COVID-19: looking beyond the peak. Challenges and tips for radiologists in follow-up of a novel patient cohort.

As the coronavirus pandemic evolves, the focus of radiology departments has begun to change. The acute phase of imaging a new disease entity whilst rationalising radiology services in the face of lockdown has passed. Radiologists are now becoming familiar with the complications of COVID-19, particularly the lung parenchymal and pulmonary vascular sequelae and are considering the impact follow-up imaging may have on departments already struggling with a backlog of suspended imaging in the face of reduced capacity. This review from the British Society of Thoracic Imaging explores both the thoracic and extra-thoracic complications of COVID-19, recognising the importance of a holistic approach to patient follow-up. The British Thoracic Society guidelines for respiratory follow-up of COVID-19 will be discussed, together with newly developed reporting templates, which aim to provide consistency for clinicians as well as an opportunity for longer-term data collection.

Impact of choice of volumetry software and nodule management guidelines on recall rates in lung cancer screening.

PURPOSE: Appropriate lung nodule management is essential to minimizing unnecessary patient recall in lung cancer screening. Two European guidelines provide differing recommendations in that participants with nodules ≥100 mm3 or ≥80 mm3 respectively should be recalled, at baseline. Nodule size estimation is known to vary between volumetry software packages (VSPs). The aim of this study was to examine the impact of choice of VSP on participant recall rates, when applying different European nodule management guidelines. An additional aim was to compare recall rates between 7 VSPs and manual diameter measurements. METHODS: 156 small-sized lung nodules (50-150 mm3) from the UK Lung Screening trial were measured using 7 different VSPs (VSP1-7) and also using manual diameter. The type of VSP used in the NELSON study (VSP1), on which European nodule management guidelines are based, provided the reference standard. Nodule size was compared using Bland Altman, and recall rates by Mcnemar's test. RESULTS: Compared to the reference standard, a 100 mm3 threshold for recall, resulted in no difference in recall rates only for VSP 5 & 7. Using an 80mm3 threshold resulted in no difference in recall rates for VSP2 & 6. Recall rates were significantly higher for VSP 4 regardless of threshold and when using manual diameter measurements. CONCLUSIONS: Appropriate nodule size thresholds for recall in screening depend on the type of volumetry software used. The results highlight the importance of benchmarking of volumetry packages.

A survey of UK percutaneous lung biopsy practice: current practices in the era of early detection, oncogenetic profiling, and targeted treatments.

AIM: To ascertain current percutaneous lung biopsy practices around the UK. MATERIALS AND METHODS: A web-based survey was sent to all British Society of Thoracic Imaging (BSTI) and British Society of Interventional Radiology (BSIR) members (May 2017) assessing all aspects of lung biopsy practice. Responses were collected anonymously. RESULTS: Two hundred and thirty-nine completed responses were received (28.8% response rate). Of the respondents, 48.5% worked in a teaching hospital and 51.5% in a district general hospital, while 32.6% (78/239) were specialist thoracic radiologists, 29.2% (70/239) "general" radiologists with a thoracic subspecialty interest, and 28% (67/239) interventional radiologists. Of the respondents, 30.1% (72/239) did not require pre-biopsy lung function tests (PFTs); 45.6% (108/237) stopped aspirin before the procedure; 97.5% primarily use computed tomography (CT) guidance for biopsy and 88.7% (212/239) perform core needle biopsy (CNB); and 86.6% of radiologists use a co-axial technique. There was wide variation in the number of samples routinely taken with most radiologists performing 1-2 passes (55.9%) or 3-4 passes (40.8%). Sixty-four percent reported using chest drain prevention techniques to minimise the impact of iatrogenic pneumothorax, with needle aspiration most frequent (43.9%). Timing of post-biopsy chest radiography (CXR), performed by 95.8% (228/239), also varied greatly: most commonly at either 1 hour (23%), 2 hours (24.7%), or 4 hours (22.6%). Moreover, the time of patient discharge after uncomplicated biopsy was variable, although the majority (66.1%) discharge patients after ≥4 hours. CONCLUSION: There are striking variations among surveyed UK radiologists performing lung biopsy in decision-making, pre-biopsy work-up, post-biopsy monitoring, management of pneumothorax, and discharge. The results suggest a need for new updated national percutaneous lung biopsy guidelines.

