CHE001-b Difficult Intrathoracic Lesionsrsna2014.rsna.org/pdf/Chest Radiology.pdfDifficult...

CHE001-b

Nearly Impossible Nodule: What a Radiologist Needs to Know for CT-guided Biopsy ofDifficult Intrathoracic Lesions Education ExhibitsLocation: CH Community, Learning Center

ParticipantsDaisy Qinjun Huang MD (Presenter): Nothing to Disclose Bradley Bryan Pua MD : Nothing to Disclose David Li MD, PhD : Nothing to Disclose David Craig Madoff MD : Nothing to Disclose

TEACHING POINTSThe rise of lung cancer screening programs and advances in medical imaging have dramatically changed the spectrum of lunglesions presented for CT-guided biopsy. Radiologists are increasingly faced with more technically challenging lesions wheretraditional fine-needle aspiration techniques are not always applicable. This exhibit will present: What constitutes a difficult lunglesion Different and innovative lung biopsy techniques Pitfalls and complications to be aware of

TABLE OF CONTENTS/OUTLINE1) Schematic approach to defining a difficult lung biopsy Patient factors (i.e. respiratory motion) Lesion location Small sizeAdjacent structures 2) Biopsy techniques to improve success (using cases from our institution which oversees a large lungcancer screening program) Atypical patient positioning Atypical biopsy needle (i.e. curved needles, bevel-steering)Hydrodissection Induced pneumothorax 3) Complications Pneumothorax Pulmonary hemorrhage

CHE002-b

The Extreme Transthoracic Biopsy: Maximizing Yield and Minimizing Complications Education ExhibitsLocation: CH Community, Learning Center

Certificate of Merit

ParticipantsWilliam T. Derry MD (Presenter): Nothing to Disclose Anshuman Kumar Bansal MD : Nothing to Disclose Scott J. Genshaft MD : Nothing to Disclose Fereidoun G. Abtin MD : Nothing to Disclose Antonio Joel Gutierrez MD : Nothing to Disclose Robert D. Suh MD : Nothing to Disclose

TEACHING POINTSThe objective of this exhibit is to illustrate tips for performing successful percutaneous biopsy of lesions in precariousintrathoracic locations. We highlight practices that should help maximize the chances for a successful tissue yield whileminimizing the rate of biopsy-associated complications. Management and prevention of common complications will also beaddressed.

TABLE OF CONTENTS/OUTLINE

A. Patient preparation and contraindications

B. Pre-procedure preparation (indications, contraindications, choice of imaging modality, methods of sampling)

C. Periprocedural considerations (positioning, anesthesia)

D. Parenchyma (subpleural and central lesions, needle trajectories that decrease risk of pneumothorax, avoiding vascularstructures, displacing lung)

E. Mediastinum (inducing pleural effusions, direct mediastinal approach, transpleural approach with iatrogenic pneumothorax,techniques to expand the extrapleural window)

F. Post-procedure care

G. Complications and prevention

CHE003-b

Basic Principles and Benefits of Dual Energy Computed Tomography (DECT) for Diagnosis andManagement of Pulmonary Embolism Education ExhibitsLocation: CH Community, Learning Center

ParticipantsYing Chen MD, PhD (Presenter): Nothing to Disclose Shima Aran MD : Nothing to Disclose

Shima Aran MD : Nothing to Disclose Khalid Walid Shaqdan MD : Nothing to Disclose Elmira Hassanzadeh MD : Nothing to Disclose Efren Jesus Flores MD : Nothing to Disclose Hani H. Abujudeh MD, MBA : Research Grant, Bracco Group Consultant, RCG HealthCare Consulting Author, Oxford UniversityPress

TEACHING POINTS

CT pulmonary angiography has become the standard of care for assessment of patients with pulmonary embolism (PE). Thereare many exciting new applications of Dual-energy CT (DECT) for advanced imaging of PE. The capability of the DECT to usediagnostic information from both 80 and 140 kVp datasets optimizes the contrast-to-noise ratio within vessels and facilitatesdetection of peripheral endoluminal clots. Low-kV dataset increases vascular enhancement. A number of predictive markers areestablished for risk stratification and to evaluate the prognosis in acute and chronic PE. DECT is capable of iodine mapping of thepulmonary parenchyma, to show segmental defects in iodine distribution in areas corresponding to embolic vessel occlusions.Diagnostic scans and lung perfusion scans are routinely reconstructed and several available image reconstruction techniques areavailable for DECT imaging to enhance detection and management of PE.

TABLE OF CONTENTS/OUTLINE1. Basic principles of spectral CT and available techniques of DE data acquisition. 2. Image processing and reconstruction ofDECT data. 3. Clinical application of DECT for diagnosis and management PE. 4. Sample cases 5. Advantages of DECT imagingover other imaging modalities for diagnosis of PE. 6. Limitations of DECT imaging such as the effects on image quality andradiation dose.

CHE005-b

Acute Respiratory Distress Syndrome: Update on the Berlin Criteria and Review ofRadiographic and CT Findings Education ExhibitsLocation: CH Community, Learning Center

ParticipantsKetan Yogesh Shah MD, BS (Presenter): Nothing to Disclose Arun C. Nachiappan MD : Nothing to Disclose Achala Donuru MD : Nothing to Disclose Rafael Andres Vicens-Rodriguez MD : Nothing to Disclose Girish S. Shroff MD : Nothing to Disclose Daniel Ocazionez MD : Nothing to Disclose Xiao Shi MD : Nothing to Disclose Lorell Ruiz-Flores MD : Nothing to Disclose Elizabeth Guy MD : Nothing to Disclose Rodolfo Laucirica MD : Nothing to Disclose Farber John MD : Nothing to Disclose

TEACHING POINTS

1) Describe the definition (new Berlin criteria) of ARDS, etiologies, and clinical presentation

2) Define three histopathologic phases of ARDS

3) Illustrate chest radiographic and CT findings in ARDS, with rad-path correlation to 3 phases

4) Explain the role of imaging in diagnosis, prognostication, and follow-up of ARDS


1) Definition of ARDS and the new Berlin clinical criteria

2) Updated histopathologic phases of ARDS (exudative/acute, proliferative/intermediate, and fibrotic/late)

3) Chest radiographic and CT findings in the different phases of ARDS

4) Role of imaging in prognostication, determining etiology, and follow-up

CHE006-b

“Sponge Lung”: Radiographic and CT Appearance of Pulmonary Edema Superimposed onEmphysema Education ExhibitsLocation: CH Community, Learning Center

ParticipantsSuraj Jay Kabadi MD (Presenter): Nothing to Disclose Juliana Marcela Bueno MD : Co-author, Oxford University Press Michael Hanley MD : Nothing to Disclose

TEACHING POINTS1. Understand why underlying chronic lung disease, particularly COPD, can cause atypical patterns of pulmonary edema 2.Recognize the appearance of a novel term, "sponge lung", in describing the radiographic and CT findings of pulmonary edemasuperimposed on emphysema 3. Understand how "sponge lung" also aptly describes the underlying physiology of pulmonaryedema

TABLE OF CONTENTS/OUTLINE1. Classic appearance of pulmonary edema on chest radiography and CT imaging 2. Review of findings previously described inthe literature of atypical patterns of pulmonary edema in patients with underlying COPD, e.g. regional distribution of edema tothe bases 3. A novel description of pulmonary edema superimposed on emphysema termed "sponge lung" due to itscharacteristic likeness to the appearance of a sponge a. On radiographs, this appears as diffuse reticular and alveolar opacities

characteristic likeness to the appearance of a sponge a. On radiographs, this appears as diffuse reticular and alveolar opacitieswith scattered rounded lucencies b. On CT, this appears as smooth interlobular septal thickening and alveolarconsolidation/ground-glass on a background of centrilobular lucencies 4. How "sponge lung" fittingly also describes theunderlying physiology of pulmonary edema, i.e. lung parenchyma acting as a reservoir for transudative fluid much like asponge

CHE007-b

What Radiologists Need to Know: Surgical Management of Non-neoplastic Thoracic Diseases Education ExhibitsLocation: CH Community, Learning Center

ParticipantsHwi Ryong Park (Presenter): Nothing to Disclose Semin Chong MD : Nothing to Disclose Ju-Won Choe : Nothing to Disclose Mi Kyung Kim : Nothing to Disclose Jae Seung Seo : Nothing to Disclose Yang Soo Kim MD : Nothing to Disclose

TEACHING POINTSTo categorize the non-neoplastic thoracic diseases in which the surgical management can be required To review their clinicaland imaging findings in preoperative assessment, discuss with the surgical findings, and investigate the postoperativecomplications of these diseases

TABLE OF CONTENTS/OUTLINECategorization of non-neoplastic thoracic diseases requiring surgical management Infection/inflammation Trauma CongenitalIdiopathic/miscellaneous Clinical and imaging findings of non-neoplastic thoracic diseases requiring surgical management 1.Pneumothorax, hemothorax and hemopneumothorax - Spontaneous/Trauma/Others 2. Empyema, lung abscess and combined -Infection : bacterial, fungal, tuberculous, NTM - Miscellaneous 3. Bronchiectasis 4. Pneumatocele : infection/trauma 5. Acutemediastinitis 6. BPF/TEF/Pleuroperitoneal communication 7. Emphysema 8. Others Review of the surgical findings andpostoperative complications Summary

CHE008-b

Long Term CT Follow Up of Ground Glass Opacities Progressing to Invasive Adenocarcinoma:A Review and Case Series Education ExhibitsLocation: CH Community, Learning Center

Cum Laude

ParticipantsDaria Manos MD, FRCPC (Presenter): Author, Springer Science+Business Media Deutschland GmbH Joy Nina Borgaonkar MD, FRCPC : Nothing to Disclose

TEACHING POINTS1. At least 75% of persistent ground glass opacities represent atypical adenomatous hyperplasia or adenocarcinoma in situ. 2.Management of persistent ground glass opacities is controversial and resection of ground glass neoplasm has been criticized forcontributing to overdiagnosis in CT screening. 2. The 5-year prognosis for resected adenocarcioma in situ is 100%. 3. Pureground glass neoplasm typically grows slowly but can progress to invasive adenocarcinoma. Worrisome CT features include largesize, rate of growth, increase in density and association with an irregular lung cyst. 4. The decision to resect a ground glassopacity should be made on an individual basis with consideration of the nodule characteristics, the risks of surgery andcompeting causes of death in the next 5 years.

TABLE OF CONTENTS/OUTLINE1. Differential of focal ground glass opacity on CT 2. Natural history of persistent ground glass opacities; what is known, what isunknown. 3. Work up options for ground glass opacities. 4. Illustration of teaching points including a case series of 20tissue-proven adenocarcinomas originally appearing on CT as ground glass opacities. All cases have serial CT documenting CTbehavior over 5 to 12 years. 5. Risks and benefits regarding the resection of ground glass neoplasm.

CHE009-b

Thoracic Manifestations Following CyberKnife Radiosurgery Therapy on High Resolution CT Education ExhibitsLocation: CH Community, Learning Center

ParticipantsMyriam Irislimane (Presenter): Nothing to Disclose Myriam Bouchard : Nothing to Disclose Annie Ebacher MD : Nothing to Disclose Jean Chenard MD : Nothing to Disclose Pierre-Luc P Becotte MD : Nothing to Disclose Patricia Diez Martinez MD : Nothing to Disclose

TEACHING POINTSDescribe CyberKnife Radiosurgery Therapy in lung cancer. Review and illustrate radiologic findings post-radiosurgery on HighResolution CT

TABLE OF CONTENTS/OUTLINECyberKnife radiosurgery treatments offer a safe and non-invasive approach in poor surgical candidates. High Resolution CT is

frequently performed to monitor tumoral response. In some patients, the tumour tends to shrink gradually over a period ofweeks to months with desmoplastic reaction around the irradiated field. High Resolution CT is also used to assess complicationspost-radiosurgery therapy. Early and late toxicity from radiosurgery include radiation pneumonitis, pneumothorax, radiationfibrosis, bronchiectasis. We plan to discuss these complications with illustrative examples. Understanding the imaging featurespost radiosurgery is essential for the radiologist. Distinction between usual post-treatment changes, local recurrence and tumournecrosis is sometime challenging.

CHE010

Thoracic Multi-Disciplinary Tumor Board: Essential Knowledge for Every Radiologist Education ExhibitsLocation: CH Community, Learning Center


ParticipantsArun C. Nachiappan MD : Nothing to Disclose Morgan Elizabeth Telesmanich MD (Presenter): Nothing to Disclose Stephanie Spann : Nothing to Disclose Scott Harada MD : Nothing to Disclose Veronica Lenge de Rosen MD : Nothing to Disclose Michael Bruce Gotway MD : Nothing to Disclose Ketan Yogesh Shah MD, BS : Nothing to Disclose Lorell Ruiz-Flores MD : Nothing to Disclose Girish S. Shroff MD : Nothing to Disclose Daniel Ocazionez MD : Nothing to Disclose Jun Zhang MD : Nothing to Disclose Rodolfo Laucirica MD : Nothing to Disclose Peter I. Tsai MD : Nothing to Disclose Goutham Dronavalli MD : Nothing to Disclose Pavan Jhaveri MD : Nothing to Disclose

TEACHING POINTS

1) Compare and contrast various histopathologic markers for classification of lung cancer and pulmonary metastatic disease.

2) Discuss the International Association for the Study of Lung Cancer (IASLC) seventh edition TNM staging criteria for primarylung cancer.

3) Outline treatment options based on staging, histopathology, and patient-specific factors (including pulmonary function,performance, nutritional status, and comorbidities).

TABLE OF CONTENTS/OUTLINE1) Importance of multi-disciplinary care, patient-specific prognosticators, and radiologist's role in patient outcome 2) Types ofprimary lung cancers and discussion of their histopathologic appearance, markers, and TNM staging 3) CT and PET- pros andcons of each modality 4) Decision to biopsy- percutaneous, bronchoscopic, EBUS, mediastinoscopy, surgical 5) Treatmentoptions including chemotherapy, several types of radiation therapy, and surgery.

CHE011-b

Rationale and Logistics of Lung Cancer Screening Education ExhibitsLocation: CH Community, Learning Center

Certificate of Merit Selected for RadioGraphics

ParticipantsAdam Marc Bernheim MD : Nothing to Disclose Florian J. Fintelmann MD, FRCPC (Presenter): Nothing to Disclose Subba Rao Digumarthy MD : Nothing to Disclose Inga T. Lennes : Nothing to Disclose Mannudeep K. S. Kalra MD : Nothing to Disclose Jo-Anne O. Shepard MD : Consultant, Agfa-Gevaert Group

TEACHING POINTS

Minor but imporant differences exist among low dose CT lung cancer screening trialsEligibility criteria of USPSTF slightly differ from prominent medical societiesSuccessful implementation of a screening program requires careful organization, from patient education to follow up, andrequires a step-wise approachNew technologies of dose reduction, nodule detection, and biomarkers make screening safer and more efficient


Salient differences between European and American clinical trialsEligibility criteria as per major medical societiesEssentials (pillars) for a lung cancer screening program, organized in a easy to understand format, covering all aspects,from hospital administration support to educational initiatives, management guidelines, and reimbursementSummarize guidelines and lexicon for standardized reportingPotential integration of emerging dose reduction technology, nodule detection and biomarkersDo radiologists need dedicated training to read screening CTs

Conclusion: The exhibit provides the rationale for Lung Cancer Screening, and requisites for starting a successful lung cancerscreening program organized in tables, charts, figures and examples for an international audience with practical pointers forboth novice and expert

CHE012-b

Build it Right: Tools and Instructions for Assembling a Lung Cancer Screening Program Education ExhibitsLocation: CH Community, Learning Center

ParticipantsJulianna M. Czum MD (Presenter): Consultant, M2S, Inc William C. Black MD : Nothing to Disclose Cherie P Erkmen MD : Nothing to Disclose

TEACHING POINTS1. An ideal lung cancer screening program (LCSP): is easily accessible, fair, safe, affordable, understandable and efficacious forpatients; provides clear, accurate and timely results and meaningful recommendations for providers; emphasizes primaryprevention/smoking cessation and facilitates education, research and continuous quality improvement. 2. Recognizing that eachinstitution will develop a best-fit LCSP for its needs/priorities, program architects should prepare a comprehensive blueprintincluding cornerstone values, clinical pathway, shared decision making, financial plan, timetable, and resource assessment tomuster support from institutional leadership and the community.

TABLE OF CONTENTS/OUTLINEBackground: NLST/USPSTF Identifying institutional values Stakeholders/ multidisciplinary team Key personnel/ programcoordinator Defining screening population Screening timing/duration Program rollout: informational brochures/outreachCommunity stewardship: education/ethical media strategy Primary prevention/smoking cessation Shared decision makingCQI/safety: database CT technical standards Volumetric nodule analysis Reporting standards: LUNG-RADS Resultsnotification/tracking Management algorithms for positive CT findings Clinical pathway Population research: registry Financialsolvency: pricing/reimbursement

CHE013-b

What are Essential Imaging Findings and Clinical Information for the Diagnosis of LungNodules? An Analysis Based on a Large Database of Thin-slice CT Image Education ExhibitsLocation: CH Community, Learning Center

ParticipantsTakeshi Kubo MD : Nothing to Disclose Gakuto Aoyama (Presenter): Employee, Canon Inc Ryo Sakamoto MD,PhD : Nothing to Disclose Masahiro Yakami MD, PhD : Nothing to Disclose Koji Fujimoto MD, PhD : Nothing to Disclose Kaori Togashi MD, PhD : Research Grant, Bayer AG Research Grant, DAIICHI SANKYO Group Research Grant, Eisai Co, LtdResearch Grant, FUJIFILM Holdings Corporation Research Grant, Nihon Medi-Physics Co, Ltd Research Grant, ShimadzuCorporation Research Grant, Toshiba Corporation Research Grant, Covidien AG Yutaka Emoto MD, PhD : Nothing to Disclose Hiroyuki Sekiguchi : Nothing to Disclose Koji Sakai : Nothing to Disclose Masami Kawagishi : Employee, Canon Inc Yoshio Iizuka : Employee, Canon Inc Keita Nakagomi MSc : Employee, Canon Inc Bin Chen : Employee, Canon Inc Hiroyuki Yamamoto : Employee, Canon Inc

TEACHING POINTS

The purpose of this exhibit are;

To demonstrate essential clinical information for the diagnosis of lung noduleTo describe the distribution of imaging findings observed in primary lung cancer, metastasis and benign nodule onthin-slice CT

The knowledge of these nodule characteristics will enhance diagnostic performance of radiologists.

