Investigation of brachial plexus dose that exceeds RTOG constraints for apical lung tumors treated with four- or five-fraction stereotactic body radiation therapy.

PURPOSE/OBJECTIVESS: We sought to determine the rate of brachial plexopathy (BPX) in patients exceeding RTOG dose constraints for treatment of apical lung tumors. MATERIALS/METHODS: Patients with apical lung tumors treated with four- or five-fraction SBRT were identified from a prospective registry. Dosimetric data were obtained for ipsilateral subclavian vein (SCV) and anatomic BP (ABP) contours. Cumulative equivalent dose in 2 Gy equivalents (EQD2) was calculated for the SCV contour in patients with a history of prior ipsilateral RT. Five-fraction SBRT RTOG constraints of D0.03cc ≤32.0 Gy and D3cc ≤30.0 Gy were used. BPX was graded according to Common Terminology Criteria for Adverse Events 3.0. RESULTS: A total of 64 patients met inclusion criteria. Median follow-up was 21 months. Six patients (9.4%) had prior ipsilateral conventional fractionated RT with varying degrees of overlap with subsequent SBRT field. Eleven patients without prior ipsilateral RT exceeded D0.03cc ≤32.0 Gy to SCV (mean 43.8 Gy ± 5.8). No BPX was observed in these patients. Out of the six patients who had prior ipsilateral RT, three patients exceeded D0.03cc ≤32.0 Gy to SCV (44.2 Gy ± 11.3), with two of these patients developing Grade 2 BPX within one year of SBRT. The EQD2 cumulative maximum point dose to BP was 122.6 Gy and 184.7 Gy for the two patients who developed Grade 2 BPX. The D0.03cc was >10 Gy higher to the ABP contour than the SCV contour in 14 patients. CONCLUSION: Without a history of prior ipsilateral RT, no BPX was observed at 21 month follow-up in 11 patients who exceeded the RTOG five-fraction BP constraint. This observation is hypothesis generating and more experience with longer follow-up is necessary to validate these findings. For tumors located in close proximity to apical structures, there was substantial variation in dose between the ABP and SCV contours.

Video-Assisted Thoracic Surgery Resection without Intraoperative Fluoroscopy after CT-Guided Microcoil Localization of Peripheral Pulmonary Nodules.

The aim of this brief report is to determine the safety and reliability of minimally invasive video-assisted thoracic surgery (VATS) resection without the aid of intraoperative fluoroscopy after computed tomography (CT)-guided microcoil localization of small peripheral pulmonary nodules. Twenty patients with peripheral lung nodules underwent percutaneous needle localization with a microcoil that was tagged back to the visceral pleural surface. Same-day VATS resection was performed without the use of intraoperative fluoroscopy. All 20 nodules were successfully localized in the CT procedure room, and all 20 nodules were resected with negative margins and no major complications.

Electromagnetic Navigational Bronchoscopy versus CT-guided Percutaneous Sampling of Peripheral Indeterminate Pulmonary Nodules: A Cohort Study.

Purpose To compare the diagnostic yield and complication rates of electromagnetic navigational bronchoscopic (ENB)-guided and computed tomography (CT)-guided percutaneous tissue sampling of lung nodules. Materials and Methods Retrospectively identified were 149 patients sampled percutaneously with CT guidance and 146 patients who underwent ENB with transbronchial biopsy of a lung lesion between 2013 and 2015. Clinical data, incidence of complications, and nodule pathologic analyses were assessed through electronic medical record review. Lung nodule characteristics were reviewed through direct image analysis. Molecular marker studies and pathologic analyses from surgical excision were reviewed when available. Multiple-variable logistic regression models were built to compare the diagnostic yield and complication rates for each method and for different patient and disease characteristics. Results CT-guided sampling was more likely to be diagnostic than ENB-guided biopsy (86.0% [129 of 150] vs 66.0% [99 of 150], respectively), and this difference remained significant even after adjustments were made for patient and nodule characteristics (P < .001). Age, American Society of Anesthesiologists class, emphysema grade, nodule size, and distance from pleura were not significant predictors of increased diagnostic yield. Intraprocedural time for physicians was significantly lower with CT-guided sampling (P < .001). Similar yield for molecular analyses was noted with the two approaches (ENB-guided sampling, 88.9% [32 of 36]; CT-guided sampling, 82.0% [41 of 50]). The two groups had similar rates of major complications (symptomatic hemorrhage, P > .999; pneumothorax requiring chest tube and/or admission, P = .417). Conclusion CT-guided transthoracic biopsy provided higher diagnostic yield in the assessment of peripheral pulmonary nodules than navigational bronchoscopy with a similar rate of clinically relevant complications. © RSNA, 2017 Online supplemental material is available for this article.

Spectrum of Imaging Findings Following Bronchoscopic Intervention.

Interventional pulmonology (IP) is a relatively new field that uses endoscopy and other technologies for both the diagnosis and treatment of pulmonary and thoracic conditions. IP is a continually developing field driven by clinical need as well as technological and therapeutic innovation. Developments in IP have increased both the efficacy and breadth of procedures that may be encountered by radiologists on periprocedural and postprocedural imaging. In this article, we will describe commonly performed IP procedures, with a focus on relevant imaging implications for radiologists.

Radiographic Evaluation of Valvular Heart Disease With Computed Tomography and Magnetic Resonance Correlation.

