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Journal of Thoracic Imaging - Current Issue

Journal of Thoracic Imaging - Current Issue
  1. The Four Corners Sign: A Specific Imaging Feature in Differentiating Systemic Sclerosis-related Interstitial Lung Disease From Idiopathic Pulmonary Fibrosis
    imagePurpose: Differentiating between systemic sclerosis-related interstitial lung disease (SSc-ILD) and idiopathic pulmonary fibrosis (IPF) is important because of the differences in workup, prognosis, and treatment. However, there is much overlap in the appearance of these 2 entities on high-resolution computed tomography. We propose that inflammation and/or fibrosis focally or disproportionately involving the bilateral anterolateral upper lobes and posterosuperior lower lobes [“Four Corners” Sign (FCS)] is specific for SSc-ILD. Materials and Methods: Randomized high-resolution computed tomography studies from 74 IPF and 73 SSc-ILD cases were evaluated by 2 thoracic radiologists blinded to all patient data. For each case the reviewers noted whether the FCS was present and assigned a confidence level on the basis of a 7-point Likert scale. The same process was then performed on a randomized external validation group of 42 SSc-ILD and 42 IPF cases. Results: For Likert scores of 6 or 7 (“mostly agree” or “entirely agree” that the FCS is present, respectively) the sensitivity in SSc was 16.4% (95% confidence interval, 9.7%, 26.6%), specificity 100.0% (95% confidence interval, 95.1%, 100.0%). There was a significant association between a confidently present FCS and SSc compared with a confidently present FCS and IPF (P=0.0003). Analysis on an external validation group of 42 SSc and 42 IPF cases conferred similarly high specificity for SSc in cases characterized as FCS with high confidence. Conclusion: The FCS, a pattern of focal or disproportionate inflammation and/or fibrosis involving the bilateral anterolateral upper lobes and posterosuperior lower lobes, is specific for SSc-ILD when readers are confident of its presence.



  2. Imaging in Congenital and Hereditary Abnormalities of the Interventricular Septum: Clinical Anatomy and Diagnostic Clues
    imageEarly identification of congenital heart diseases, specifically those affecting the structural integrity and function of the interventricular septum, in childhood is important toward decreasing the morbidity and mortality of those affected. We review the pertinent clinical and imaging manifestations for those with ventricular septal defects, ventricular septal aneurysms, tetralogy of Fallot, and hypertrophic (obstructive) cardiomyopathy, in addition to discussing first-line imaging studies, including echocardiography, and indications for advanced imaging.



  3. Kinematic Magnetic Resonance Imaging of the Thorax Using 2-Dimensional Balanced Subsecond Steady-state Free Precession Sequence During Forced Breathing in Comparison With Spirometry
    imagePurpose: The purpose of this article was to investigate the feasibility of kinematic magnetic resonance imaging (MRI) during forced breathing for the assessment of thoracic and diaphragmatic movement and to compare the results of MRI and spirometry to determine the MRI parameters that are predominantly associated with pulmonary function. Materials and Methods: Forty-nine healthy volunteers who underwent kinematic MRI using 2-dimensional balanced subsecond steady-state free precession sequence during forced breathing were included. Several items on the MRI were measured and calculated: these were anteroposterior diameter (APD) of the thorax, APD1, ΔAPD, and cross-sectional area (CSA) of the lung field. The results were compared with the results of spirometry. Results: In the comparison between the spirometry results and the MRI kinematic changes, CSA1, ΔCSA, and CSA1% were most significantly correlated with forced expiratory volume in 1 second (right: P<0.001, r=0.814; left: P<0.001, r=0.759); vital capacity (right: P<0.001, r=0.797; left: P<0.001, r=0.780); and forced expiratory volume% in 1 second (right: P<0.001, r=0.530; left: P<0.001, r=0.518), respectively. The APD1 values in the upper position were significantly larger than those in the middle (right: P<0.001; left: P<0.001) and lower (right: P<0.001; left: P<0.001) positions. The ΔAPD values in the upper position were also significantly larger than those in the middle (right: P<0.001; left: P<0.001) and lower (right: P<0.001; left: P<0.001) positions. Conclusion: Kinematic MRI with 2-dimensional balanced subsecond steady-state free precession can be used to assess thoracic and diaphragmatic movement during forced breathing. The dynamic changes in CSA correlated well with the results of spirometry.



  4. Cardiac Computed Tomography: Before and After Cardiac Surgery
    imageCardiac computed tomography angiography (CCTA) is a noninvasive imaging technique that has been rapidly adopted into clinical practice. Over the past decade, technological advances have improved CCTA accuracy, and there is an increasing amount of data supporting its prognostic value in the assessment of coronary artery disease. Recently, “appropriate use criteria” has been used as a tool to minimize inappropriate testing and reduce patient exposure to unnecessary risk and inconclusive studies. This review will summarize the appropriate uses of CCTA in patients before and after cardiac surgery. Although the most common indication for CCTA is assessment of patency of native coronary arteries, other potential perioperative uses (eg, assessment of congenital heart disease, valvular heart disease, pericardial disease, myocardial disease, cardiac anatomy, bypass grafts, aortic disease, and cardiac masses) will be reviewed.