TABLE OF CONTENTS/OUTLINEWe will present the distribution of well-known imaging findings and clinical information for interpreting lung nodules with figuresof representative nodule. The distribution was derived from a large data base constructed by the following method; Onethousand nodules with pathologically or clinically confirmed diagnoses (primary lung cancer or metastasis or benign) werecollected. For each nodule, 37 types of clinical information (e.g. age, sex, smoking history, laboratory data, medical history,etc.) were retrospectively collected. For each nodule, 51 imaging findings (e.g. shape, spiculation, ratio of GGO, airbronchogram, etc.) were scored based on 2 to 7 point scales by the consensus of two board-certified radiologists. As an extraanalysis, distributions of both imaging findings and clinical information for solid adenocarcinoma and squamous cell carcinomawere also compared for the better interpretation of solid lung nodules.

CHE014-b

Complex but Uncomplicated: Simplifying the Task of CT Protocol Optimization withMultiple-Vendor based Iterative Reconstruction Techniques Education ExhibitsLocation: CH Community, Learning Center

Selected for RadioGraphics

ParticipantsRanish Deedar Ali Khawaja MD (Presenter): Nothing to Disclose

Ranish Deedar Ali Khawaja MD (Presenter): Nothing to Disclose Sarabjeet Singh MD : Research Grant, Siemens AG Research Grant, Toshiba Corporation Research Grant, General ElectricCompany Research Grant, Koninklijke Philips NV Rachna Madan MD : Nothing to Disclose Subba Rao Digumarthy MD : Nothing to Disclose Jo-Anne O. Shepard MD : Consultant, Agfa-Gevaert Group Mannudeep K. S. Kalra MD : Nothing to Disclose Atul Padole MD : Nothing to Disclose Sarvenaz Pourjabbar MD : Nothing to Disclose

TEACHING POINTS1. Method of setting up protocols for vendor-specific IR techniques 2. Image quality is dependent on an optimal balance betweenpatient size, tube voltage and tube current 3. Clinical indication and patient size specific CT protocols for application of differentIR technique (routine, low dose lung nodule and CT pulmonary embolism) 4. Appearance of chest pathologies that can bescanned at substantially lower radiation dose levels with IR techniques, 5. Appearance of chest findings that need relativelyhigher dose even with IR techniques.

TABLE OF CONTENTS/OUTLINE1. Overview of iterative reconstruction (IR) techniques from four major CT vendors (AIDR3D, ADMIRE, ASiR, iDose, IMR, IRIS,SAFIRE, SafeCT, VEO). 2. Protocols for chest CT with above mentioned IR techniques, 3. Effect of IR techniques on lesiondetection, characterization and overall image quality of chest CT examination at different radiation doses. 4. Illustration ofexamples from our institutions for chest CT performed at an array of radiation doses. 5. Illustrate effect of different tubepotential (kV) and tube current (mA) on the image quality across multiple CT platforms.

CHE015-b

Dual Energy CT (DECT) Cinematography on Spectrum of Thoracic Abnormalities: How ThingsLook on DECT Images Education ExhibitsLocation: CH Community, Learning Center


ParticipantsAlexi Otrakji MD (Presenter): Nothing to Disclose Roberto Lo Gullo MD : Nothing to Disclose Andrew Primak PhD : Employee, Siemens AG Subba Rao Digumarthy MD : Nothing to Disclose Mannudeep K. S. Kalra MD : Nothing to Disclose Jo-Anne O. Shepard MD : Consultant, Agfa-Gevaert Group Efren Jesus Flores MD : Nothing to Disclose Sarabjeet Singh MD : Research Grant, Siemens AG Research Grant, Toshiba Corporation Research Grant, General ElectricCompany Research Grant, Koninklijke Philips NV

TEACHING POINTSRoutine use of DECT for routine chest examinations is feasible with radiation dose neutral scanning protocols. In our institutions,contrast enhanced chest CT are performed with DECT, which can provide substantial clinical information in many clinicalsituations. We use our institutional experience to highlight following teaching points: A. Distinct appearances of variouspulmonary processes on DECT images including pulmonary embolism, pneumonia, atelectasis, and pulmonary masses. B. Use ofperfused blood volume or iodine map (PBV/I) images for evaluation of pulmonary findings: What nuclear medicine perfusionscans teach us. C. Appropriate use of quantitative spectral and iodine uptake values in DECT. D. Multivendor scanningtechnique and radiation dose with DECT

TABLE OF CONTENTS/OUTLINEAll included cases, images and data will be from our institutional experience. Blended, monoenergetic and PBV/I images will beused for describing a host of findings including 1. Normal chest on DECT 2. Pulmonary embolism with and without defects andinfarcts 3. Chronic pulmonary thrombo-embolic disease 4. Pneumonia 5. Atelectasis 6. Pulmonary and mediastinal masses 7.Post radiofrequency appearance of lung masses on DECT 8. Lung abscess on DECT 9. Pulmonary lucencies on DECT(emphysema, lung cysts, and air trapping)

CHE016-b

Find Airway Lesions on Chest Radiography? Digital Tomosynthesis Can Help your Diagnosisof Airway Lesions Education ExhibitsLocation: CH Community, Learning Center

ParticipantsJi Yung Choo MD : Nothing to Disclose JungWon Kwak (Presenter): Nothing to Disclose Ki Yeol Lee MD, PhD : Nothing to Disclose Jung Won Choi : Nothing to Disclose Je Hyeong Kim : Nothing to Disclose Seung Heon Lee : Nothing to Disclose Eun-Young Kang MD : Nothing to Disclose Whan Oh : Nothing to Disclose

TEACHING POINTS1. To understand the technical concept of low dose digital tomosynthesis of the chest and its implementation 2. To understandwhich type of airway lesion can be evaluated under digital tomosynthesis 3. To recognize the limitations and benefits of digitaltomosynthesis of the chest in radiation exposure and image acquisition

TABLE OF CONTENTS/OUTLINEOur exhibit will be divided into 5 sections and presented with illustration and relevant cases: 1. Background and physics ofdigital tomosynthesis of the chest 2. Clinical application of digital tomosynthesis in airway abnormalities A. Neoplasticabnormalities a. Lung cancer b. Endobronchial metastasis c. Evaluation as a follow up tool in post-chemotherapy or

abnormalities a. Lung cancer b. Endobronchial metastasis c. Evaluation as a follow up tool in post-chemotherapy orpost-operation status B. Non-neoplastic airway abnormalities a. Post-operative change 1) Lobectomy, biolobectomy orpneumonectomy state 2) Evaluation of dead space 3) Localization of drain catheter localization b. Congenital anomaly of airways- accessory bronchus C. Ancillary findings a. Lung parenchymal -Interstitial lung disease/ Emphysema, bullae/ Nodule (solid,ground glass opacity nodule)/ Consolidations (Tuberculosis, pneumonia, lung cancer, etc.) b. Chest wall and pleura-Pneumothorax with blebs/ Bone lesion 3. Benefits and limitation of tomosynthesis of the chest

CHE017-b

Imaging of the Patient with Thoracic Outlet Syndrome Education ExhibitsLocation: CH Community, Learning Center


ParticipantsConstantine Apostolos Raptis MD (Presenter): Nothing to Disclose

TEACHING POINTS

Thoracic outlet syndrome (TOS) refers to the constellation of symptoms produced as a result of compression of theneurovascular structures which traverse the thoracic outlet. As part of a large referral center for patients with TOS, ourradiology department has had the opportunity to participate in the care of thousands of patients with TOS or suspected TOS.The purpose of this poster is to share our experiences and highlight the role the radiologist plays in the care of these patientsfrom initial diagnosis to post-surgical care. Specifically, we will:

1. Review relevant anatomy of the thoracic outlet on cross sectional imaging

2. Present imaging findings associated with the diagnosis of TOS

3. Discuss common post-operative complications of corrective surgery for TOS

TABLE OF CONTENTS/OUTLINEI. Anatomy of the thoracic outlet on CT and MRI II. Clinical aspects of TOS III. Role of imaging and findings seen in thediagnosis of TOS Conventional radiographs CT MRI Angiography IV. Complications of thoracic outlet decompression surgeryEarly complications: Hemothorax, chylothorax, pneumothorax, supraclavicular infection or hematoma, pulmonary infection Moredelayed complications: Lung herniation, nerve damage, graft thrombosis, vascular stenosis, remnant rib, contralateralsymptoms

CHE018-b

Lateral Chest Radiography, is it a Forgotten Study? Systematic Analysis in 8 Easy Steps andCorrelation with Computed Tomography Education ExhibitsLocation: CH Community, Learning Center


ParticipantsLuis Alberto Ruiz Elizondo MD (Presenter): Nothing to Disclose Regina De La Mora Cervantes MD : Nothing to Disclose Mary Carmen Herrera-Zarza MD : Nothing to Disclose Daniel Alejandro Guerrero MD : Nothing to Disclose Victor Alfonso Ortega Marrugo MD : Nothing to Disclose Jose Manuel Cardoso MD : Nothing to Disclose Gerardo Villegas MD : Nothing to Disclose Jose Luis Criales Cortes MD : Nothing to Disclose

TEACHING POINTSTo describe a systematic analysis approaching the lateral chest x-ray with computed tomography correlation. To review thenormal anatomy, including some common anatomical variants seen on the lateral radiograph. To determine the mainpathologies that obliterate the different areas delineated in the lateral radiograph

TABLE OF CONTENTS/OUTLINEDevelopment of systematic analysis and differential diagnosis including promptly 8 steps: 1. Retrotracheal clear space: Vascularanomalies, esophageal entities, lung cancer, thyroid pathology 2. Anterior clear space (retrosternal): Lymphoma, timoma,teratoma, infectious disease, hematoma. 3. Retrocardiac clear space: Hiatal hernia, pneumonia, esophageal disease, pleuraleffusion, left ventricle hypertrophy. 4. Posterior space (vertebral): Neurogenic tumors, extra medullary hematopoiesis,infectious disease. 5. Inferior hilar window: Lymphadenopathies, tumors. 6. Aortopulmonary window: Lymphadenopathies,tumors. 7. Heart and great vessels: Cardiomegaly, pulmonary hypertension, aneurisms. 8. Large airways: Tumors, cysts.

CHE019-b

Pitfalls in Imaging of Benign Thymic Lesions; How Thymic MRI Can Help Education ExhibitsLocation: CH Community, Learning Center

ParticipantsMicheal McInnis MD : Nothing to Disclose Efren Jesus Flores MD (Presenter): Nothing to Disclose Jo-Anne O. Shepard MD : Consultant, Agfa-Gevaert Group Jeanne B. Ackman MD : Nothing to Disclose

TEACHING POINTSFrom this exhibit, the viewer will have a better understanding of: 1. Misleading CT and/or PET appearances of thymichyperplasia and thymic cysts; how MRI can prevent potential diagnostic errors and unnecessary diagnostic intervention. 2. Howto avoid pitfalls in Thymic MR imaging and interpretation. 3. How to tailor the Thymic MRI protocol to the clinical question andkeep the exam as short and efficacious as possible.

TABLE OF CONTENTS/OUTLINE1. Approach to MR imaging of the thymus a. Our standard Thymic MRI protocol; an algorithm depicting how to tailor it to clinicalquestion. b. The nuts and bolts of chemical shift ratio assessment of thymic lesions, when applicable. 2. Pitfalls of thymic lesionassessment and how to avoid them a. Case-based figures illustrating how inaccurate assessment of CT, PET, thymic anatomy onMRI, and chemical shift MR imaging can yield pseudolesions and other misinterpretations that can negatively impact clinicalmanagement. b. Case-based figures illustrating how correct performance and interpretation can provide accurate diagnosis andaid clinical management. 3. Summary From this exhibit, the viewer will be able to understand pitfalls in multimodality thymicimaging interpretation and how Thymic MRI, when performed correctly, can help.

CHE020-b

Birt Hogg Dube Syndrome: Not Your Usual Cystic Lung Disease Education ExhibitsLocation: CH Community, Learning Center


ParticipantsPrachi P. Agarwal MD (Presenter): Nothing to Disclose Ezra Haggerty MD : Nothing to Disclose Barry Howard Gross MD : Nothing to Disclose Victoria Raymond : Nothing to Disclose Ella A. Kazerooni MD : Nothing to Disclose William J. Weadock MD : Owner, Weadock Software, LLC

TEACHING POINTS1. To illustrate the clinical manifestations of Birt Hogg Dube (BHD) syndrome 2. To demonstrate the spectrum of imagingfindings in BHD syndrome pertaining to kidneys and lungs 3. To compare and contrast cyst characteristics in BHD syndrome andother cystic lung diseases

TABLE OF CONTENTS/OUTLINE1. Introduction 2. Skin manifestations: Classic triad 3. Renal manifestations a. Solid renal tumors (oncocytomas and renal cellcancers) b. D/D for bilateral hereditary renal masses 4. Lung manifestations a. Cyst characteristics in BHD syndrome i. Cysts ofvariable shapes and sizes ii. Lower lung predominance b. Differentiating features from other cystic diseases i.Lymphangioleiomyomatosis (LAM): Similarities between LAM and BHD include skin, renal and lung involvement. Cysts involvecostophrenic (CP) angles in both. Differentiating features of LAM are uniform round cysts, diffuse distribution and the type ofrenal (angiomyolipomas) and skin lesions (facial angiofibromas etc). ii. Langerhans cell histiocytosis (LCH): Similarities includevariably shaped lung cysts. Differentiating features of LCH are sparing of CP angles, upper lung predominance and associationwith nodules iii. Lymphocytic interstitial pneumonitis: Typically perivascular cysts in a specific clinical setting (e.g. Sjogrensyndrome) often associated with nodules 5. Conclusion

CHE021-b

Pulmonary Function Testing for the Radiologist Education ExhibitsLocation: CH Community, Learning Center

ParticipantsUjval B. Patel MD (Presenter): Nothing to Disclose Michael A. Kadoch MD : Nothing to Disclose Corey Drew Eber MD : Nothing to Disclose Mary Margaret Salvatore MD : Nothing to Disclose Adam Jacobi MD : Nothing to Disclose

TEACHING POINTSPURPOSE The purpose of this exhibit is: 1. To review the major types of pulmonary function tests (PFTs) including spirometry(FEV1, FVC), measurements of lung volumes (TLC), and quantification of diffusion capacity (DLCO). 2. To review theinterpretation of pulmonary function test values in determining the pattern of abnormality (i.e. obstructive, restrictive, ormixed). 3. To correlate abnormal pulmonary function test patterns with chest x-ray and/or chest CT imaging findings.TEACHING POINTS The major teaching points are: 1. To review the basic principles of lung physiology and the major types ofpulmonary function testing. 2. To provide the radiologist with an organized approach to interpreting PFTs and identify patternsof lung disease. 3. To correlate abnormal pulmonary function test patterns with chest imaging findings. 4. To guide theradiologist in forming and narrowing differential diagnoses based on the combination of imaging findings and PFT values.

TABLE OF CONTENTS/OUTLINECONTENT ORGANIZATION Briefly review lung physiology associated with PFT measurements. Describe abnormal PFT results andtheir clinical significance. Provide a simple algorithm in identifying the main patterns of lung disease based on PFT values.Review chest x-ray and chest CT imaging findings that correlate with specific abnormal PFT patterns.

CHE022-b

Architectural Distortion and Fibrotic Response of the Lung: Pictorial Essay Education ExhibitsLocation: CH Community, Learning Center

Participants

Sandra Milena Ramirez MD (Presenter): Nothing to Disclose Ana Cristina Manzano MD : Nothing to Disclose Catalina de Valencia MD : Nothing to Disclose Diana Constanza Quesada MD : Nothing to Disclose Carlos Javier Cogollo MD : Nothing to Disclose Catalina Barragan MD : Nothing to Disclose

TEACHING POINTSDevelopment of abnormal fibrous tissue in the lung is the final sequel of a variety of pathologies. Processes that result inparenchymal fibrosis distort normal architecture of the lung. The purpose of this exhibit is: 1. To explain imaging signs of lungfibrosis 2. To present imaging of different diseases where the lung may be involved in a fibrotic response and also explain howthese processes occur 3. To establish regional distribution at CT of fibrotic process

TABLE OF CONTENTS/OUTLINE1. Definition 2. Imaging signs of fibrotic response of the lung, patterns and distribution 3. Causes of pulmonary fibrous reaction -Idiophatic disorders - Congenital conditions - Iatrogenic - Post infectious - Connective tissue disorders - Inhalation oroccupational exposure - Others 4. Conclusions

CHE023-b

Syndromes and Congenital Diseases: Attaching Relevance for the Adult Chest Radiologist toInformation Long Forgotten Education ExhibitsLocation: CH Community, Learning Center

ParticipantsCindy Renee Miller MD (Presenter): Nothing to Disclose

TEACHING POINTS1. Complications of congenital disease may manifest in adulthood. 2. Congenital diseases may mimic acquired diseases. 3.Congenital diseases are no longer seen only in children due to improved treatments. 4. Treatment of congenital malformationsmay lead to confusing appearances on adult radiographs. 5. Knowledge that a patient has an underlying syndrome may allowfor a narrower differential diagnosis of abnormalities.