State-of-the-art: Radiological investigation of pleural disease.

Pleural disease is common. Radiological investigation of pleural effusion, thickening, masses, and pneumothorax is key in diagnosing and determining management. Conventional chest radiograph (CXR) remains as the initial investigation of choice for patients with suspected pleural disease. When abnormalities are detected, thoracic ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET) can each play important roles in further investigation, but appropriate modality selection is critical. US adds significant value in the identification of pleural fluid and pleural nodularity, guiding pleural procedures and, increasingly, as "point of care" assessment for pneumothorax, but is highly operator dependent. CT scan is the modality of choice for further assessment of pleural disease: Characterising pleural thickening, some pleural effusions and demonstration of homogeneity of pleural masses and areas of fatty attenuation or calcification. MRI has specific utility for soft tissue abnormalities and may have a role for younger patients requiring follow-up serial imaging. MRI and PET/CT may provide additional information in malignant pleural disease regarding prognosis and response to therapy. This article summarises existing techniques, highlighting the benefits and applications of these different imaging modalities and provides an up to date review of the evidence.

Idiopathic pulmonary fibrosis: current and future directions.

Idiopathic pulmonary fibrosis (IPF) is the most common idiopathic interstitial pneumonia and is increasingly recognised. Prior to the advent of effective therapies, achieving an early diagnosis was arguably of little prognostic consequence given IPF was considered an untreatable and uniformly fatal disease. The advent of new drug treatments has given hope for the future and raised the profile of IPF. International management guidelines highlight the critical role of radiology as part of an interstitial lung disease multidisciplinary team approach in reaching an accurate and early diagnosis of IPF. The diagnostic criteria and levels of diagnostic confidence for the radio-pathological pattern associated with the clinical syndrome of IPF, usual interstitial pneumonia (UIP), appear seemingly straightforward; however, with increasing research and recognition of radiopathological interobserver variability, limitations of this classification model are becoming increasingly apparent. This review describes ancillary radiological features, comorbidities, and emerging new entities that potentially co-exist with IPF. Beyond diagnosis radiology is developing as a key prognostic tool to inform longitudinal patient evaluation. These diagnostic and prognostic clinical challenges and the future role of radiology in IPF are discussed.

Organising pneumonia due to dronedarone.

Organising pneumonia is one of the responses of the lung to injury and can mimic bacterial pneumonia but importantly it does not respond to antibiotic therapy. We present the case of a 67-year-old male who was diagnosed with organising pneumonia secondary to dronedarone. Drug reactions are a common cause and early identification of the culprit is mandatory to prevent further morbidity and ensure a favourable outcome. On chest radiography there may be fleeting peripheral consolidation, while computed tomography can show a range of stereotyped patterns including perilobular consolidation. Bronchoscopic biopsy may not always be possible but response to steroids is often rapid following removal of the culprit drug. Dronedarone should be included in the list of possible drugs and the Pneumotox database remains a useful resource for the clinician when acute drug-related pneumotoxicity is suspected.

The Bristol Radiology Report Assessment Tool (BRRAT): developing a workplace-based assessment tool for radiology reporting skills.

AIM: To review the development of a workplace-based assessment tool to assess the quality of written radiology reports and assess its reliability, feasibility, and validity. MATERIALS AND METHODS: A comprehensive literature review and rigorous Delphi study enabled the development of the Bristol Radiology Report Assessment Tool (BRRAT), which consists of 19 questions and a global assessment score. Three assessors applied the assessment tool to 240 radiology reports provided by 24 radiology trainees. RESULTS: The reliability coefficient for the 19 questions was 0.79 and the equivalent coefficient for the global assessment scores was 0.67. Generalizability coefficients demonstrate that higher numbers of assessors and assessments are needed to reach acceptable levels of reliability for summative assessments due to assessor subjectivity. CONCLUSION: The study methodology gives good validity and strong foundation in best-practice. The assessment tool developed for radiology reporting is reliable and most suited to formative assessments.

