography and the increasing contribution of image-guided interventional procedures in patient management. The deleterious effects of mechanical ventilation due to barotrauma will also be discussed.

Radiology in the intensive care unit (Part I).

The increasing complexity of the intensive care patient combined with the recent advances in imaging technology has generated a new perspective on intensive care radiology. The purpose of this 2-part review article is to describe the contribution of radiology to the management of these critically ill patients. The first article will discuss the impact of picture archiving and communication system (PACS) on critical care management and utility of the portable chest radiograph in the detection and evaluation of pulmonary disease with correlation to computed tomography (CT). The second article describes in more detail the increasing role of CT in diagnosis and therapeutic procedures. In particular, the implementation of CT pulmonary angiography in the evaluation of pulmonary emboli and the introduction of the new multislice detector CT scanners that allow even the most dyspneic patient to be evaluated. Pleural complications in the intensive care unit and image-guided intervention will also be discussed.