TABLE OF CONTENTS/OUTLINEI. Background II. Complications of congenital anomalies a. Malignancy within a CPAM b. Malignancy within a colonicinterposition used in the setting of esophageal atresia III. Congenital disease mimicking acquired disease a. Job syndromemimicking allergic bronchopulmonary malformation b. Sequestration mimicking pneumonia c. Absent pulmonary artery andassociated fibrosis mimicking interstitial lung disease IV. Congenital disease previously restricted to children, now seen in adultsa. Cystic fibrosis V. Confusing findings attributable to treatment of congenital malformations a. Pacer lead position in patientwith TGA post Mustard procedure VI. Knowledge of underlying syndrome allowing for narrowing of differential diagnosis a.Solitary pulmonary nodule in patient with HHT = AVM b. Paraspinous lesions in patient with neurofibromatosis = meningoceles

CHE100

Congenitial and Acquired Diseases of the Aorta Education ExhibitsLocation: CH Community, Learning Center

ParticipantsShirley Chan MD (Presenter): Nothing to Disclose Mohammed Mohsin Khadir MD : Nothing to Disclose Abhishek Chaturvedi MD : Nothing to Disclose

TEACHING POINTSCharacterize the most common anomalies and diseases of the aorta. Review the imaging findings of these entities usingillustrations, radiographs, CT, and MR

TABLE OF CONTENTS/OUTLINEReview the developmental anatomy of the aorta. Discuss most common congenital and development aortic anomalies anddiseases. Present the imaging findings of these entities using illustrations, radiographs, CT, and MR. After the review, the readerwill be shown 15 unknown cases in a multiple choice format to cover the most important teaching points Congential anomaliesof the Aortic Arch Double aortic arch Mirror image right aortic arch Right aortic arch with an aberrant left subclavian artery Leftaortic arch with an aberrant right subclavian artery Coarctation Pseudocoarctation Cervical aortic arch Transposition of the greatvessels Patent ductus arteriosus Acquired anomalies of the Aortic Arch: Intramural hematoma Aortic aneurysm Aortic dissectionAortic inflammation Aortic Sarcoma Intramural hematoma Acute aortic injury

CHE101

Emerging Concepts in Intramural Hematoma Education ExhibitsLocation: CH Community, Learning Center


ParticipantsSusan Elizabeth Gutschow MD (Presenter): Nothing to Disclose Christopher Walker MD : Author, Amirsys, Inc Author, Reed Elsevier Santiago Martinez-Jimenez MD : Author, Amirsys, Inc Melissa L. Rosado De Christenson MD : Author, Thieme Medical Publishers, Inc Author, Amirsys, Inc Author, American Registry

of Pathology Author, Oxford University Press Jeffrey Russell Kunin MD : Investigator, Oncimmune LLC

TEACHING POINTS1. Define acute aortic syndrome with emphasis on intramural hematoma 2. Describe pathogenesis, natural progression, andpotential complications of intramural hematoma 3. List cross-sectional imaging findings that impact management and prognosis

TABLE OF CONTENTS/OUTLINE1. Definition of acute aortic syndrome and its subtypes, including intramural hematoma and differences with penetrating aorticulcer and incomplete dissection. 2. Controversies regarding pathogenesis of intramural hematoma (e.g. ruptured vasa vasorumversus microscopic intimal tear versus penetrating aortic ulcer). 3. Description of natural progression and possible complicationsof intramural hematoma including focal mural contrast enhancement (intramural blood pools and ulcerlike projections),progression to complete aortic dissection, and localized aortic dilatation or saccular aneurysm. 4. Cross-sectional findings whichimpact prognosis: initial size of intramural hematoma, initial maximum aortic diameter, Stanford type, initial presence ordevelopment of focal mural contrast enhancement, distinction of intramural blood pool from ulcerlike projection. 5. Outlinecurrent controversies regarding surgical, endovascular, and medical management of intramural hematoma.

CHE102

The Many Faces of Sinus of Valsalva Aneurysms Education ExhibitsLocation: CH Community, Learning Center


ParticipantsMina F. F. Hanna MBBCh (Presenter): Nothing to Disclose Nagina Malguria MBBS : Nothing to Disclose Kirk Gerald Jordan MD : Nothing to Disclose Brian Burns Ghoshhajra MD : Nothing to Disclose Suhny Abbara MD : Research Consultant, Radiology Consulting Group

TEACHING POINTS1. Recognition of Sinus of Valsalva (SOV) aneurysms in their myriad presentations on crossectional imaging. 2. Clinical andImaging presentation of ruptured and unruptured SOV aneurysms.

TABLE OF CONTENTS/OUTLINE1. Normal anatomy of the aortic root and sinuses of valsalva 2. Pathophysiology and origin of Sinus of Valsalva aneurysmsCongenital: Incomplete fusion of proximal and distal bulbar cordis, anatomic defect in the elastc tissue, deficiency of the conalseptum. Acquired: posttraumatic, prior aortic surgery, endocarditis, cystic medial necrosis 3. Typical and Atypical appearancesof Sinus of Valsalva aneurysms on CT • Saccular contrast outpouching: (Typical aneurysmal) • Mass like (intracardiac, aortic,interatrial septum) • Thrombosed 4. Associated cardiac abnormalities. 5. Ruptured SOV aneurysm or fistula: Incidence, siteswith frequency, clinical significance. 6. Pitfalls and variants. Asymmetric dilatation of the sinuses of valsalva, aorta-right atrialtunnel.

CHE103

Thoracic Aortic Aneurysms: What Every Radiologist Should Know To Effectively CommunicateWith Cardiologists and Cardiothoracic Surgeons Education ExhibitsLocation: CH Community, Learning Center

ParticipantsAmanda Lea Steinberger DO (Presenter): Nothing to Disclose Oleg Teytelboym MD : Nothing to Disclose

TEACHING POINTS1. Examine current guidelines (American, European, and other international) with respect to radiologic diagnosis and treatmentof thoracic aortic aneurysms (TAAs) 2. Illustrate imaging appearance and proper measurement techniques of TAAs acrossmultiple modalities (CT, MRI, Echo) based on current guidelines through pictorial illustration 3. Review common pitfalls in TAAmeasurement 4. Illustrate TAA complications 5. Review post-repair imaging of TAAs

TABLE OF CONTENTS/OUTLINEOur exhibit will review 3D imaging of the aorta as well as proper measurement and diagnosis of thoracic aortic aneurysms basedupon the current guidelines. After a brief discussion and comparison of current guidelines, we will demonstrate multimodalityimaging of thoracic aortic aneurysms, with an emphasis on proper measurements and examples of common pitfalls. Additionally,we will pictorially illustrate the appearances of complications of TAAs such as dissection and intramural hematomas. Review postrepair appearance of TAAs and optimal imaging techniques. Finally, we will summarize our presentation with key points formeasuring TAAs in daily radiology practice.

CHE104

Typical and Atypical Imaging Features of Takayasu Arteritis Education ExhibitsLocation: CH Community, Learning Center

ParticipantsIchiro Sakamoto (Presenter): Nothing to Disclose Hideyuki Hayashi : Nothing to Disclose Hiroki Nagayama : Nothing to Disclose Hironori Onizuka MD : Nothing to Disclose

Eijun Sueyoshi MD : Nothing to Disclose Masataka Uetani MD : Nothing to Disclose

TEACHING POINTS1. To learn optimal imaging techniques (CT, MRI, PET, angiography) in the diagnosis of Takayasu arteritis (TA) 2. To learntypical imaging features of TA 3. To learn atypical imaging features of TA 4. To learn pitfalls and limitations of each imagingmodality

TABLE OF CONTENTS/OUTLINE1. Introduction 2. Optimal imaging techniques in the diagnosis of TA 3. Typical imaging features of TA - Stenoocclusive lesions ofthe aorta and its major branches, and pulmonary artery - Aneurysmal changes of the aorta and its major branches - Thickeningand contrast-enhancement of the vessel wall in early-phase TA 4. Atypical imaging features of TA - Dissection, rupture, andpseudoaneurysm of the aorta - Pulmonary infarction - Pulmonary artery dissection - Coronary artery aneurysm - Cardiacinvolvement (myocarditis, pericarditis) 5. Pitfalls in the diagnosis of TA 6. Summary

CHE105

Non-neoplastic Intrathoracic Masses: When Cancer is not the Answer Education ExhibitsLocation: CH Community, Learning Center

ParticipantsArmando S. Herradura MD (Presenter): Nothing to Disclose Pierre D. Maldjian MD : Nothing to Disclose

TEACHING POINTS

Radiologists often encounter mass lesions in the lungs and mediastinum on imaging studies. It is essential for radiologists torecognize findings that suggest non-neoplastic disease when evaluating an intrathoracic mass to most efficiently directsubsequent patient workup and management. The purpose of this exhibit is to:

Illustrate the appearances of some unusual non-neoplastic lesions of the lungs and mediastinum that can mimicmalignancy.

1.

Discuss features that suggest a benign etiology or a specific diagnosis.2.


Introduction: Importance of differentiating benign from malignant lesions.1.Mediastinal lesions to be discussed include: bronchopulmonary foregut malformations, extramedullary hematopoiesis,diaphragmatic defects, non-neoplastic adenopathy, meningocele, and fibrosing mediastinitis.

2.

Lung parenchymal lesions presented include: bronchogenic cysts, sequestration, rounded atelectasis and mass lesions ofinfectious or inflammatory etiology.

3.

Summary - imaging features that suggest benign disease.4.References5.

CHE106

Pathology of the Trachea and Central Bronchi with Radiologic-pathologic Correlation Education ExhibitsLocation: CH Community, Learning Center

Cum Laude

ParticipantsGirish S. Shroff MD (Presenter): Nothing to Disclose Daniel Ocazionez MD : Nothing to Disclose Pushpender Gupta MBBS : Nothing to Disclose Arun C. Nachiappan MD : Nothing to Disclose Rosa M. Estrada-Y-Martin : Nothing to Disclose Caleb C. Richards MD : Nothing to Disclose Emma Cathryn Ferguson MD : Nothing to Disclose Daniel Vargas MD : Nothing to Disclose Carlos S. Restrepo MD : Nothing to Disclose Sandra Alice Ann Oldham MD : Nothing to Disclose

TEACHING POINTS

The trachea and central bronchi are often ignored on radiographic and computed tomographic exams of the chest. Afterreviewing this exhibit, the participant will have a greater interest in, and an improved understanding of, disease processes thataffect the trachea and central bronchi.

In this exhibit, we will:

Briefly review anatomy of the trachea and central bronchi

Review imaging of pathologic conditions of the trachea and central bronchi with pathologic correlation

TABLE OF CONTENTS/OUTLINENormal anatomy of trachea and central bronchi Tracheal and central airway pathology Cartilaginous diseases(tracheobronchopathia osteochondroplastica, relapsing polychondritis) Inflammatory (Wegener's, sarcoidosis, amyloidosis)Infectious (bacterial tracheobronchitis, Aspergillus tracheobronchitis) Neoplastic (squamous cell carcinoma, adenoid cysticcarcinoma, carcinoid, metastatic disease) Trauma/iatrogenic (perforation, post-intubation stenosis) Other (Mounier-Kuhn)

CHE107

Radiological and Histopathological Correlation of Thymic Epithelial Tumors Education ExhibitsLocation: CH Community, Learning Center

Magna Cum Laude

ParticipantsTakahiko Nakazono MD, PhD (Presenter): Nothing to Disclose Ken Yamaguchi MD : Nothing to Disclose Ryoko Egashira MD : Nothing to Disclose Masanobu Mizuguchi MD : Nothing to Disclose Hiroyuki Irie MD, PhD : Nothing to Disclose

TEACHING POINTSThe purposes of this exhibit are to: review computed tomography (CT) and magnetic resonance (MR) imaging features with thecorrelation of histopathological features of thymic epithelial tumors illustrate the differential diagnosis of anterior mediastinallesions show the imaging evaluation points to be considered before the treatment of thymic epithelial tumors

TABLE OF CONTENTS/OUTLINEWorld Health Organization histopathological classification of thymic epithelial tumors CT and MR imaging features of thymicepithelial tumors (including thymomas [types A, AB, B1, B2, and B3], squamous cell carcinomas, mucoepidermoid carcinomas,basaloid carcinomas, lymphoepithelioma-like carcinomas, carcinoid and neuroendocrine carcinomas, undifferentiatedcarcinomas, thymoma and thymic carcinomas arising in multilocular thymic cysts, etc.) with histopathological correlationDifferential diagnosis of other anterior mediastinal lesions (including thymic hyperplasia, thymolipoma, malignant lymphomas,germ cell tumors, intrathoracic goiter, etc.) Imaging evaluation points to consider before the treatment of thymic epithelialtumors (including Masaoka classification, TNM classification, extracapsular invasion, dissemination, metastasis, and more)

CHE108

Ready... Set... Go... How Much Do I Know About Esophageal Strictures? Education ExhibitsLocation: CH Community, Learning Center


ParticipantsJustin Ross Hutto MD : Nothing to Disclose Jessica Garrette Zarzour MD (Presenter): Nothing to Disclose Sushilkumar K. Sonavane MD : Nothing to Disclose Rupan Sanyal MD : Research Grant, Bracco Group Michelle Mae McNamara MD : Nothing to Disclose Christine O. Menias MD : Nothing to Disclose

TEACHING POINTS

Strictures in the esophagus are caused by many etiologies apart from esophagitis.

The aim of the exhibit is to subject the readers to challenging cases in order to improve their understanding of variousesophageal abnormalities causing strictures.

TABLE OF CONTENTS/OUTLINEEsophageal stricture cases from common and uncommon entities will be presented in a quiz format. Images with brief clinicalhistory will be displayed along with multiple choices to pick the correct diagnosis from. Key points for the case will behighlighted subsequently. Following cases will be included- Cervical esophageal web Vascular ring Cricopharyngeal barEpidermolysis bullosa Eosiniphillic esophagitis Squamous cell carcinoma Barrett's esophagus with adenocarcinoma LymphomaProlonged NG tube placement Caustic Crohn's Post treatment, ie post esophageal banding for varices Post radiation Pill inducedPeptic stricture

CHE109

Tracheal Lumps and Bumps: The Good, the Bad and the Unusual Education ExhibitsLocation: CH Community, Learning Center


ParticipantsSonia Liliana Betancourt Cuellar MD (Presenter): Nothing to Disclose Annikka Weissferdt MD : Nothing to Disclose Diana Maria Palacio MD : Nothing to Disclose Brett Wilson Carter MD : Author, Reed Elsevier Consultant, St. Jude Medical, Inc Edith Michelle Marom MD : Nothing to Disclose

TEACHING POINTS1-To describe unusual tracheal tumors, other than squamous cell carcinoma and adenoid cystic carcinoma 2- To review the CTand clinical findings of uncommon tracheal tumors, emphasizing axial imaging and clinical characteristics that can help narrowthe differential diagnosis 3- To alert the radiologist to imaging features typical for benign versus malignant lesions 4-To describethe pathology characteristics of these tumors.

TABLE OF CONTENTS/OUTLINE1.Anatomic and histologic overview of the trachea 2.Histologic classification of atypical tracheal tumors 3.Review imaging

findings (CT and FDG PET/CT) with histopathology and clinic correlation 4.Summary

CHE110

Approach to Diagnosis of Pulmonary Fungal Infections Education ExhibitsLocation: CH Community, Learning Center

ParticipantsAshish Rajendra Khandelwal MD (Presenter): Nothing to Disclose Prashant Nagpal MD : Nothing to Disclose Naman Sanjiv Desai MD : Nothing to Disclose James Conner MD : Nothing to Disclose Ameya Jagadish Baxi MBBS, DMRD : Nothing to Disclose Sachin Shyamsunder Saboo FRCR, MD : Nothing to Disclose

TEACHING POINTS

Reader will be able to accomplish following by viewing the exhibit-

Rational and simplified clinic-radiological algorithm for radiologists to diagnose pulmonary fungal infectionsImaging spectrum of common pulmonary fungal infections with focus on diagnostic clues for arriving at the diagnosisImaging of emerging uncommon fungal infections

TABLE OF CONTENTS/OUTLINE1. Case based review of common and uncommon pulmonary fungal infections. 2. Each case to be discussed as: key imagingpearls, diagnostic pitfalls, common mimics and differential diagnosis. 3. Role of imaging in management and follow-up ofpulmonary fungal infections.

CHE111

Bronchiolitis: A Schematic Diagnostic Approach with Radiologic-pathologic Correlation Education ExhibitsLocation: CH Community, Learning Center


ParticipantsMariana Nelida Benegas Urteaga MD (Presenter): Nothing to Disclose Marcelo Sanchez MD : Nothing to Disclose Jose Ramirez MD : Nothing to Disclose Daniel Barnes MD : Nothing to Disclose Teresa Maria de Caralt : Nothing to Disclose Rosario Jesus Perea MD, PhD : Nothing to Disclose

TEACHING POINTS1. To show the classification of bronchiolitis with radio-pathological correlation 2. To provide an easy and schematic diagnosticapproach, based on HRCT findings and relevant clinical information 3. To emphasize the role of post-processing techniques: MIP,MinIP and densitometric evaluation

TABLE OF CONTENTS/OUTLINE1. Introduction 2. Anatomy and histology of the pulmonary secondary lobule 3. HRCT imaging: contribution of MIP and MinIPreconstructions a. Direct signs: Centrilobular Nodules and Tree-in-Bud patterns b. Indirect signs: Mosaic attenuation and Airtrapping patterns 4. Dual-Energy CT imaging and post-processing techniques in air trapping quantification. 5. Classification ofBronchiolitis: HRCT findings with pathologic correlation a. Cellular bronchiolitis i. Infections ii. Hypersensitivity pneumonitis iii.Aspiration iv. Respiratory bronchiolitis v. Follicular bronchiolitis vi. Diffuse panbronchiolitis b. Constrictive bronchiolitis i.Swyer-James syndrome ii. Post-transplantation iii. Systemic lupus erythematosus iv. Inhalational disease v. Pulmonaryneuroendocrine hyperplasia 6. Schematic diagnostic approach and key points of the radiological report 7. Conclusions

CHE112

Imaging of Pulmonary Eosinophilia: Not Just a Fleeting Abnormality Education ExhibitsLocation: CH Community, Learning Center

ParticipantsTariq Ali MBBS, MRCP (Presenter): Nothing to Disclose Judith Lynn Babar MBChB : Nothing to Disclose Pasupathy Sivasothy : Nothing to Disclose Anu Balan MBBS, MRCP : Nothing to Disclose

TEACHING POINTS

To recognise a broad spectrum of eosinophilic lung disease on imaging.

Clinical and radiological correlation are required as there are similarities and overlaps within the broad range of diseasemanifestations.

TABLE OF CONTENTS/OUTLINEPurpose/Aim: Review the imaging manifestations of eosinophilic lung disease in patients with blood eosinophilia from ourinstitutional experience. Eosinophilic lung disease is rare, comprising a variety of clinical entities associated with tissue and

blood eosinophilia showing typical and uncommon radiologic manifestations. Content organization: Review of key imagingfindings on radiography and MDCT in pulmonary eosinophilic disease, enhancing knowledge of underlying causes including: 1)Idiopathic a. Eosinophilic pneumonia i. Acute Eosinophilic pneumonia ii. Loffler Syndrome (may have an underlying cause) iii.Chronic Eosinophilic pneumonia; b. Hypereosinophilic syndrome 2) Secondary a. Vasculitis: Churg-Strauss syndrome b. Allergicbonchopulmonary aspergillosis (ABPA); c. Bronchocentric granulomatosis d. Drug reactions e. Tropical eosinophilia f. InfectionSummary: To identify imaging features which help in the classification of pulmonary eosinophilic lung disease, by illustratingkey differences and overlaps, in order to aid correct clinical management.