Valvular heart disease is a group of complex entities with varying etiologies and clinical presentations. There are a number of imaging tools available to supplement clinical evaluation of suspected valvular heart disease, with echocardiography being the most common and clinically established, and more recent emergence of computed tomography and magnetic resonance imaging as additional supportive techniques. Yet even with these newer and more sophisticated modalities, chest radiography remains one of the earliest and most common diagnostic examinations performed during the triage of patients with suspected cardiac dysfunction. Recognizing the anatomic and pathologic features of cardiac radiography including the heart's adaptation to varying hemodynamic changes can provide clues to the radiologist regarding the underlying etiology. In this article, we will elucidate several principles relating to chamber modifications in response to pressure and volume overload as well as radiographic appearances associated with pulmonary fluid status and cardiac dysfunction. We will also present a pattern approach to optimize analysis of the chest radiograph for valvular heart disease, which will help guide the radiologist down a differential diagnostic pathway and create a more meaningful clinical report.

Historical Evolution of Imaging Techniques for the Evaluation of Pulmonary Embolism.

As we celebrate the 100th anniversary of the founding of the Radiological Society of North America (RSNA), it seems fitting to look back at the major accomplishments of the radiology community in the diagnosis of pulmonary embolism. Few diseases have so consistently captured the attention of the medical community. Since the first description of pulmonary embolism by Virchow in the 1850s, clinicians have struggled to reach a timely diagnosis of this common condition because of its nonspecific and often confusing clinical picture. As imaging tests started to gain importance in the 1900s, the approach to diagnosing pulmonary embolism also began to change. Rapid improvements in angiography, ventilation-perfusion imaging, and cross-sectional imaging modalities such as computed tomography (CT) and magnetic resonance imaging have constantly forced health care professionals to rethink how they diagnose pulmonary embolism. Needless to say, the way pulmonary embolism is diagnosed today is distinctly different from how it was diagnosed in Virchow's era; and imaging, particularly CT, now forms the cornerstone of diagnostic evaluation. Currently, radiology offers a variety of tests that are fast and accurate and can provide anatomic and functional information, thus allowing early diagnosis and triage of cases. This review provides a historical journey into the evolution of these imaging tests and highlights some of the major breakthroughs achieved by the radiology community and RSNA in this process. Also highlighted are areas of ongoing research and development in this field of imaging as radiologists seek to combat some of the newer challenges faced by modern medicine, such as rising health care costs and radiation dose hazards.

Building a bridge to save a failing ventricle: radiologic evaluation of short- and long-term cardiac assist devices.

Heart failure is recognized with increasing frequency worldwide and often progresses to an advanced refractory state. Although the reference standard for treatment of advanced heart failure remains cardiac transplantation, the increasing shortage of donor organs and the unsuitability of many patients for transplantation surgery has led to a search for alternative therapies. One such therapy is mechanical circulatory support, which helps relieve the load on the ventricle and thereby allows it to recover function. In addition, there is increasing evidence supporting the use of mechanical devices as a bridge to recovery in patients with acute refractory heart failure. In this article, the imaging evaluation of various commonly used short- and long-term cardiac assist devices is discussed, and their relevant mechanisms of action and physiology are described. Imaging, particularly computed tomography (CT), plays a crucial role in preoperative evaluation for assessment of candidacy for implantation of a left ventricular assist device (LVAD) or total artificial heart (TAH). Also, echocardiography and CT are indispensable in assessment of complications associated with cardiac devices. Complications commonly associated with short-term assist devices include bleeding and malpositioning, whereas long-term devices such as LVADs may be associated with infection, pump thrombosis, and cannula malfunction, as well as bleeding. CT is also commonly performed for preoperative planning before LVAD or TAH explantation, replacement of a device or one of its components, and cardiac transplantation. Online supplemental material is available for this article.

Intraluminal air within an obstructed appendix: a CT sign of perforated or necrotic appendicitis.

RATIONALE AND OBJECTIVES: The aim of this study was to evaluate the predictive value of intraluminal air for appendiceal necrosis and/or perforation when not apparent on imaging. Additional factors of intraluminal appendicoliths, age, and gender were also assessed. MATERIALS AND METHODS: Patients with pathologically proven appendicitis who underwent multidetector computed tomographic imaging over a 3-year period (n = 487) were retrospectively reviewed. Those with imaging evidence for perforation were excluded to create a study population of apparent uncomplicated acute appendicitis (n = 374). Each scan was assessed for intraluminal appendiceal air and appendicoliths on multidetector computed tomography and compared against surgical and pathologic results for appendiceal necrosis and/or perforation. RESULTS: Image-occult necrosis or perforation was present in 17.4% (65 or 374) of the study cohort. Intraluminal air and appendicoliths were predictive variables by univariate logistic regression (P = .001 and P ≤ .001, respectively), with odds ratios of 2.64 (95% confidence interval, 1.48-4.73) for intraluminal air and 2.67 (95% confidence interval, 1.55-4.61) for appendicoliths. Both remained independent variables on multivariate modeling despite multicollinearity. Increasing age was also predictive (odds ratio, 1.25; 95% confidence interval, 1.09-1.44; P = .002), whereas gender was not (P = .472). CONCLUSIONS: Intraluminal appendiceal air in the setting of acute appendicitis is a marker of perforated or necrotic appendicitis. Recognition of this finding in otherwise uncomplicated appendicitis at imaging should raise suspicion for image-occult perforation or necrosis.