  5. Cardiac Positron Emission Tomography-Magnetic Resonance Imaging: Current Status and Future Directions
    imageSimultaneous acquisition positron emission tomography-magnetic resonance imaging (PET-MRI) has the ability to combine anatomic information derived from cardiac MRI with quantitative capabilities of cardiac PET and MRI and the promise of molecular imaging by specific PET tracers. This combination of cardiac PET and MRI delivers a robust and comprehensive clinical examination. It has the potential to assess various cardiovascular conditions, including assessment of myocardial ischemia, infarction, and function, as well as specific characterization of inflammatory and infiltrative heart diseases such as cardiac sarcoid and amyloid. It also offers fascinating possibilities in imaging other cardiovascular-related disease states, such as tumor imaging and vascular imaging. In this review, we begin with a general overview of the potentials of PET-MRI in cardiovascular imaging, followed by a discussion of the technical challenges unique to cardiovascular PET-MRI. We then discuss PET-MRI in various cardiovascular disease imaging applications. Potential limitations of PET-MRI and future directions are also considered.


  6. Incidental Cardiac Findings in Non–Electrocardiogram-gated Thoracic Computed Tomography of Intensive Care Unit Patients: Assessment of Prevalence and Underreporting
    imagePurpose: Cardiac findings frequently remain unreported on non–electrocardiogram (ECG)-gated computed tomography (CT). Although the clinical relevance of such findings may be limited in a general patient population, they may have significant impact in intensive care patients. Thus, the purpose of this study was to evaluate the prevalence, underreporting, and clinical relevance of incidental cardiac findings in intensive care unit (ICU) patients. Materials and Methods: Non–ECG-gated chest CT examinations of ICU patients were retrospectively analyzed for incidental cardiac findings. The findings were classified into 3 categories (A to C): category A findings, which carry potential for risk to life; category B findings, which have a potential for significant morbidity; category C findings, which have a possible effect on prognosis. Results: A total of 500 patients who underwent non–ECG-gated thoracic CT examinations were included. Of the 500 patients, 403 presented with 1443 cardiac findings. Of all cardiac findings, 37% were described in the initial written report. Sixty category A findings were detected, of which 48% were not mentioned in the report. Six hundred forty category B findings were detected, of which 77% were not described in the report. The remaining 743 findings were classified as category C, 55% of which were not reported in the report. Conclusions: The prevalence as well as the rate of underreporting of incidental cardiac findings in non–ECG-gated chest CT of ICU patients is very high. The results of this study underscore the importance of dedicated training for assessment of cardiac structures and conditions, which may be detected on non–ECG-gated chest CT.



  7. Improving Quality of Dynamic Airway Computed Tomography Using an Expiratory Airflow Indicator Device
    imagePurpose: Dynamic computed tomography (CT) of the airways is increasingly used to evaluate patients with suspected expiratory central airway collapse, but current protocols are susceptible to inadequate exhalation caused by variable patient compliance with breathing instructions during the expiratory phase. We developed and tested a low-cost single-use expiratory airflow indicator device that was designed to improve study quality by providing a visual indicator to both patient and operator when adequate expiratory flow was attained. Materials and Methods: A total of 56 patients undergoing dynamic airway CT were evaluated, 35 of whom were scanned before introduction of the indicator device (control group), with the rest comprising the intervention group. Lung volumes and tracheal cross-sectional areas on inspiratory/expiratory phases were computed using automated lung segmentation and quantitative software analysis. Inadequate exhalation was defined as absolute volume change of <500 mL during the expiratory phase. Results: Fewer patients in the intervention group demonstrated inadequate exhalation. The average change in volume was higher in the intervention group (P=0.004), whereas the average minimum tracheal cross-sectional area was lower (P=0.01). Conclusions: The described expiratory airflow indicator device can be used to ensure adequate exhalation during the expiratory phase of dynamic airway CT. A higher frequency of adequate exhalation may improve reliability and sensitivity of dynamic airway CT for diagnosis of expiratory central airway collapse.



  8. Computed Tomography Features associated With the Eighth Edition TNM Stage Classification for Thymic Epithelial Tumors
    imagePurpose: The eighth edition of the TNM classification of malignant tumors for the first time includes an official staging system for thymic epithelial tumors (TETs) recognized by the American Joint Committee on Cancer (AJCC) and the Union for International Cancer Control (UICC). Staging is critical for the management of TETs, and determining stage accurately from imaging has the potential to improve clinical outcomes. We examine preoperative computed tomography (CT) characteristics of TETs associated with AJCC/UICC pathologic TNM stage. Materials and Methods: In this retrospective study, patients were included if they met all the following criteria: (1) diagnosis of TET, (2) had primary curative intent surgery performed at Stanford University, and (3) had available preoperative CT imaging for review. Tumor pathology was staged according to the eighth edition TNM classification. Fifteen CT scan features were examined from each patient case according to the International Thymic Malignancy Interest Group standard report terms in a blinded manner. A Lasso-regularized multivariate model was used to produce a weighted scoring system predictive of pathologic TNM stage. Results: Examining the 54 patients included, the following CT characteristics were associated with higher pathologic TNM stage when using the following scoring system: elevated hemidiaphragm (score of 6), vascular endoluminal invasion (score of 6), pleural nodule (score of 2), lobulated contour (score of 2), and heterogeneous internal density (score of 1). Area under the receiver operating characteristic curve was 0.76. Conclusions: TETs with clearly invasive or metastatic features seen on CT are associated with having higher AJCC/UICC pathologic TNM stage, as expected. However, features of lobulated contour and heterogeneous internal density are also associated with higher stage disease. These findings need to be validated in an independent cohort.



  9. Aortic Root Sign
    imageNo abstract available



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