CHE113

Imaging of Thoracic Infections in the Oncologic Setting Education ExhibitsLocation: CH Community, Learning Center

Cum Laude

ParticipantsMyrna Cobos Barco Godoy MD, PhD (Presenter): Nothing to Disclose Patricia Monique de Groot MD : Nothing to Disclose Marcelo Kuperman Benveniste MD : Nothing to Disclose Brett Wilson Carter MD : Author, Reed Elsevier Consultant, St. Jude Medical, Inc Edith Michelle Marom MD : Nothing to Disclose Mylene Thi Mytien Truong MD : Nothing to Disclose Gerald F. Abbott MD : Author, Thieme Medical Publishers, Inc Author, Amirsys, Inc

TEACHING POINTS1. The use of MDCT to detect infection 2. Worrisome complications of infection requiring immediate intervention 3. CT findingsthat are suggestive of specific types of infection in immunocompromised hosts to initiate tailored therapy in a timely fashion. 4.Pitfalls in imaging of infection in the oncologic setting

TABLE OF CONTENTS/OUTLINE1. Most common infections in immune compromised patients 2. Radiologic patterns of infection and signs a. Halo Sign b.Hypodense sign c. Crescent sign d. Reversed halo sign 3. Complications of invasive fungal pneumonia 4. Differential diagnosis

CHE115

Know How your Lungs Behave with Newer Drugs—Imaging Appearances of Lung ToxicityRelated to Recently Marketed Drugs Education ExhibitsLocation: CH Community, Learning Center

ParticipantsDhiraj Baruah MD (Presenter): Nothing to Disclose Kaushik S. Shahir MD : Nothing to Disclose Rahul N. Sawlani MD : Nothing to Disclose Zachary R. Laste MD : Nothing to Disclose Vijay Ramalingam MD : Nothing to Disclose Kavita Joshi MD : Nothing to Disclose Amit Taneja MD : Nothing to Disclose Nagarjun Rao : Nothing to Disclose Lawrence R. Goodman MD : Nothing to Disclose

TEACHING POINTSPulmonary toxicity of many established drugs have been described in the literature along with their imaging appearances (likeamiodarone, busulfun, lidocaine etc). However, we have encountered changes with several newer drugs (bortezomib, cimzia,voriconazole, remicaide etc.), which are not well described. These changes are very important to understand for proper patientcare. Aim of our exhibit is to present examples of pulmonary changes related to some of the newer drugs and theirpathophysiologic mechanism. This review will help radiologists understand these changes and keep them in differentialconsideration in proper clinical situations.

TABLE OF CONTENTS/OUTLINEa. Overview of pathophysiology of pulmonary changes related to newer drugs. b. Correlating those changes in imaging with caseexamples

CHE116

Parasitic Infections of the Chest: A Guide for Radiologists in 2014 Education ExhibitsLocation: CH Community, Learning Center

ParticipantsGustavo S.P. Meirelles MD, PhD (Presenter): Partner, DICOM Grid Stockholder, Fleury Group Julia Capobianco MD : Nothing to Disclose Dany Jasinowodolinski MD : Nothing to Disclose Dante Luiz Escuissato MD, PhD : Nothing to Disclose Arthur Soares Souza MD, PhD : Nothing to Disclose Pedro Daltro MD : Nothing to Disclose Edson Marchiori MD, PhD : Nothing to Disclose

TEACHING POINTS

The teaching points of this exhibit are:

1. To describe the main tropical and subtropical parasitic diseases in terms of their geographic distribution.

2. To demonstrate their most common imaging, clinical and pathological findings.

TABLE OF CONTENTS/OUTLINEThe authors will focus on the following points: 1. Geographic distribution of tropical and subtropical parasitic diseases which mayaffect the thorax. 2. Review of clinical, imaging and pathological findings of the following diseases, with sample cases: 2.1Malaria 2.2 Amebiasis 2.3 Toxoplasmosis 2.4 Trypanosomiasis 2.5 Ascariasis 2.6 Strongyloidiasis 2.7 Dirofilariasis 2.8Cysticercosis 2.9 Toxocariasis 2.10 Syngamosis 2.11 Hydatidosis 2.12 Paragonimiasis 2.13 Schistosomiasis 3. Summary offindings and conclusions.

CHE117

Pulmonary Tuberculosis Beyond Cavitation Education ExhibitsLocation: CH Community, Learning Center

ParticipantsRosana Souza Rodrigues MD, PhD (Presenter): Nothing to Disclose Miriam Menna Barreto MD, PhD : Nothing to Disclose Edson Marchiori MD, PhD : Nothing to Disclose Domenico Capone : Nothing to Disclose Saula Hamad Timene Farias MD : Nothing to Disclose Andrea Brito : Nothing to Disclose

TEACHING POINTS1. Discuss the physiopathology, epidemiology, and clinical manifestations of pulmonary tuberculosis (PTB). 2. Learn to recognizethe atypical distribution and patterns in PTB, such as clusters of small nodules, confluent micronodules, reversed halo sign,fissural nodularity, tracheobronchial abnormalities, endogenous reactivation, Rasmussen's aneurysm. 3. Review and illustrateassociated imaging findings and the differences between active and inactive disease. 4. Discuss the main differential diagnosis.

TABLE OF CONTENTS/OUTLINE1.Comprehensive Review of Pulmonary Tuberculosis: a. Pathogenesis b. Epidemiology c. Clinical manifestations 2. Atypical HRCTimaging findings: a. Clusters of small nodules b. Confluent micronodules (sarcoid galaxy sign) c. Reversed halo sign d. Fissuralnodularity e. Tracheobronchial abnormalities e. Endogenous reactivation f. Rasmussen's aneurysm 3. Differences between activeand inactive disease 4. Associated imaging findings 5. Main differential diagnosis

CHE118

Pulmonary Tuberculosis: An Algorithm for Radiologic Evaluation, Management, andTreatment Education ExhibitsLocation: CH Community, Learning Center


ParticipantsXiao Shi MD (Presenter): Nothing to Disclose Arun C. Nachiappan MD : Nothing to Disclose Kasra Rahbar : Nothing to Disclose Lorell Ruiz-Flores MD : Nothing to Disclose Girish S. Shroff MD : Nothing to Disclose Daniel Ocazionez MD : Nothing to Disclose Ketan Yogesh Shah MD, BS : Nothing to Disclose Elizabeth Guy MD : Nothing to Disclose Andrew DiNardo MD : Nothing to Disclose Rodolfo Laucirica MD : Nothing to Disclose Alan Schlesinger MD : Nothing to Disclose

TEACHING POINTSThe purpose o this exhibit is to: 1. Discuss the utility of imaging and laboratory tests in the diagnosis and management ofpulmonary tuberculosis. 2. Demonstrate the radiographic and CT findings of tuberculosis with emphasis on differences betweenimmunocompetent and immunocompromised patients. 3. Discuss an algorithm for the management and treatment of active andlatent tuberculosis.

TABLE OF CONTENTS/OUTLINE1. Description of TB classification system. 2. Illustration of an algorithm for diagnosis and management of pulmonarytuberculosis. 3. Discussion of how the radiographic finding of cavitation affects management and prognosis. 4. Pictorial review ofradiographic and CT findings in pulmonary tuberculosis.

CHE119

Radiologic and Pathologic Manifestations of Thoracic Fungal Disease in theImmunocompetent and Immunocompromised Hosts Education ExhibitsLocation: CH Community, Learning Center

ParticipantsKyle Elmer Pfeifer MD (Presenter): Nothing to Disclose Vivek Bihari Kalra MD : Nothing to Disclose Brian Haas MD : Nothing to Disclose

Adebowale Adeniran MD : Nothing to Disclose Myung Soo Shin MD, DSc : Nothing to Disclose

TEACHING POINTS

1. Thoracic fungal disease result in significant morbidity and mortality and can be best classified according to patient immunestatus.

2. We discuss how the appropriate diagnosis of thoracic fungl disease is important for patient care/prognosis.

3. We review the pathophysiology and radiographic findings of thoracic fungal disease in immunocompetent hosts, focusing ongeographic location, as well as implications for treatment and prognosis

4. We review the pathophysiology and radiographic findings of thoracic fungal disease in the immunocompromised host,focusing on implications for patient care.

TABLE OF CONTENTS/OUTLINEWe describe the prevalence, imaging features, pathological characteristics of common thoracic fungal pathogens, dividingpathogens into opportunistic and endemic categories. Common opportunistic fungal pathogens include Aspergillus, Candida,Cryptococcus, Pneumocystis, and Mucor. Prompt recognition of disease is important for patient morbidity and mortality and canbe difficult in the immunocmpromised host. We then focus on the radiographic and pathologic appearance of common endemicfungal pathogens such as Histoplasma, Coccidioides, Blastomycosis, and Paracocciodiomycosis which have a specific geographicdistribution, and discuss the importance of recognizing thoracic fungal infections as it pertains to patient care.

CHE120

Regional Theater: Avoiding Pitfalls in Thoracic Radiology by Understanding Regional Mycoses Education ExhibitsLocation: CH Community, Learning Center

Cum Laude Selected for RadioGraphics

ParticipantsClinton Eugene Jokerst MD (Presenter): Nothing to Disclose Sterling Kellon Hansen MD : Nothing to Disclose Gregory Kicska MD, PhD : Nothing to Disclose Demetrios A. Raptis MD : Nothing to Disclose Daniel Vargas MD : Nothing to Disclose Veronica Ann Arteaga MD : Nothing to Disclose Sanjeev Bhalla MD : Nothing to Disclose

TEACHING POINTS1. Be familiar with the geographic distribution and prevalence of common endemic mycoses in the United States 2. Recognizethat thoracic manifestations of endemic mycoses can mimic malignancy or tuberculosis and may be encountered on screeningchest CT 3. Identify findings (such as clustered nodules, thin-walled cavities, etc.) which help to differentiate endemic mycosesfrom other entities

TABLE OF CONTENTS/OUTLINE1. Introduction including a discussion of how thoracic manifestations of endemic mycoses are likely to be encountered regularlyon lung cancer screening CTs 2. Discussion of prevalence, distribution, and common clinical manifestations of common endemicmycoses in the United States 3. Review of imaging findings which will help the radiologist avoid pitfalls such as misinterpretingregional mycosis as malignancy or tuberculosis 4. Case examples including: a. Histoplasmosis b. Blastomycosis c.Coccidiomycosis d. Cryptococcus gattii e. Mimics (including but not limited to tuberculosis, bronchogenic carcinoma) 5.Conclusions

CHE121

TB or not TB? CT Findings of DS, MDR and XDR Pulmonary Tuberculosis in Non-AIDS Patients Education ExhibitsLocation: CH Community, Learning Center

ParticipantsEdilberto David Villanueva MD : Nothing to Disclose Larry Marden Alpaca Rodriguez MD (Presenter): Nothing to Disclose Lourdes Angela Chumbimune Vivanco MD : Nothing to Disclose

TEACHING POINTS• Tuberculosis (TB) is a common worldwide airborne infection and it is a medical and social problem with high mortality andmorbidity, especially in developing countries like Peru and Haiti that share the highest incidence of MDR and XDR TB. •Pulmonary TB images depend on diverse aspects, being CT a highly sensitive technique in the detection of minimal exudativelesions, subtle or occult parenchymal disease and in assessing disease activity and treatment effectiveness. • Micronodules,nodules, "tree-in-bud" appearance, consolidation, and cavities are the most common CT findings in active pulmonary TB,whereas disappearance of tree-in-bud, pleural effusion and presence of fibrotic change appear to be indicators of treatmenteffectiveness. • Imaging appearances of MDR TB are the same as those of non-MDR TB, however, multiple cavities, nodules andbronchial dilatation seen on CT in young patients with acid-fast bacilli positive sputum, can suggest the presence of MDR TB orXDR TB rather than DS TB.

TABLE OF CONTENTS/OUTLINE1. Introduction 2. Objectives 3. Epidemiology 4. Clinical presentation 5. Imaging features - Primary tuberculosis - Post-primarypulmonary tuberculosis - Miliary pulmonary tuberculosis 6. Multidrug-resistant and Extensively drug-resistant tuberculosis 7.Treatment and prognosis 8. Complications 9. Conclusions

CHE122

The Fungus Among Us: A Review of Pulmonary Aspergillosis Education ExhibitsLocation: CH Community, Learning Center

ParticipantsPatrick Kobes DO (Presenter): Nothing to Disclose Anthony Dennis Mohabir MD : Nothing to Disclose Ilana Kafer MD : Nothing to Disclose Leon Bacchus MD : Nothing to Disclose Arfa Khan MD : Nothing to Disclose

TEACHING POINTS

The purpose of this exhibit is:1. To review the pathophysiology and imaging findings of the spectrum of Pulmonary Aspergillosis.2. To discuss pertinent differential diagnoses as related to the imaging findings and clinical history.

TABLE OF CONTENTS/OUTLINE1. Pathophysiology of Pulmonary Aspergillosis 2. The spectrum of imaging characteristics of Pulmonary Aspergillosis a.Immunocompetent patients i. ABPA ii. Mycetoma b. Immunocompromised patients i. Angioinvasive Aspergillosis ii.Semi-invasive Aspergillosis iii. Airway invasive Aspergillosis 3. Differential Diagnosis / Mimics 4. Summary

CHE123

Thoracic Manifestations of Sickle Cell Disease: Complete Radiological Spectrum Education ExhibitsLocation: CH Community, Learning Center


ParticipantsAmeya Jagadish Baxi MBBS, DMRD (Presenter): Nothing to Disclose Carlos S. Restrepo MD : Nothing to Disclose Gregg William Bean MD : Nothing to Disclose Amy Laura Mumbower MD : Nothing to Disclose Michael James McCarthy MD : Nothing to Disclose Rashmi S. Katre : Nothing to Disclose Mateen Siddiqui MBBS : Nothing to Disclose

TEACHING POINTS1. To study thoracic manifestations of sickle cell disease 2. To discuss the role of imaging in the diagnosis and evaluation ofsuspected complications of sickle cell disease 3. To differentiate manifestations of sickle cell disease from diseases havingsimilar radiological appearances

TABLE OF CONTENTS/OUTLINEPatients with sickle cell anemia frequently develop pulmonary complications due to slow progressive decline in pulmonaryfunction. Though it affects multiple organs, pulmonary complications are the prime cause of morbidity and mortality in sicklecell disease. Pulmonary manifestations can be divided into acute and chronic. The acute manifestations include acute chestsyndrome, asthma, pneumonia, thromboembolism and left ventricle failure. Chronic manifestations include cardiomegaly,pulmonary edema, pleural effusion, pulmonary fibrosis and pulmonary hypertension. In addition, patients with sickle celldisease frequently suffer from skeletal manifestations which include bone necrosis, osteomyelitis, extramedullaryhematopoiesis, osteopenia and pathologic fractures. Many of these manifestations have a distinct radiological appearance onplain radiographs, CT scans and MRI. A timely and accurate radiological diagnosis of thoracic manifestations and complications ofsickle cell may have significant impact on treatment and patient survival.

CHE124

Thoracic Tuberculosis: Typical and Atypical Radiological Manifestations. An Anatomic-basedApproach Education ExhibitsLocation: CH Community, Learning Center

ParticipantsSebastian Bravo-Grau MD, MSc (Presenter): Nothing to Disclose Jose Gutierrez Chacoff MD : Nothing to Disclose Ignacio Maldonado MD : Nothing to Disclose Cristian Varela MD : Nothing to Disclose Veruska de Luccas : Nothing to Disclose

TEACHING POINTSSigns of bronchiolitis associated with the presence of cavitation with or without hilar or mediastinal hypodense adenophaties arefindings highly suggestive of TB (tuberculosis). The knowledge of the uncommon presentations of thoracic TB helps to improvethe diagnosis, thereby avoiding unnecessary procedures. For proper interpretation of the unusual manifestations of TB, it isnecessary to integrate in the diagnostic algorithm the radiological, clinical and microbiological findings.

TABLE OF CONTENTS/OUTLINEIntroduction -Pathogenesis -Microbiological and genetic diagnosis Large airway -Acute tracheobronchitis -Tracheobronchialstenosis -Tracheobronchomegaly tuberculous Small airway -Acute Bronchiolitis -Contrictiva Bronchiolitis Pulmonary parenchyma-Consolidations -Cavitations -Miliary pattern -Nodules -Galaxy sign -Reverse halo sign Pleuro-parietal -Pleuricy -Empyemanecessitans -Bronchopleural fistula -Fibrothorax -Spondylitis Mediastinum -Lymphadenopathy -Fibrosing mediastinitis-Constrictive pericarditis -Esophageal fistula -Pott disease Cardiovascular -Myocarditis -Arteritis and arterial thrombosis -Arterial

pseudoaneurism Diagnostic algorithm

CHE125

Current Concepts in Hypersensitivity Pneumonitis Education ExhibitsLocation: CH Community, Learning Center

ParticipantsSantiago Martinez-Jimenez MD (Presenter): Author, Amirsys, Inc Melissa L. Rosado De Christenson MD : Author, Thieme Medical Publishers, Inc Author, Amirsys, Inc Author, American Registryof Pathology Author, Oxford University Press Christopher Walker MD : Author, Amirsys, Inc Author, Reed Elsevier Jeffrey Russell Kunin MD : Investigator, Oncimmune LLC Paul P. Pettavel MD : Nothing to Disclose

TEACHING POINTS1. The traditional classification of hypersensitivity pneumonitis (HP) includes acute, subacute and chronic types. Subacute HP ischaracterized by diffuse centrilobular ground-glass nodules. Chronic HP typically manifests as upper lobe predominantarchitectural distortion and fibrosis and may exhibit ground-glass opacity and air-trapping. 2. A proposed new classificationdivides HP into two disease clusters. Cluster 1 HP is characterized by respiratory symptoms (e.g. chest tightness), occurrencehours after exposure, systemic symptoms (e.g. chills, body aches), and imaging features of acute and subacute HP. Cluster 2 HPis characterized by symptoms similar to those of chronic interstitial lung disease (i.e. clubbing, hypoxemia, inspiratorycrackles), abnormal pulmonary function tests, and imaging features of chronic HP.

TABLE OF CONTENTS/OUTLINE1. Describe traditional classification and imaging features of HP. 2. Discuss limitations of the traditional classification includingpoor epidemiologic and pathologic validation and poor evidence of disease progression along the acute, subacute, and chronicspectrum. 3. Outline proposed new classification based on demographic, clinical and HRCT features which divides disease intoCluster 1 and Cluster 2. 4. Present typical imaging findings of HP in both clusters with supporting histopathology.