Thoracic complications of rheumatoid disease.

Rheumatoid arthritis is a relatively common multisystem disease associated with significant mortality and morbidity. Thoracic disease, both pleural and pulmonary, is a frequent extra-articular manifestation of rheumatoid arthritis and responsible for approximately 20% of rheumatoid-associated mortality. Rheumatoid disease and its associated therapies can affect all compartments of the lung inciting a range of stereotyped pathological responses and it is not infrequent for multiple disease entities to co-exist. In some instances, development of pulmonary complications may precede typical rheumatological presentation of the disease and be the first indication of an underlying connective tissue disease. The spectrum of thoracic disease related to rheumatoid arthritis is reviewed.

Incidentally detected small pulmonary nodules on CT.

The widespread use of multidetector computed tomography for imaging of the chest has lead to a significant increase in the number of incidentally detected pulmonary nodules. The significance of these nodules is often uncertain and further investigations may be required. This article will review the spectrum of imaging appearances of small pulmonary nodules, and highlight the few features that allow confident characterization of a nodule as benign or malignant; current guidelines for the management of incidentally detected nodules will also be discussed.

CT lung cancer screening in the UK.

Lung cancer is the most common cause of cancer-related death in the UK. Despite aggressive primary prevention measures and improved medical care, the 5-year survival rate is less than 10% for patients in the UK who present with symptoms. The possibility of CT screening for lung cancer provides some hope of reducing mortality. However, the case for screening remains unproven. This article explores the issues surrounding lung cancer screening in the context of historical studies, trials in progress and tentative plans for a UK CT lung cancer screening trial.

Ultrasound imaging of liver metastases in the delayed parenchymal phase following administration of Sonazoid using a destructive mode technique (Agent Detection Imaging).

AIM: To determine whether delayed-phase liver imaging using a destructive imaging mode is able to provide similar information to phase-inversion imaging regarding detection and conspicuity of liver metastases. MATERIAL AND METHODS: Patients with a known primary malignancy with suspected liver metastases were recruited. Ultrasound was performed at baseline, and up to 5 min after the administration of Sonazoid, using phase-inversion imaging at both low and high mechanical indices (MI) and at 10-15 min using destructive imaging. One of four doses of Sonazoid was used: 0.008, 0.08, 0.12, and 0.36 microl/kg of body weight. Two observers documented lesion number and conspicuity subjectively, and divided the patients into group A (no lesions), group B (one to seven lesions), and group C(I-III) (more than eight lesions, subdivided with increasing lesion number) depending on the number of lesions and categories I-IV based on lesion conspicuity. These parameters were compared with contrast-enhanced computed tomography (CECT) as the reference standard. RESULTS: Sixteen patients were examined (six women, 10 men), mean age 67.3 years (range 48-83 years). Based on CECT imaging, the division was as follows: group A n=1, group B n=8, group C(I)n=1, group C(II)n=4, group C(III)n=2. The accuracy of baseline ultrasound versus CECT was 75% (in 12 of the 16 patients the group concurred) and the accuracy for contrast-enhanced ultrasound (CEUS) versus CECT was 93.8% (15/16). There was a significant improvement in lesion conspicuity for both low (p=0.0029) and high MI phase-inversion (p=0.0004) and destructive (p=0.0015) CEUS imaging in comparison with baseline ultrasound. Artefact was noted at higher doses of Sonazoid; and no side effects were recorded. CONCLUSION: Following a single, intravenous injection of Sonazoid, the properties of this microbubble allow for a and robust examination of the liver using two different techniques with comparable results.