CHE126

Imaging Characteristics of Pleuroparenchymal Fibroelastosis, A Rare form of InterstitialPneumonia: What the Radiologist Needs to Know Education ExhibitsLocation: CH Community, Learning Center

ParticipantsLan-Chau Thi Kha MD, MSc (Presenter): Nothing to Disclose David M Hwang MD,PhD : Nothing to Disclose Demetris Andrea Patsios MBBCh : Nothing to Disclose Gordon Weisbrod MD : Nothing to Disclose Taebong Chung MD : Nothing to Disclose

TEACHING POINTSPleuroparenchymal fibroelastosis (PPFE) has recently been classified as a separate interstitial pneumonia. PPFE may beidiopathic or may be related to underlying medical conditions such as bone marrow and lung transplantation, recurrent infectionand autoimmunity. An understanding of the etiologies, histopathology and imaging characteristics of this rare interstitialpneumonia is important, particularly as the radiologist may be the first member of the health care team to consider thisdiagnosis in the presenting patient. The purpose of the exhibit is: 1. To review the etiologies, clinical presentation anddemographic of PPFE. 2. To review the underlying histopathologic changes that produces the chest radiograph and CT imagingappearances of PPFE. Histopathologic imaging with correlative radiographic imaging from our institution will be used as teachingcases. 3. To highlight the characteristic findings of PPFE on chest radiograph and CT. Idiopathic, bone marrow transplant andlung transplant cases of PPFE from our institution will be used to illustrate specific imaging features. Imaging of progressive PPFEwill also be presented.

TABLE OF CONTENTS/OUTLINE1. Demographics and clinical presentation 2. Etiologies of PPFE 3. Imaging-histopathologic correlation of PPFE: 4. Imagingcharacteristics of PPFE on: • chest radiograph • chest CT

CHE127

Just Breathe! A SLEw of CT Findings in SLE Patients with Thoracic Involvement andCorrelations with Serology, Smoking and PFT's Education ExhibitsLocation: CH Community, Learning Center

ParticipantsKim Lee MD (Presenter): Nothing to Disclose Anna Shmukler MD : Nothing to Disclose Benjamin Zalta MD : Nothing to Disclose Linda Broyde Haramati MD, MS : Investor, OrthoSpace Ltd Investor, Kryon Systems Ltd Spouse, Board Member, Bio Protect LtdSpouse, Board Member, OrthoSpace Ltd Spouse, Board Member, Kryon Systems Ltd

TEACHING POINTS

The purpose of this exhibit is to:

1) Review the pathophysiology of SLE focusing on the development of the antibodies to native dsDNA, as they are relativelyspecific for the diagnosis of SLE

2) Identify and describe thoracic imaging manifestations of SLE on chest CT.

2) Identify and describe thoracic imaging manifestations of SLE on chest CT.

3) Discuss the pulmonary function abnormalities associated with SLE.

4) Correlate imaging findings with smoking status, pulmonary function tests, and double-stranded DNA (dsDNA) serology.

TABLE OF CONTENTS/OUTLINEReview of pathophysiology of SLE Review of cases demonstrating chest CT findings in SLE Airway involvement- BronchiectasisParenchymal disease- From ground glass opacities and linear opacities to manifestations of fibrosis including honeycombing andarchitectural distortion Pleural Involvement- Pleural Effusions, Pleural Thickening Cardiac Involvement- Cardiomegaly,Pericardial effusions,Pericardial Thickening Pulmonary Embolism Pulmonary Hypertension Lymphadenopathy- Axillary,Mediastinal, Hilar Esophageal disease- Esophageal dilatation, Esophageal thickening Upper abdominal findings- Splenomegaly,Lymphadenopathy Discussion of correlations between smoking status and PFTs with imaging abnormalities in SLE Discussion ofcorrelations between dsDNA serology with imaging abnormalities in SLE Future directions and summary

CHE128

Long-term Follow-up CT Findings in Chronic Interstitial Lung Diseases Education ExhibitsLocation: CH Community, Learning Center

ParticipantsMasanori Akira MD (Presenter): Nothing to Disclose Sayoko Tokura : Nothing to Disclose Tomohisa Okuma MD, PhD : Nothing to Disclose Narufumi Suganuma MD : Nothing to Disclose

TEACHING POINTS1. To describe CT findings, pathologic findings, and long-term follow-up CT findings in several of chronic interstitial lungdiseases 2. To learn honecombing and various changes other than honeycombing on long-term follow-up CT scans in chronicinterstitial lung diseases

TABLE OF CONTENTS/OUTLINETABLE OF CONTENTS: 1. Idiopathic plmonary fibrosis (IPF) 2. Non-specific interstitial pneumonia (NSIP) 3. Desquamativeinterstitial pneumonia (DIP) 4. Combined pulmonary fibrosis and emphysema (CPFE) 5. Pleuroparenchymal fibroelastosis (PPFE)6. Chronic hypersensitivity pneumonitis 7. Sarcoidosis 8. Pulmonary Langerhans' cell histiocytosis OUTLINE: The previousconcept of end-stage lung disease suggested a final common pathway for most ILD. The end-stage disease is characterized bythe presence of extensive honeycombing, however, sequential CT scans in chronic ILD show various changes other thanhoneycombing. In long-standing fibrotic NSIP, a small focus of honeycombing is found and mainly consists of dilatation ofbronchioles rather than dilatation of peripheral air spaces. In DIP and pulmonary Langerhans' cell histiocytosis, ground-glassopacity and nodular opacity evolve into emphysema-like lesions on CT. In CPFE and sarcoidosis, honeycomb cysts tend to belarger than in UIP.

CHE129

Perilobular Anatomy and Abnormalities on CT: Radiologists Should Memorize and UnderstandThem! Education ExhibitsLocation: CH Community, Learning Center

ParticipantsTakeshi Johkoh MD, PhD (Presenter): Research Consultant, Bayer AG Research Consultant, F. Hoffman-La Roche Ltd Kazuya Ichikado MD, PhD : Nothing to Disclose Kiminori Fujimoto MD, PhD : Nothing to Disclose Tomonori Tanaka MD : Nothing to Disclose Junya Fukuoka : Nothing to Disclose Noriyuki Tomiyama MD, PhD : Nothing to Disclose

TEACHING POINTSTo acknowledge the essential anatomy in perilobular areas To learn precise pathologic backgrounds of perilobular abnormalitieson CT

TABLE OF CONTENTS/OUTLINEContents A.Anatomy Perilobuloar structures; interlobular septa, pleura, veins, and large bronchus and arteries Extralobularpulmonary arteries and bronchi are borders of lobules. Perilobular interstitium encloses lymphatic vessels. B.Perilobularabnormalities on CT; Perilymphatics Showing nodular border; Lymphangitic carcinomatosis, sarcoidosis, etc Showing smoothborder Interstitial edema, etc Parenchymal Showing irregular border Usual interstitial pneumonia, organizing pneumonia,etc.Summary Although pulmonary lobules are the most important lung units, acknowledgement of lobular borders and perilobularabnormalities on CT has not still been enough. All normal structures other than centrilobular arteries and bronchioles on CTlocate on lobular borders. Parenchymal diseases as good as interstitial ones cause perilobular abnormalities. We will let youunderstand perilobular structures and abnormalities using many impressive histological and CT images.

CHE130

Thoracic Manifestations of Inherited Interstitial Lung Diseases: Genotype vs. Phenotype Education ExhibitsLocation: CH Community, Learning Center

ParticipantsSaurabh Agarwal MD (Presenter): Nothing to Disclose Marilyn J. Siegel MD : Research Consultant, Siemens AG Speakers Bureau, Siemens AG Cylen Javidan-Nejad MD : Nothing to Disclose

TEACHING POINTS1. Discuss inheritance patterns and genotypes of inherited lung diseases in adults 2. Understand CT features of these diseases3. Describe a pattern-based approach to diagnosing inherited lung diseases, based on predominant CT abnormality: nodules,lines, airspace patterns, and cysts.

TABLE OF CONTENTS/OUTLINEIntroduction: Importance of multidisciplinary consultation in diagnosis of inherited lung disease Genetics in inherited lungdisease CT findings of diseases with diffuse systemic abnormalities Tuberous sclerosis LymphangioleiomyomatosisNeurofibromatosis Cystic Fibrosis Marfan Syndrome Birt-Hogg-Dube Other rare diseases CT findings of diseases withpredominantly pulmonary phenotypes Congenital pulmonary alveolar proteinosis Alpha1-antitrypsin deficiency Kartagenersyndrome Key primary elements to identify inherited lung disease: a pattern based approach Conclusion: Understanding the CTfeatures of inherited interstitial lung diseases is vital for appropriate diagnosis and treatment planning Future directions ofgenetic analysis in inherited lung diseases

CHE131

Update of the International Multidisciplinary Classification of the Idiopathic InterstitialPneumonias: Revised Concepts and Radiologic Implications Education ExhibitsLocation: CH Community, Learning Center

ParticipantsYeon Joo Jeong MD : Nothing to Disclose Ji Won Lee MD (Presenter): Nothing to Disclose Geewon Lee MD : Nothing to Disclose Chang Hun Lee MD : Nothing to Disclose Seungbaek Hong MD : Nothing to Disclose

TEACHING POINTSThe purpose of this exhibit is to provide an illustrated overview of the update of the 2002 ATS/ERS internationalmultidisciplinary classification of the idiopathic interstitial pneumonias with an emphasis upon what the radiologist needs toknow in order to successfully contribute to the multidisciplinary strategic management of the patients. The major teachingpoints: 1. Substantial progress has been made in idiopathic interstitial pneumonias since the previous classification. 2. A groupof rare entities, including pleuroparenchymal fibroelastosis and rare histologic patterns, is introduced. 3. Unusual manifestationof idiopathic interstitial pneumonias and important differential diagnostic considerations will be reviewed. 4. The accurateclassification of idiopathic interstitial pneumonias is best done with a collaborative approach between clinicians, radiologists, andpathologists.

TABLE OF CONTENTS/OUTLINE1. Summary of major revisions of the idiopathic interstitial pneumonias classification 2. Multidisciplinary approach for idiopathicinterstitial pneumonias 3. Progress in specific idiopathic interstitial pneumonias since 2002 4. Clinical classification of diseasebehavior 5. Unusual manifestation of idiopathic interstitial pneumonias and important differential diagnostic considerations

CHE133

Cryoablation of Perivascular Neoplasms: Novel Minimally Invasive Approach to TreatUnresectable Tumors Education ExhibitsLocation: CH Community, Learning Center

ParticipantsAmmar Ahmed Chaudhry MD (Presenter): Nothing to Disclose Jung Hwoon Edward Yoon MD : Nothing to Disclose William Henry Moore MD : Research Grant, EDDA Technology, Inc Medical Board, EDDA Technology, Inc Research Grant, GalilMedical Ltd Research Grant, Endo Health Solutions Inc Kenny Lien MD : Nothing to Disclose

TEACHING POINTS1- Review indications, interventional methods, contraindications, complications, pearls and pitfalls of percutaneous cryoablation.2- Cryoablation was previously not recommended for perivascular neoplasms due to heat sink effects and potential damage toadjacent organs. We will discuss novel approach to treat these previously 'do NOT cryo' lesions and how to minimize potentialrisks while obtaining an appropriate size ablation zone. 3- Algorithm to help determine the best treatment modality in managinglung masses.

TABLE OF CONTENTS/OUTLINEA. Anatomy- Effect of cryoablation on vessels, nerves (vagus, phrenic), tracheobronchial tree, esophagus, etc. B. ClinicalFindings secondary to mass effect/obstruction C. Highlight imaging findings (e.g. significance of fat planes) that serve as key topatient inclusion and exclusion criteria. D. Pathophysiology: Cryobiology: Intra- and extracellular mechanisms that promotetumor cell death E. Procedure Technique: discuss key do's and don'ts e.g. not crossing fissures, not ablating needle tract, etc.F. Follow-up: Immediate post-procedure management and follow-up guidelines G. Outcomes: a. Complications: Immediate(PTX, hemorrhage, BPF, nerve injury, etc), Delayed (recurrence, BPF, pleural effusions, etc) b. Survival

CHE134

CT-Guided Biopsy and Fine-Needle Aspiration of Lung Lesions: Technique, DiagnosticPerformance and Complications Education ExhibitsLocation: CH Community, Learning Center

Participants

M. Rosa Calero (Presenter): Nothing to Disclose Esteban Peghini MD : Nothing to Disclose Enrique Rico : Nothing to Disclose GERARDO AYALA : Nothing to Disclose Sergio Alonso : Nothing to Disclose Daphne Castano : Nothing to Disclose

TEACHING POINTSPurpose: 1) To review the advantages of lung imaging-guided interventional procedures. 2) To present our experience withCT-guided procedures, practical difficulties, spectrum of findings and complications you may encounter during FNA/Biopsy.

TABLE OF CONTENTS/OUTLINEINTRODUCTION: The procedure is indicated for indeterminate pulmonary lesions. In lung cancer, when feasible, we should havetumour assessed for the presence of a driver mutation in order to offer a personalized targeted therapy (ALK, EGFR, KRAS)METHOD: All lung lesions punctured with CT-guidance at our institution since January 2012 are reviewed, with 130 lesions sofar. DIAGNOSTIC ACCURACY: Most procedures have been diagnostic with non-small cell lung cancer being the most commondiagnosis followed by metastasis. COMPLICATIONS AND DIFFICULTIES: Pneumothorax is the most common complication,usually small and not requiring chest tube. Hemoptysis is the second more common complication, rarely severe. CONCLUSION:Percutaneous needle biopsy of the lung has high sensitivity, specificity and is relatively safe, and should be considered animportant diagnostic tool in the evaluation of pulmonary lesions. We can obtain reliable samples for mutational analysis. Carefulcase and technique selection is necessary to increase diagnostic yield and avoid unnecessary complications.

CHE135

Do’s and Don’ts of CT-guided Mediastinal Biopsy Education ExhibitsLocation: CH Community, Learning Center

ParticipantsShaunagh McDermott FFR(RCSI) (Presenter): Nothing to Disclose Milena Petranovic MD : Nothing to Disclose Carol C. Wu MD : Author, Reed Elsevier Matthew David Gilman MD : Nothing to Disclose Jo-Anne O. Shepard MD : Consultant, Agfa-Gevaert Group

TEACHING POINTSPre-procedural contrast enhanced CT or MR and PET are helpful in biopsy planning Biopsies of bronchogenic cysts or vascularlesions should be avoided Safe biopsy needle trajectory should be directed away from major vessels, the pericardium, and theheart and not cross the pleura when possible On site rapid cytology can help optimize allocation of biopsy specimen for flowcytometry or special immunological stains Core biopsy improves diagnostic yield compared to FNA alone

TABLE OF CONTENTS/OUTLINE1. Brief introduction to differentials of mediastinal lesions and benefits of CT-guided biopsy 2. Interactive case-based quizquestions to illustrate: a) Pre-biopsy evaluation and patient selection i)Role of contrast-enhanced CT, MR, and PET ii)Do nottouch lesions such as bronchogenic cyst b) Biopsy technique i)Targeting solid, FDG-avid portion of mediastinal mass ii)Needlepath away from major vessels and heart iii) Avoid crossing pleura iv) Role of onsite rapid cytology v) Importance of core biopsyand flow cytometry c) Post-biopsy care i)Complications: pneumothorax, hemothorax, hemopericardium ii) Needle biopsy resultand treatment options

CHE136

Imaging Findings Following Common and Uncommon Bronchoscopy Procedures Education ExhibitsLocation: CH Community, Learning Center


ParticipantsJoseph Thomas Azok MD (Presenter): Nothing to Disclose Ahmed El-Sherief MD : Nothing to Disclose Jason K. Lempel MD : Nothing to Disclose Ruchi Yadav MD : Nothing to Disclose Charles T. Lau MD : Nothing to Disclose Rahul Dinkar Renapurkar MD : Nothing to Disclose

TEACHING POINTS

1. Understand the current diagnostic and therapeutic bronchoscopic techniques utilized by interventional pulmonologists

2. Recognize the normal and abnormal imaging appearance following both diagnostic and interventional bronchoscopyprocedures

TABLE OF CONTENTS/OUTLINE1. Introduction 2. Diagnostic bronchoscopy - description of technique and associated imaging findings 3. Interventionalbronchoscopy - The following procedures will be discussed with their associated imaging findings: - Transbronchial biopsy (e.g.,EBUS, electromagnetic navigation) - Mechanical debulking (e.g., rigid bronchoscopy, balloon bronchoplasty) - Bronchial stentplacement and management - Ablative therapies (e.g., argon laser, cryotherapy, electrocautery) - Endobronchial valveplacement (e.g., endoscopic lung volume reduction, bronchopleural fistula treatment) - Bronchial thermoplasty for managementof asthma - Fiducial marker placement for stereotactic radiosurgery

CHE137

Making of the Distortion for the Real Time IVR-CT System using Slice Image ProjectionMapping Method

Mapping Method Education ExhibitsLocation: CH Community, Learning Center

ParticipantsKatsumi Tsujioka PhD (Presenter): Nothing to Disclose Yasutomo Sato : Nothing to Disclose Hirona Kimata : Nothing to Disclose Masayoshi Niwa : Nothing to Disclose Yoshitaka Isobe : Nothing to Disclose Ryoichi Kato MD : Nothing to Disclose

TEACHING POINTSWe developed the real time IVR-CT system using slice image projection mapping method. It is necessary to let a CT imagewarp to reflect this on the surface of the patient definitely. The operator watches a crooked CT image at the surface of thepatient and understands that it is a CT image in the human body. We carried out the making of the image distortion usingprojection mapping software. And we evaluated the visual precision.(1) A liquid crystalline projector was used to reflect a CTimage. (2) Video Projection Tools (VPT) was used as software to make a distortion. (3) The position of the projector changed itinto Z-axis direction and the X-Y direction. (4) We evaluated the sharpness and the visual effect.

TABLE OF CONTENTS/OUTLINE(1) The angle for the Z-axis was good at 70 degrees from 50 degrees. (2) The angle for the X-Y axis was good at 90 degreesfrom 70 degrees. (3) The change of the sharpness was small. (4) It was recognized as an image in the human body visually. Itwas necessary to let an image warp to perform slice image projection mapping method. By using VPT software, we could makethe distortion precisely and freely.

CHE138

Touch Imprint Cytology during Thoracic Needle Biopsy: Everything the Radiologist Needs toKnow Education ExhibitsLocation: CH Community, Learning Center

ParticipantsMuntasir Hoque MD : Nothing to Disclose Leah Muhm Lin MD : Nothing to Disclose Sue Ellen Martin MD : Nothing to Disclose Christopher Lee MD : Nothing to Disclose Alison Wilcox MD : Speaker, Toshiba Corporation Cameron Hassani MD (Presenter): Nothing to Disclose Farhood Saremi MD : Nothing to Disclose

TEACHING POINTS

Touch imprint cytology (TIC), is a real-time method for microscopic examination of core needle biopsy specimens. TIC providescytologic confirmation of needle position within the target lesion, which may improve diagnostic yield.

An experienced cytopathologist or cytotechnologist is required for assessment of TIC. Inexperience can lead to longer proceduretime and unnecessary manipulation of the biopsy needle, which may result in higher procedural complication rate.Unfortunately, many radiologists may not have access to experienced cytopathologists/cytotechnologists. For these reasons, itcan be extremely useful for the radiologist to determine cytologic adequacy of the biopsy material themselves.

Teaching goals:1. The radiologist will have an understanding of the procedure for creating meaningful TIC slides2. The radiologist will be able to determine adequacy of material on a broad array of histologies


IntroductionDefinition of touch imprint cytology (TIC)Review material required for TICLearn technique for proper TIC preparationIdentify properly and improperly stained slidesReview of cytologic findings, anatomically divided (lung, pleura, mediastinum, chest wall).- Normal cells- Inflammatory findings- Infectious findings- Benign findings- Malignant findingsSample casesSummary

CHE140

A Certifying Examination System for Lung Cancer CT Screening in Japan Education ExhibitsLocation: CH Community, Learning Center

ParticipantsKouzou Hanai PhD : Nothing to Disclose Toru Matsumoto PhD : Nothing to Disclose Yoshihisa Muramatsu PhD (Presenter): Nothing to Disclose Kohei Murao PhD : Manager, Fujitsu Limited Isao Yamaguchi PhD, RT : Nothing to Disclose

Keiichi Nagao MD : Nothing to Disclose

TEACHING POINTS

To establish of a certifying examination system for an authorization radiological technologist expert.

TABLE OF CONTENTS/OUTLINEThe Japan Accreditation Council for Lung Cancer CT Screening in Japan was founded in 2009, and started the system toauthorize radiological technologist (RT). . The capability to detect an unusual finding with the knowledge of lung cancer wasrequired of the authorized RT. In order to examine the capability to detect an unusual finding, software was developedspecifically for this purpose. An administrator registers and loads an image set onto a designated server. Marking of the unusualfindings is performed in advance by the person uploading the image set to create the "truth" answers, which are not displayed.An examinee accesses the image database from a PC on a network, reviews the designated image set and marks any unusualfindings seen in the study. TPF and FPF are calculated automatically and outputted by these operations. 11 certifyingexaminations have been administered. The successful candidate's TPF was 95% or more, and FPF was an average of 0.45 percase. To date, 1122 persons have taken the examination and 947 persons have passed. The authorized RT assists a certifiedPhysician and is indispensable to implementation of a lung cancer CT screening.

CHE141

CT Imaging after Lung Resection: Review of Expected Findings and Guidelines for AccurateInterpretation Education ExhibitsLocation: CH Community, Learning Center

ParticipantsSarel Gaur MD (Presenter): Nothing to Disclose William Henry Moore MD : Research Grant, EDDA Technology, Inc Medical Board, EDDA Technology, Inc Research Grant, GalilMedical Ltd Research Grant, Endo Health Solutions Inc

TEACHING POINTSAs CT imaging techniques have improved, indeterminate nodules are being found with greater frequency. Treatment of thesenodules often leads to open and video assisted minimally invasive lung surgeries. Knowledge of these techniques is necessaryto accurately interpret post treatment scans and prevent confusion on part of the refering base. At our institution, we have alarge cohort of patients who are co-managed by thoracic interventional radiologists and thoracic surgeons and who present forroutine CT follow up. 1. Understand the critical aspects of open and minimally invasive lung resection surgery. 2. Understandthe spectrum of expected findings in the post surgical patient. 3. Review of expected alteration to normal lung anatomy. 4.Guidelines and helpful tips for interpreting follow up CT imaging on patients who are status post open or minimally invasive lungsurgery

TABLE OF CONTENTS/OUTLINEBrief review of surgical techniques for removal of lung nodules and masses. Brief review of normal lung architectureExplanation of alteration to normal anatomy based on alterations incurred in (1) and (2). Guideline / List of Steps for accurateinterpretation of CT images

CHE142

CT, FDG-PET/ CT and MR Imaging of Lung Adenocarcinoma Corresponding to Newly AppliedIASLC/ATS/ERS International Multidisciplinary Classification: Radiologic - PathologicCorrelation Education ExhibitsLocation: CH Community, Learning Center


ParticipantsShinsuke Shimoyama MD (Presenter): Nothing to Disclose Hisanobu Koyama MD, PhD : Nothing to Disclose Yoshiharu Ohno MD, PhD : Research Grant, Toshiba Corporation Research Grant, Koninklijke Philips NV Research Grant,Bayer AG Research Grant, DAIICHI SANKYO Group Research Grant, Eisai Co, Ltd Research Grant, Terumo CorporationResearch Grant, Fuji Yakuhin Co, Ltd Research Grant, FUJIFILM Holdings Corporation Research Grant, Guerbet SA Shinichiro Seki : Nothing to Disclose Mizuho Nishio MD, PhD : Research Grant, Toshiba Corporation Kazuro Sugimura MD, PhD : Research Grant, Toshiba Corporation Research Grant, Koninklijke Philips NV Research Grant,Bayer AG Research Grant, Eisai Co, Ltd Research Grant, DAIICHI SANKYO Group

TEACHING POINTSAdenocarcinoma is the most common histologic subtypes of lung cancer, and advances have taken place in oncology, molecularbiology, pathology, radiology, and surgery during the past few decades. In 2011, an international multidisciplinary classificationsponsored by the International Association for the Study of Lung Cancer, American Thoracic Society, and European RespiratorySociety (IASLC/ATS/ERS) was proposed. This new adenocarcinoma classification provides uniform terminology and diagnosticcriteria for multidisciplinary strategic management. Therefore, the knowledge of radiological findings on not only CT, but alsoFDG-PET/CT and MRI according to this classification may be helpful for clinicians' more accurate classification or subtyping thenodules in routine clinical practice. The major teaching points of this exhibit are: 1. To learn IASLC/ATS/ERS classification oflung adenocarcinomas. 2. To determine the radiological features at various modalities including not only CT, but also PET/CT andMRI with corresponding pathologic findings in each subtype of adenocarcinoma based on IASLC/ATS/ERS Classification

TABLE OF CONTENTS/OUTLINE1. IASLC/ATS/ERS classification of lung adenocarcinomas 2. Management of lung adenocarcinomas and the role of radiologists3. Radiologic, such as CT, FDG-PET, and MRI, - pathologic correlation

CHE143

Dual Energy CT (DECT) in Thoracic Oncology: Qualitative and Quantitative Evaluation Education ExhibitsLocation: CH Community, Learning Center

ParticipantsRoberto Lo Gullo MD (Presenter): Nothing to Disclose Alexi Otrakji MD : Nothing to Disclose Subba Rao Digumarthy MD : Nothing to Disclose Noah Chan H. Choi MD : Nothing to Disclose Jo-Anne O. Shepard MD : Consultant, Agfa-Gevaert Group Mannudeep K. S. Kalra MD : Nothing to Disclose Ranish Deedar Ali Khawaja MD : Nothing to Disclose Sarabjeet Singh MD : Research Grant, Siemens AG Research Grant, Toshiba Corporation Research Grant, General ElectricCompany Research Grant, Koninklijke Philips NV Atul Padole MD : Nothing to Disclose Sarvenaz Pourjabbar MD : Nothing to Disclose Diego Alfonso Lira MD : Nothing to Disclose

TEACHING POINTSRecent publications and our experience suggest role of DECT in thoracic malignancies for differentiating benign versus malignantlesions as well as for assessing treatment response. Teaching points of our educational exhibit are A. Specific scanning protocoland contrast injection delay time are required for evaluation of patients with intrathoracic masses with DECT. B. Use of DECTdatasets to generate blended, monoenergetic and perfused blood volume image types C. Differences between the qualitativeinterpretations of DECT datasets versus single energy chest CT. D. Role of quantitative indexes of contrast uptake in the thoracicmasses from DECT datasets in characterization of thoracic masses. E. Role of DECT for assessing treatment response F.Radiation dose with DECT can be similar to single energy routine chest CT protocols.

TABLE OF CONTENTS/OUTLINE1. Scanning protocol and contrast injection techniques 2. Image processing of DECT datasets 3. Qualitative evaluation ofprocessed images 4. Quantitative metrics of DECT in thoracic oncology: Relative contrast enhancement and iodine concentration5. Advantages and limitations 6. Pictorial depiction of teaching points with series of cases from our institution

CHE144

Evaluating Response to New Targeted Therapies in Lung Cancer: Functional Imaging andPerfusion CT—What Should We Know? Education ExhibitsLocation: CH Community, Learning Center


ParticipantsMarcelo Antonio Sanchez Gonzalez MD (Presenter): Nothing to Disclose Mariana Nelida Benegas Urteaga MD : Nothing to Disclose Noemi Reguart MD : Nothing to Disclose Daniel Barnes MD : Nothing to Disclose Josep Guitart MD : Nothing to Disclose Oscar Sabino Chirife Chaparro MD : Nothing to Disclose Rosario Jesus Perea MD, PhD : Nothing to Disclose Teresa Maria de Caralt : Nothing to Disclose

TEACHING POINTS1. To explain alternative methods to RECIST to evaluate the therapeutic response to new molecularly targeted therapies in lungcancer. 2. To know perfusion CT as a non invasive method to evaluate tumoral angiogenesis 3. To describe the CT technique,data processing and reporting to perform a perfusion CT of pulmonary tumors.

TABLE OF CONTENTS/OUTLINE1. Introduction 2. Molecularly targeted therapies in lung cancer 3. Limitations of RECIST to evaluate response 4. Alternativemethods a. Cavitations: Crabb diameter b. Necrosis: Choi criteria 5. Functional imaging a. Ultrasound b. PET-CT c. MRI d.Perfusion CT 6. Perfusion CT a. Perfusion CT and Angiogenesis b. Pathologic correlation c. Technique i. CT system requirementsii. Contrast administration iii. Post-processing iv. Terminology and units v. Reporting d. Drawbacks/Caveats i. Radiationexposure ii. Reproducibility iii. Standardization of procedures e. Perfusion CT and antiangiogenic treatments 7. Dual-CT to assessperfusion 8. Multifunctional profiling: PET-CT combined with perfusion CT 9. Conclusions

CHE145

Lung Cancer: Limitations and Imaging Pitfalls in Multimodality Staging Education ExhibitsLocation: CH Community, Learning Center


ParticipantsSonia Liliana Betancourt Cuellar MD (Presenter): Nothing to Disclose Diana Maria Palacio MD : Nothing to Disclose Marcelo Kuperman Benveniste MD : Nothing to Disclose Brett Wilson Carter MD : Author, Reed Elsevier Consultant, St. Jude Medical, Inc Patricia Monique de Groot MD : Nothing to Disclose Jeremy J. Erasmus MD : Nothing to Disclose

TEACHING POINTSBy reading this exhibit the learner should accomplish: 1. An improved understanding of the limitations of the TNM-7 for the

staging of NSCLC 2. A greater awareness of the imaging pitfalls encountered in TNM staging and the clinical implications of themis-interpretation of these findings 3. A clinical and imaging approach to clarify imaging pitfalls that can impact staging andpatient management

TABLE OF CONTENTS/OUTLINEDescribe and illustrate the limitations of staging as they pertain to the primary tumor, nodal metastasis and M1 a and M1bmetastatic disease Describe and illustrate imaging pitfalls as they pertain to the primary tumor, nodal metastasis and M1a andM1b metastatic disease Review appropriate use of different imaging modalities including MRI and PET-CT and invasiveprocedures including EBUS to clarify limitations and potential imaging pitfalls that are encountered during the evaluation ofpatients with NSCLC and can result in inaccurate TNM staging

CHE146

Managing Subsolid Lung Nodules: A Case-Based Approach Education ExhibitsLocation: CH Community, Learning Center


ParticipantsMyrna Cobos Barco Godoy MD, PhD (Presenter): Nothing to Disclose Stephen G. Swisher MD : Consultant, GlaxoSmithKline plc John V Heymach MD,PhD : Nothing to Disclose Junya Fujimoto MD, PhD : Nothing to Disclose Ignacio Wistuba MD : Nothing to Disclose Jeremy J. Erasmus MD : Nothing to Disclose

TEACHING POINTS1. Subsolid nodule includes pure ground-glass nodules (GGNs) and part-solid nodules (PSNs). 2. Strong correlation has beendemonstrated between the histologic findings of lung adenocarcinoma with lepidic growth pattern and the CT appearance ofpersistent subsolid nodules. 3. Serial CT imaging has demonstrated stepwise progression of GGNs in a subset of patients,characterized by increase in size and density, as well as development of a solid component. 4. Given the slow growth rate ofGGNs, standardized guidelines with long-term (≥ 3 years) CT follow-up have been proposed using low-dose CT technique. 5.Given the correlation of invasive tumor with the solid component in persistent PSNs, surgical resection should be considered. 6.Radiologists must be familiar with current guidelines for management of solitary and multiple subsolid nodules.

TABLE OF CONTENTS/OUTLINE1. CT-pathologic correlation of the IASLC/ATS/ERS lung adenocarcinoma classification and its clinical significance. 2. Case-basedreview of differential diagnosis of subsolid nodule. 3. Case-based review of isolated subsolid lung nodules management. 4.Case-based review of management of multiple subsolid lung nodules. 5. Case-based review of CT/genomic biomarkercorrelation.

CHE147

Minimally Invasive Adenocarcinoma of the Lung on Thin-section CT Education ExhibitsLocation: CH Community, Learning Center

ParticipantsKeiko Kuriyama MD (Presenter): Nothing to Disclose Yoshinori Kodama MD : Nothing to Disclose

TEACHING POINTS

To understand the new concept of minimally invasive adenocarcinoma of the lung (MIA) proposed by the InternationalAssociation for the Study Lung Cancer, American Thoracic Society, and European Respiratory Society.

1.

To review and validate the contribution of thin-section CT with special attention to ground-glass opacity (GGO) for smallperipheral lung adenocarcinomas associated with good prognosis after surgical resection.

2.

To propose a simple and practical CT criteria for MIA for selecting candidates suitable for limited surgical resection.3.

TABLE OF CONTENTS/OUTLINERadiologic-pathologic correlation Atypical Adenomatous Hyperplasia (AAH) Adenocarcinoma in situ (AIS) Minimally invasiveadenocarcinoma (MIA) Invasive adenocarcinoma with lepidic growth predominant Methods of differentiating MIA from invasiveadenocarcinoma on CT Visual assessment of the GGO area using the lung window (>50%) Maximum diameter of the solidcomponent versus that of the tumor with GGO using the lung window (<0.5) Semi-quantitative measurement:Tumordisappearance rate using the mediastinal and lung window (>0.5) Quantitative analysis using computer software:Computer-aided nodule assessment

CHE148

Misleading Findings at a Chest CT Computer-assisted Detection System Education ExhibitsLocation: CH Community, Learning Center

ParticipantsHiroshi Moriya MD (Presenter): Nothing to Disclose Manabu Nakagawa : Nothing to Disclose Koutarou Sakuma : Nothing to Disclose

TEACHING POINTSTo explain the clinical utility of a computer-assisted detection system (CAD) for pulmonary metastases of extra-thoracic-cancerpatients. 1. To show the false-positive CT findings in CAD system. 2. To show the false-negative nodules in CAD system.

TABLE OF CONTENTS/OUTLINE[Materials and Methods] Consecutive 43 cases with post-operative status of digestive organ cancer or breast cancer. CTscanner:Aquilion ONE,plain chest scan, conventional dose,FC17/FC13. Computer-assisted lung nodule detection system:Xelislung(effective diameter:1mm). Radiologist-detected-nodules and CAD-detected-nodules were compared. [Results] 995nodules(diameter >3mm:536, 3mm>:459) of 43 cases were evaluated. When limited to the size of 5-10mm, sensitivity was89%, and positive predictive value was 85%. [Conclusion] CAD detected a large number of nodules less than 3 mm. As aresult, there was an increase in false positives. And, there were some large nodules in false negative of CAD, however, therewas no oversight of the radiologists. Detection algorithm is quite different from the thinking patterns of radiologists, CAD can beused as a supportive system for pulmonary nodule screening.

CHE149

Next Generation of Low-dose CT Screening for Lung Cancer: Simultaneous Achievement ofRadiation Dose Reduction and Image Quality Improvement Education ExhibitsLocation: CH Community, Learning Center

ParticipantsYoshinori Funama PhD (Presenter): Nothing to Disclose Taiga Goto : Employee, Hitachi, Ltd Yuko Aoki : Employee, Hitachi, Ltd Osamu Miyazaki : Employee, Hitachi Ltd Fumio Kawamata : Nothing to Disclose Kazuo Awai MD : Research Grant, Toshiba Corporation Research Grant, Hitachi Ltd Research Grant, Bayer AG ResearchConsultant, DAIICHI SANKYO Group Research Grant, Eisai Co, Ltd

TEACHING POINTS1. Present an approach to reduce the X-ray radiation dose by using advanced CT techniques in the screening and the follow-upexamination of the lung cancer. 2. Provide a possible countermeasure to reduce radiation dose to the patient while improvingclinical workflow.

TABLE OF CONTENTS/OUTLINETable of Contents: 1. Screening and follow-up examination scheme for lung cancer 2. The roles and challenges of lung cancerscreening CT (LCSCT) 3. Outline of two types of iterative reconstruction (IR) techniques 1) Hybrid IR 2) Model-based IR 4. Theimaging performance of both hybrid and model-based IR 5. Near future aspect of LCSCT 1) Low dose high resolution CT (HRCT)2) Ultra-low dose CT for lung cancer screening Outline: The most challenging part of the LCSCT, recommended by manyorganizations for high risk patients, is to lower radiation dose to the patient. This exhibit presents The key aspects to beconsidered in LCSCT for reducing the radiation dose Reconstruction of high resolution CT (HRCT) images from low-dose CT scandata (1-2mSv) using IR techniques to avoid unnecessary repeat CT scans How IR affects the visibility of the lung nodulesincluding ground-glass opacity (GGO) nodule The feasibility of ultra low-dose CT (0.1mSv) for lung cancer screening

CHE150

Pitfalls in Pulmonary Nodule Characterization Education ExhibitsLocation: CH Community, Learning Center

ParticipantsMyrna Cobos Barco Godoy MD, PhD (Presenter): Nothing to Disclose Brett Wilson Carter MD : Author, Reed Elsevier Consultant, St. Jude Medical, Inc Patricia Monique de Groot MD : Nothing to Disclose Chitra Viswanathan MD : Consultant, Hollister Incorporated Mylene Thi Mytien Truong MD : Nothing to Disclose Jane P. Ko MD : Editor, Reed Elsevier

TEACHING POINTS1. Specific features to differentiate benign from malignant lung nodules include the presence of certain patterns of calcification,interval decrease in nodule size and lack of FDG uptake on PET/CT. 2. Potential pitfalls regarding characteristics to differentiatebenign from malignant lung nodules and decision analysis algorithms will be reviewed. 3. Awareness of potential pitfalls in lungnodule characterization is important in avoiding misinterpretation and in appropriate patient management.

TABLE OF CONTENTS/OUTLINE1. Chest radiograph pitfalls Artifacts Chest wall/ skin lesions Dual-energy radiograph pitfalls 2. Chest CT pitfalls Importance ofthin section CT to characterize lung nodules Transient subsolid nodules Bubbly appearance of malignant ground glass nodulesmimicking emphysema and scarring Malignant nodules growing next to cystic air spaces Malignant nodules with 'benign'patterns of calcification eg. metastases from osteosarcoma, chondrosarcoma Temporary regression of malignant nodulesPost-radiation changes mimicking malignancy Limitations of lung nodule measurement 3. PET/CT Piftalls False positive FDGuptake in infection and inflammation False negative FDG uptake in small lung cancers, adenocarcinoma of the lung andcarcinoid

CHE151

Progression and Recurrence of Lung Cancer: Established Patterns and New Concepts Education ExhibitsLocation: CH Community, Learning Center

Magna Cum Laude

ParticipantsCharlie Sayer MBBS, FRCR (Presenter): Nothing to Disclose Tim Benepal : Nothing to Disclose Arjun Nair MBBCh, FRCR : Nothing to Disclose Myrna Cobos Barco Godoy MD, PhD : Nothing to Disclose Ioannis Vlahos MRCP, FRCR : Research Consultant, Siemens AG Research Consultant, General Electric Company

TEACHING POINTSTumor recurrence is common. o 30-40% of surgically treated stage 1 lung cancer recur due to undetected micrometastases oEarly recurrence on imaging may be missed o Early recognition potentiates the success of second line therapy. Geneticheterogeneity is common. o New therapies based on genetic mutations improve NSCLC outcome o Resistance due to newgenetic mutations/transformation is common o 15% transform to small cell cancer, or develop other defects (50% T790M, 5%MET amplification) (Sequist 2011, Sci Trans Med). Expansion of treatment resistant clones and genetic transformation indicatesneed for therapy change. Surveillance of new therapies may differ from RECIST/WHO criteria and determine when rebiopsy isindicated.

TABLE OF CONTENTS/OUTLINE3 international lung cancer treatment centers. Cases to demonstrate: • Expected timelines and locations for disease recurrence• Influence of initial therapy (surgery, chemoradiation, biologic) on RECIST/WHO criteria, imaging appearances/progression •Unusual patterns of spread - Imaging protocols to address • Pitfalls of progression - biologic therapy, bone disease • Tumorheterogeneity and evolution on treatment • Tumor genetic/histological transformation - when to re-biopsy to change treatmentor rechallenge with original therapy

CHE152

Radiologic Findings of Lung Adenocarcinoma and Differential Diagnosis: When is it LungCancer? A Radiologic-pathologic Correlation and Management Approach Education ExhibitsLocation: CH Community, Learning Center

ParticipantsMariana Nelida Benegas Urteaga MD (Presenter): Nothing to Disclose Marcelo Sanchez MD : Nothing to Disclose Jose Ramirez MD : Nothing to Disclose Francisco Lomena MD : Nothing to Disclose Edmundo Rosales-Mayor : Nothing to Disclose

TEACHING POINTS1- To describe the spectrum of CT features of lung adenocarcinoma according to the new classification with particular emphasison subsolid nodules 2- To provide a differential diagnosis approach of subsolid nodules with pathologic correlation 3- To reviewthe diagnosis and management implications of subsolid nodules

TABLE OF CONTENTS/OUTLINE1. Introduction of the 2011 classification of adenocarcinoma of the lung 2. CT features of the spectrum of lesions of lungadenocarcinoma with pathologic correlation: atypical adenomatous hyperplasia, adenocarcinoma in situ, minimally invasiveadenocarcinoma, invasive adenocarcinoma 3. Differential diagnosis of subsolid nodules and the imaging characteristics frombenign inflammatory processes to malignant conditions: a - Infections: Aspergillus, virus, atypical pneumonia b - Malignantdiseases: lymphoma, metastases c - Vascular diseases: pulmonary hemorrhage, vasculitis, pulmonary endometriosis d -Inflammatory diseases: organizing pneumonia, focal interstitial fibrosis, eosinophilic pneumonia 4. Usefulness of PET-CT indiagnosis approach 5. Imaging guided biopsy of subsolid nodules and surgical approach 6. Current management guidelines forpulmonary subsolid nodules

CHE153

Screening, Treatment and Post-treatment Surveillance of Lung Cancer: A ComprehensiveReview of Current Standards Education ExhibitsLocation: CH Community, Learning Center

ParticipantsCameron Hassani MD (Presenter): Nothing to Disclose Carol C. Wu MD : Author, Reed Elsevier Christopher Lee MD : Nothing to Disclose Alison Wilcox MD : Speaker, Toshiba Corporation Farhood Saremi MD : Nothing to Disclose Brett Wilson Carter MD : Author, Reed Elsevier Consultant, St. Jude Medical, Inc

TEACHING POINTS

Lung cancer screening (LCS) has been on the forefront of discussion within a broad array of medical societies. Followingrecommendations by the AATS, NCCN, ACCP, the US Preventive Services Task Force now recommends CT lung cancerscreening in high risk patients.

LCS and treatment is best done in a multidisciplinary setting. To effectively participate in a multi-disciplinary structure,radiologists must have a firm grasp of screening, treatment and proper imaging follow-up after curative intent therapy.

Teaching goals:

- Understand the role of radiology in the multi-disciplinary approach to lung cancer detection, treatment and follow-up.

- Understand the imaging findings critical to lung cancer detection in initial screening and post-treatment surveillance

TABLE OF CONTENTS/OUTLINEIntroduction Definition of lung cancer screening and review lung cancer screening technique -Sample cases Discuss biopsy andstaging methods (CT, navigational bronchoscopy, EBUS, mediastinoscopy, etc) Review treatment modalities: Ablation, Radiationtherapy (SBRT, IMRT, Proton, Brachytherapy), Chemotherapy Review goals of surveillance imaging after curative intent therapy

therapy (SBRT, IMRT, Proton, Brachytherapy), Chemotherapy Review goals of surveillance imaging after curative intent therapy(recurrence vs. new lung cancer) Review current recommendations for surveillance imaging -Sample cases (Normal andabnormal post-treatment CT and PET/CT) Summary References

CHE154

Stage Fright: Test Your Knowledge of Lung Cancer Staging Education ExhibitsLocation: CH Community, Learning Center

ParticipantsAbigail Victoria Berniker MD (Presenter): Nothing to Disclose Justin Edward Mackey MD : Nothing to Disclose Oleg Teytelboym MD : Nothing to Disclose

TEACHING POINTSLung cancer is the leading cause of cancer death worldwide and is encountered routinely on imaging. Radiologists should befamiliar with the most updated TNM lung cancer staging system and be comfortable applying it in succinct and accurateinterpretations.

TABLE OF CONTENTS/OUTLINEGoals This exhibit aims to: -Review the TNM lung cancer staging system (AJCC 7th edition) -Reinforce key concepts through afun, interactive, case-based quiz to help radiologists feel more comfortable applying staging criteria in daily practice Background-Lung cancer represents 14% of all new cancers and is the leading cause of cancer death worldwide -Staging has importantimplications on lung cancer treatment and prognosis -Radiologists encounter lung cancer routinely and should be able to reportaccurate staging Case-Based Quiz -TNM criteria -Stages I-IV -Bonus round: challenging cases Summary/Future Directions Lungcancer is an important source of morbidity and mortality worldwide. Radiologists should be comfortable providing concise andaccurate lung cancer staging to help guide referring clinicians and facilitate appropriate management. As lung cancer screeningprograms gain popularity, radiologists will have an even greater impact on lung cancer detection and treatment.

CHE155

Subsolid Pulmonary Nodules: What Do the Radiologists and Clinicians Need to Know? Education ExhibitsLocation: CH Community, Learning Center

ParticipantsKavita Garg MD (Presenter): Nothing to Disclose Stephen Malkoski : Nothing to Disclose

TEACHING POINTS

Detection of subsolid (ground glass and part-solid nodules) nodules is expected to increase if CT screening for lungcancer becomes widespread.However, many questions remain, including whom to screen, how often, and for how long, especially in regards to thesubsolid nodules.Overdiagnosis associated with screening is also a concern because we currently do not fully understand the naturalhistory of subsolid nodules.Low-grade adenocarcinomas and adenocarcinoma in situ, typically manifest as subsolid nodules on low-dose CT imagesand are generally indolent.Integration of nodule features, pathology and patient characteristics (life expectancy, co-morbidities) are important inclinical decision making for management.


Most frequently asked questions about subsolid nodules by cliniciansSpectrum of CT findings of subsolid nodules and follow-up algorithmAssessment on follow-up CT and measurement techniques and variabilityCT and pathology correlations based on 2011 International Lung Adenocarcinoma Classification and implications for 7thedition of the TNM stagingCase studies illustrating integrated personalized management decision making ranging from watchful waiting to surgicalintervention

CHE157

The N Staging of Lung Cancer: To Biopsy or Not to Biopsy Education ExhibitsLocation: CH Community, Learning Center

ParticipantsAmanda Lea Steinberger DO (Presenter): Nothing to Disclose Oleg Teytelboym MD : Nothing to Disclose

TEACHING POINTS1. Understanding tumor biology and appropriate imaging utilization to guide clinical decision-making 2. Appropriate use ofimaging, particularly FDG PET-CT, may obviate the standard biopsy based approaches for lymph node staging of lung cancer 3.Early stage lung cancer detected at screening may have little metastatic potential, requiring primarily local therapy 4. Routinelyused biopsy based lymph node staging has a morbidity burden, and may not significantly reduce surgical upstaging

TABLE OF CONTENTS/OUTLINE1. Review and illustrate AJCC 7th ed of TNM staging for lung cancer 2. Review the National Comprehensive Cancer Network

guidelines for N-staging lung cancer 3. Address the role of mediastinoscopy and other interventional biopsy techniques instaging of potentially resectable lung cancer 4. Describe current treatment approaches to potentially curable lung cancer andreview implications for N-staging 5. Review accuracy of CT imaging for N-staging and utility of various size based cutoffs 6.Discuss the usage of FDG PET-CT in evaluating lymph nodes a. Review SUV based cut offs b. Illustrate FDG PET-CT pitfalls 7.Review utilization of emerging techniques such as MRI for N staging of lung cancer 8. Provide practical protocols for dealing withtypical staging dilemmas in work up of early lung cancer detected at screening

CHE158

Uncommon but Not Forgotten: Unusual Tumors and Tumor-like Lesions of the Lung Education ExhibitsLocation: CH Community, Learning Center

ParticipantsEmily Bao Tsai MD (Presenter): Nothing to Disclose Maitraya K. Patel MD : Nothing to Disclose Elizabeth Akiyama : Nothing to Disclose Manju Gan MD : Nothing to Disclose Monica Deshmukh MD : Nothing to Disclose Cecilia Matilda Jude MD : Author, UpToDate, Inc

TEACHING POINTS

Adenocarcinoma, squamous cell carcinoma, small cell carcinoma and large cell carcinoma comprise over 90% of primary lungtumors. The remaining neoplasms consist of uncommon histologic types of non-small cell lung carcinomas and airway,lymphopoietic and mesenchymal tumors. After viewing this presentation, participants will be able to: 1) Identify clinical andimaging features of uncommon tumors and tumor-like lesions of the lung; 2) Describe the role of cross-sectional imaging instaging and follow-up; 3) Appreciate the role of pathology in diagnosis.


The following categories of unusual lung neoplasms and tumor-like lesions are described: 1) Non-small cell lung carcinomas:adenosquamous, sarcomatoid, carcinoid, salivary gland-type; 2) Airway lesions: laryngotracheobronchial papillomatosis; 3)Lymphopoietic neoplams: angiocentric lymphoma, bronchus-associated lymphoid tissue lymphoma; 4) Mesenchymal tumors:inflammatory myofibroblastic tumor, solitary fibrous tumor, benign metastasizing leiomyoma; 5) Non-neoplastic lesions: lipoidpneumonia, amyloidoma. Imaging characteristics are mostly non-specific; however, cross-sectional imaging is useful fordocumenting extent of disease, describing associated findings and planning further diagnostic/therapeutic approaches.Pathologic examination provides definitive diagnosis in most cases.

CHE159

Unusual Radiographic Manifestations of Malignant Lung Tumors on CT Education ExhibitsLocation: CH Community, Learning Center

ParticipantsMakiko Murota (Presenter): Nothing to Disclose Yuka Yamamoto MD, PhD : Nothing to Disclose Katashi Satoh MD : Nothing to Disclose Yoshihiro Nishiyama MD : Nothing to Disclose

TEACHING POINTS

The purpose of this exhibit is:1. To illustrate and review various unusual radiographic manifestations of malignant lung tumors on chest CT which mayresemble benign lesions in appearance2. To show the differential diagnosis of these manifestations


1. To illustrate and review unusual radiographic manifestations of malignant lung tumors on chest CT- Thin-walled cavitation- Calcification- Pneumonia-like pattern- Mimicking focal organizing pneumonia- Others2. To describe the mechanisms and show the differential diagnosis of these manifestations

CHE160

“Back to the Heart”: Pearls You Can Find on Non-gated Chest CT Education ExhibitsLocation: CH Community, Learning Center

ParticipantsYon Mi Sung MD (Presenter): Nothing to Disclose Yoon Kyung Kim MD : Nothing to Disclose

TEACHING POINTSRecent developments in CT technology permits increased detection of cardiac findings on non-gated chest CT due to decreasedcardiac motion artifacts. Also, some of findings are relevant to the patient's presenting complaints. The purpose of this exhibit is

to expose radiologists to a series of challenging cases in order to help improve the radiologist's diagnostic accuracy when facingsuch cases.

TABLE OF CONTENTS/OUTLINEThe cases will be presented in a quiz format. Key features will be highlighted in the discussion of each case. The list of casesincludes: Ischemic heart diseases - acute myocardial infarction, chronic myocardial infarction Valvular heart diseases - aorticstenosis Myocardial/pericardial diseases - hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy,adriamycin induced cardiomyopathy, postpartum cardiomyopathy, constrictive pericarditis Tumors and thrombi - lipomatoushypertrophy of interatrial septum, lipoma, myxoma, angiosarcoma, liposarcoma, intravascular leiomyomatosis, intracardiacthrombus Congenital variants/anomalies - coronary artery and vein anomalies, atrial septal aneurysm, atrial septal defect,patent ductus arteriosus, remnant of common pulmonary vein, pulmonary venous varix

CHE161

4-Dimensional (4D) CT Assessment of Abnormal Upper Airway Movement and PhonationDisorders Education ExhibitsLocation: CH Community, Learning Center

ParticipantsKenneth K. Lau (Presenter): Nothing to Disclose Theodore Lau : Nothing to Disclose

TEACHING POINTS

The 320-slice multidetector CT (320-MDCT) has the ability to provide dynamic volume assessment of the laryngeal and trachealairway during breathing and phonation. The purpose of this exhibit is to demonstrate the utility of 320-MDCT in diagnosingcertain upper airway movement and phonation disorders that may not be diagnosed on conventional CT.

TABLE OF CONTENTS/OUTLINE320-MDCT is useful in detecting, monitoring, and assessing treatment response on abnormal upper airway movement in a)laryngeal dysfunction that can mimic asthma, b) different forms of tracheomalacia, c) excessive dynamic airway collapse withposterior tracheal membrane bulging into the tracheal lumen, d) primary airway amyloidosis, e) pseudoxanthoma elasticumassociated with haemoglobinopathy, f) vocal cord movement disorders in vocal cord paralysis, Parkinsonism and rheumatoidarthritis. CT and MRI are common imaging techniques for laryngeal structural pathology, but cannot demonstrate abnormalmovement of the larynx and trachea that can be symptomatic. The 320-MDCT with its 4-D capability can be a valuable tool inthe dynamic assessment of upper airway movement and phonation disorders and become a non-invasive alternative tolaryngoscopy. This CT technique would also allow better understanding of the laryngeal pathophysiology in future.

CHE162

A Quiz-based Review of Diaphragmatic Hernias and Their Presentations Education ExhibitsLocation: CH Community, Learning Center

ParticipantsLana Beth Winkler MD (Presenter): Nothing to Disclose Jeffery Hogg MD : Nothing to Disclose

TEACHING POINTS1) Diaphragmatic hernias are a common finding on radiological imaging and can be attributed to a variety of causes includingcongenital, traumatic, or idiopathic. 2) Complications, such as small bowel obstruction and compromise of lung development,can occur as a result of diaphragmatic hernias. 3) Utilizing imaging clues, such as the "dependent viscera sign' and "collar sign",will help radiologists better identify this diagnosis. 4) Certain diaphragmatic abnormalities, such as phrenic nerve injury orparalysis, mimic diaphragmatic hernias on imaging, and differentiation may be made with clinical context.

TABLE OF CONTENTS/OUTLINEThe learner will be prompted with questions followed by answers and explanations through a variety of diaphragmatic herniapresentations and mimics of diaphragmatic hernias. Topics of discussion include: - Pediatric presentation of congenitaldiaphragmatic hernias (imaged with prenatal ultrasound and MRI) - Adult presentation of congenital diaphragmatic hernias(Bochdalek and Morgagni hernias) - Traumatic diaphragmatic hernia/Diaphragm rupture (with images demonstrating'dependent viscera sign' and 'collar sign') - Diaphragmatic paralysis due to phrenic nerve injury (mimic of a diaphragmatichernia) - Complications (images demonstrating a small bowel obstruction) - Treatment

CHE163

An Overview of Uncommon Primary Pulmonary Tumors: An Imaging Spectrum Beyond LungCancer with Histopathological Correlation Education ExhibitsLocation: CH Community, Learning Center

Cum Laude

ParticipantsAmeya Jagadish Baxi MBBS, DMRD (Presenter): Nothing to Disclose Carlos S. Restrepo MD : Nothing to Disclose Michael James McCarthy MD : Nothing to Disclose Amy Laura Mumbower MD : Nothing to Disclose Rashmi S. Katre : Nothing to Disclose Sonia Liliana Betancourt Cuellar MD : Nothing to Disclose Daniel Vargas MD : Nothing to Disclose

Sachin Shyamsunder Saboo FRCR, MD : Nothing to Disclose

TEACHING POINTSThe major teaching points of this exhibit : 1. To identify and illustrate spectrum of primary pulmonary tumors on CT and MRIother than lung cancers 2. To review the pathogenesis 3. To describe and illustrate typical and atypical CT (and MRI imaging)appearances of these tumors

TABLE OF CONTENTS/OUTLINEKnowledge of imaging appearance of primary pulmonary tumors is important for accurate diagnosis and treatment. Though theuncommon primary pulmonary tumors has similar radiological appearance , they differ in epidemiology, clinical outcome andmanagement from lung cancers. Given the potential significant morbidity , it is important to understand and recognize them.We did retrospective analysis of histologically proven primary pulmonary tumors which were diagnosed during CT chest, PET CTand MRI. We also reviewed clinical features and laboratory work up of these patients. The CT scans were reviewed for thefollowing features: lesion location; size, number, contour, contrast enhancement; mass effect, invasion of surroundingstructures and presence or absence of calcification and metastasis. The primary pulmonary tumors other than lung cancer whichwe came across were carcinoid, sarcoma, chondroma, blastoma, chemoductoma, pericytoma, synovial sarcoma, epitheloidhemangioepithelioma and inflammatory fibroblastic tumor, tracheo-bronchial papillomas.

CHE164

Atlas of Tracheobronchial Positional Abnormalities Education ExhibitsLocation: CH Community, Learning Center


ParticipantsGuillaume Chassagnon (Presenter): Nothing to Disclose Baptiste Morel MD : Nothing to Disclose Elodie Carpentier : Nothing to Disclose Hubert Ducou Le Pointe MD, PhD : Nothing to Disclose Dominique Sirinelli MD : Nothing to Disclose

TEACHING POINTS- Anatomy of the tracheobronchial tree has been described by Boyden et al in 1955 and several variants of bronchial positionhave been described. - Various theories for the pathogenesis of anomalous tracheobronchial development have been proposed.Anomalies resulting in anatomic variants of tracheobronchial anatomy are assumed to occur after the 28th day of gestation. -Congenital bronchial anomalies can be symptomatic, leading to recurrent pneumonia, hemoptysis or dyspnea. - Use of auniform and comprehensive classification system is essential to describe congenital positional abnormalities of thetracheobronchial tree. - An abnormally positioned bronchus can be supernumerary or displaced. - A tracheal bronchus is themost frequent congenital bronchial positional anomaly and this term should only refer to a bronchus arising from the trachea orfrom the carina.

TABLE OF CONTENTS/OUTLINE- Normal tracheobronchial anatomy - Embryology - Comprehensive classification of congenital tracheobronchial positionalabnormalities: Pulmonary situs abnormalities Displaced bronchus Supernumerary bronchus Bridging bronchus Bronchialagenesis

CHE165

Avoiding Collateral Damage: Review of Important Collateral Pathways in the Chest and TheirClinical Significance Education ExhibitsLocation: CH Community, Learning Center

ParticipantsDemetrios A. Raptis MD (Presenter): Nothing to Disclose Sanjeev Bhalla MD : Nothing to Disclose Constantine Apostolos Raptis MD : Nothing to Disclose

TEACHING POINTSWith the increased use of computed tomography angiography for evaluation of pulmonary embolism and aortic dissection,radiologists often encounter other vascular findings within the thorax. This exhibit aims to: Review arterial, venous, and mixedcollateral vascular pathways. Review pathophysiology and CT findings of these pathways. Discuss relationship between radiologicfindings and patient's symptoms.

TABLE OF CONTENTS/OUTLINEArterial to arterial collaterals in the setting of: Anomalous left coronary artery arising from the pulmonary artery Aorticcoarcation Blalock-Taussing Shunt Chronic PE Acute PE Absence of right pulmonary artery Venous to venous collaterals:Anterior, middle, and posterior mediastinal arcades SVC and brachiocephalic obstruction (common and uncommon collaterals)Type 2 hepatopulmonary syndrome Fontan Left sided SVC Mixed arterial and venous collaterals: Intralobar and extralobarsequestration HHT pre/post-treatment Neovascularity in eisenmenger and pulmonary arterial hypertension Left SVC draining toLA

CHE166

Breaking Down the Wall: Malignant Neoplasms of the Chest Wall and Distinguishing ImagingFeatures Education ExhibitsLocation: CH Community, Learning Center



ParticipantsBrett Wilson Carter MD (Presenter): Author, Reed Elsevier Consultant, St. Jude Medical, Inc Marcelo Kuperman Benveniste MD : Nothing to Disclose Sonia Liliana Betancourt Cuellar MD : Nothing to Disclose Patricia Monique de Groot MD : Nothing to Disclose James Sorensen : Nothing to Disclose John Peter Lichtenberger MD : Author, Amirsys, Inc. Gerald F. Abbott MD : Author, Thieme Medical Publishers, Inc Author, Amirsys, Inc

TEACHING POINTS1. Neoplasms of the chest wall account for approximately 2% of all thoracic malignancies. 2. Although chest wall tumors may beinitially identified on chest radiography, they are best evaluated with advanced cross-sectional imaging studies such as MDCT,MRI, and PET/CT. 3. Malignant osseous and soft tissue tumors of the chest wall demonstrate key features across multipleimaging modalities. 4. Utilization of clinical and radiologic information enables the generation of focused differential diagnoses.

TABLE OF CONTENTS/OUTLINE1. Role of thoracic imaging in the evaluation of chest wall neoplasms Purpose of imaging Imaging modalities Imaging approachto chest wall tumors Incomplete border sign 2. Classification system of chest wall neoplasms Osseous Tumors Soft TissueTumors 3. Key radiologic and clinical features of malignant chest wall tumors 4. Treatment of chest wall neoplasms

CHE167

Calcifications in the Chest—To Worry or Not to Worry? Education ExhibitsLocation: CH Community, Learning Center


ParticipantsMaria Cruz Ageitos Casais MD (Presenter): Nothing to Disclose Sandra Baleato Gonzalez MD : Nothing to Disclose Anxo Martinez De Alegria MD : Nothing to Disclose Roberto Garcia Figueiras MD : Nothing to Disclose Maria Virginia Trujillo Ariza MD : Nothing to Disclose

TEACHING POINTSCalcifications located within the chest are a frequent and commonly overviewed finding in daily practice. But in some casescalcifications are the key feature that point out to the proper diagnosis. Radiologists must recognize them in each imagingtechnique and know its "to worry" and the "not to worry" features and locations. The purpose of this exhibit is: - To illustrate thegreat variety of thoracic calcifications and describe its morphologic appearance - To stablish the "to worry" and "not to worry"specific features. - To review the different beningn and malignant entities that may present with calcified lesions and its causes.- To classify calcifications according to its location within the chest.


1.Index

2. General overview of thoracic calcifications imaging

- General physiopathology: What should I know?

- How to recognize them in each technique: X-ray, US, CT, MRI

- Morphologic patterns: benign and malignant features, Should I be worried?

3. Entities that may present with calcified lesions, classified depending on its location:

- Calcifications within the soft tissues

- Calcifications within the vessels

- Calcifications within the mediastinum

- Calcifications within the lung and pleura

4. Take home points

CHE168

Cardiopulmonary Syndromes: Conditions with Concomitant Cardiac and PulmonaryAbnormalities Education ExhibitsLocation: CH Community, Learning Center

ParticipantsDaniel Verdini MD (Presenter): Nothing to Disclose Carlos S. Restrepo MD : Nothing to Disclose

TEACHING POINTS

1. Discuss the relationship of cardiac and pulmonary embryology to the pathophysiology of various cardiopulmonary syndromes.2. Demonstrate the multimodality imaging findings of various cardiopulmonary syndromes.

TABLE OF CONTENTS/OUTLINEPathophysiology of various cardiopulmonary syndromes, with relation to embryology Multi-modality imaging findings of variouscardiopulmonary syndromes, including: -Heterotaxia syndrome (situs abnormalities and cilia dyskinesia) -Scimitar syndrome(partial anomalous venous return and hypogenetic lung) -Partial anomalous venous return and ASD -Proximal interruption ofthe pulmonary artery with pulmonary cysts -Pulmonary sequestration and bronchogenic cyst -Ring sling complex (cartilaginoustracheal ring and pulmonary artery sling) -Tetralogy of Fallot with branch pulmonary artery stenosis

CHE169

Cavitary Pulmonary Lesions: Are There Holes in Our Approach? Education ExhibitsLocation: CH Community, Learning Center

ParticipantsJonathan Hickle MD (Presenter): Nothing to Disclose Daria Manos MD, FRCPC : Author, Springer Science+Business Media Deutschland GmbH Joy Nina Borgaonkar MD, FRCPC : Nothing to Disclose

TEACHING POINTSThere is considerable overlap in the appearance of benign and malignant cavitary pulmonary lesions; CT features alone are notsufficiently reliable to distinguish malignant from benign cavitary lesions. An algorithmic approach combining CT appearancewith key demographic and clinical features, can improve the radiologist's assessment of cavitary lesions and can provide apractical approach to management. Immunocompromised patients, or those at risk for aspiration may present with infectiouscavitary lung lesions that demonstrate malignant CT features. Both inflammatory and malignant lesions are FDG avid; the utilityof PET in distinguishing malignant from benign inflammatory lesions is dubious.

TABLE OF CONTENTS/OUTLINEReview the pathophysiology of pulmonary cavitation. Case based review of common mimics of cavitary lesions. Review imagingpredictors and features of malignancy and benignity described in the literature and discuss the limitations of this approach.Application of the described features in pathology or culture proven local cases including: Mycobacterium tuberculosis, MAC,mixed pulmonary abscess, Coxiella burnetti, aspergillus, sarcoidosis, non-small cell lung cancer, metastases, pulmonaryinfarction and vasculitis. Provide a suggested algorithm for evaluating cavitary pulmonary lesions.

CHE170

Clinical Advantages of the Diffusion Weighted MR Imaging on Chest Disorders: When andHow Useful? Education ExhibitsLocation: CH Community, Learning Center

ParticipantsHidefumi Fujisawa MD (Presenter): Nothing to Disclose Kota Watanabe MD : Nothing to Disclose Kazuya Matsunari : Nothing to Disclose Sho Funaki : Nothing to Disclose Noriko Niiya : Nothing to Disclose Tamio Kushihashi MD : Nothing to Disclose

TEACHING POINTSThe aim of this exhibit is:

To review the diffusion weighted MR imaging (DWI) with various chest disorders including pulmonary, mediastinum, andchest wall.

1.

To discuss whether DWI is useful on chest disorders.2.To show the clinical utility cases of DWI and apparent diffusion coefficient (ADC) values in the diagnosis.3.

TABLE OF CONTENTS/OUTLINECharacterof DWI on chest radiology Review of imaging findings CT and conventional MRI DWI ADC map Sample cases Low ADCvalue cases High ADC value cases Differential points between cystic and solid tumors on DWI DWI findings of the tumorrecurrence or not Distinguishing point of benign and malignant tumors Distinguishing findings of necrotic tumor and abscessDecision in treatment effect using ADC values Future directions and summary

CHE171

Clinical Decision Making in Radiology- An Algorithmic Approach to Diagnose Lung Diseaseand Demonstrate its Function Using Venn Diagrams Education ExhibitsLocation: CH Community, Learning Center

ParticipantsSana Parsian MD (Presenter): Nothing to Disclose Xue Susan Bai MD : Nothing to Disclose Gregory Kicska MD, PhD : Nothing to Disclose Jitesh Ahuja MD, MBBS : Nothing to Disclose Sudhakar N. Pipavath MD : Nothing to Disclose J. David Godwin MD : Shareholder, Cardiac Insight

TEACHING POINTS1. Introduce a unique algorithm to approach imaging findings of lung disease. 2. This unique algorithm would: A. Identifyimaging findings. B. Make an anatomic or morphologic diagnosis using the identified findings. C. Use specific imaging signs or

clues, if present, to predict etiology. D. Use Clinical findings and clinical signs or available additional clinical tools or clues tomake a specific etiologic diagnosis. 3. Demonstrate the interplay of the various components of the algorithm using a Venndiagram.

TABLE OF CONTENTS/OUTLINE1. How does the algorithm work? -Identify imaging findings -Make a morphologic or anatomic diagnosis based on therepresentative imaging findings -Identify radiologic signs or clues when present -Identify clinical findings and signs -Make anetiologic diagnosis -Display the components using a Venn diagram to understand their interplay 2. Demonstrate how thisalgorithm works using various examples of lung disease. 3. Quiz and interactive self-test using this algorithm with the providedexamples.

CHE172

Emerging Clinical Applications of Digital Tomosynthesis of the Chest Education ExhibitsLocation: CH Community, Learning Center

ParticipantsJi Yung Choo MD (Presenter): Nothing to Disclose Jisung Han MD : Nothing to Disclose Ki Yeol Lee MD, PhD : Nothing to Disclose Eun-Young Kang MD : Nothing to Disclose Whan Oh : Nothing to Disclose Je Hyeong Kim : Nothing to Disclose Seung Heon Lee : Nothing to Disclose

TEACHING POINTS1. To understand the technical concept of low dose digital tomosynthesis of the chest and its implementation 2. To understandwhich type of clinical application can be performed under digital tomosynthesis in chest section 3. To recognise the limitationsand benefits of digital tomosynthesis of the chest in radiation exposure and image acquisition


Our exhibit will be divided into 3 sections and presented with illustration and relevant cases:

1. Background and physics of digital tomosynthesis of the chest2. Clinical application of digital tomosynthesis in airway abnormalities ① Neoplastic and noneoplastic lesions involving the airways 1. Lung cancer/ 2. Benign tumor/ 3. Evaluation of post-chemotherapy or operation status as a follow up tool / 4. Congenitalanomaly of airways ② Post-operative evaluation 1. Lobectomy, biolobectomy or pneumonectomy state/ 2. Evaluation of dead space/ 3. Localization of drain catheter ③ Lung parenchymal lesion 1. Interstitial lung disease/ 2. Emphysema, bullae/ 3. Nodule (solid, ground glass opacity nodule)/ 4. Consolidations(Tuberculosis, pneumonia, lung cancer, etc.) ④ Chest wall and bone lesion ⑤ Pleura 1. Pneumothorax with blebs3. Benefits and limitation of tomosynthesis of the chest 1) Radiation exposure 2) Image acquisition

CHE173

Everything You Want to Know About Superior Vena Cava Education ExhibitsLocation: CH Community, Learning Center

Certificate of Merit Selected for RadioGraphics Selected for RadioGraphics

ParticipantsDesmin Milner MD : Nothing to Disclose Sushilkumar K. Sonavane MD (Presenter): Nothing to Disclose Abhishek Chaturvedi MD : Nothing to Disclose Ahmed Kamel Abdel Aal MD, PhD : Consultant, St. Jude Medical, Inc Consultant, Baxter International Inc Consultant, C. R.Bard, Inc Kaushik S. Shahir MD : Nothing to Disclose Satinder Pal Singh MD : Nothing to Disclose

TEACHING POINTSReview embryology and anatomy of superior vena cava (SVC) Discuss indications, protocols for imaging evaluation with ContrastCT, Contrast and Non-contrast MRA Review the common disease processes affecting the SVC Briefly discuss intervention on SVC

TABLE OF CONTENTS/OUTLINEEmbryology and anatomy of SVC Role of imaging modalities • CT with contrast • MR Angiography with contrast: Time resolved,First pass, steady state • Noncontrast MR Angigraphy • Catheter venogram Discuss abnormalities with examples: Congenital:Duplication, Left SVC, Right upper lobe partial anomalous pulmonary venous return and sinus venosus atrial septal defect,Sub-aortic left innominate vein, lipoma Trauma: Hematoma Stricture: Catheterization, Radiation, Fibrosing mediastinitisThrombus: Bland, Fibrin sheath, Tumor emboli Compression/ SVC Syndrome: • Lymphadenopathy • Neoplasm: Secondary-Lung, Pleura, Mediastinal mass; Primary- Sarcoma Catheter based interventions: Angioplasty, Stent, Filter placement, Biopsy

CHE174

Evil Humors: Thoracic Manifestations of Immunoglobulin Related Disease in Adults Education ExhibitsLocation: CH Community, Learning Center

Cum Laude

ParticipantsMatthew Harlan Lee MD (Presenter): Nothing to Disclose Jeffrey P. Kanne MD : Research Consultant, Perceptive Informatics, Inc Cristopher A. Meyer MD : Stockholder, Cellectar Biosciences, Inc

TEACHING POINTS- Disorders of humoral immunity result in a variety of clinically significant immunoglobulin (Ig) related diseases. - Identifyrepresentative Ig related diseases and their characteristic thoracic imaging findings. - Demonstrate how familiarity with Igrelated diseases informs thoracic imaging findings and narrows differential diagnosis.

TABLE OF CONTENTS/OUTLINE- Introduction with overview of antibody-mediated immunity, specific Ig function, autoimmunity, and basic mechanismsunderlying autoimmunity. - Illustrate Ig related diseases with overview and discussion of clinical manifestations, serologicprofiles (i.e. increased/decreased Ig subtype), and typical radiographic and CT findings. Examples: Primary immune deficiency:Agammaglobulinemia, common variable immunodeficiency, IgA and IgG deficiency. Autoimmune: IgG4 and IgG3 relateddisease, IgA nephropathy, Goodpasture disease, pulmonary alveolar proteinosis. Allergy related: ABPA. Plasma cell disorder:Multiple myeloma/MGUS. Drug related: antibody therapies. Other: Amyloid, light chain deposition disorder. Summary: - Amyriad of Ig related diseases have thoracic manifestations. - Recognizing the imaging findings of Ig related diseases and theirspecific serologic profiles aids in establishing a specific diagnosis or limiting differential diagnosis.

CHE175

Funny Bones: Incidental Bone Findings on Chest Radiographs Education ExhibitsLocation: CH Community, Learning Center

ParticipantsAlan Matthew Ropp MD (Presenter): Nothing to Disclose Jay Patel MD : Nothing to Disclose Derik L. Davis MD : Nothing to Disclose Jean Jeudy MD : Nothing to Disclose

TEACHING POINTS1. Describe cases of bone pathology incidentally encountered on chest radiographs. 2. Discuss clinically relevant informationrelated to the processes. 3. Assess participant's knowledge with CME style questions.

TABLE OF CONTENTS/OUTLINEMany interesting and important skeletal findings may be incidentally encountered while interpreting chest radiographs. Thesefindings may present a diagnostic dilemma to the general radiologist. Chest radiograph case examples of various skeletalfindings seen on imaging performed for unrelated diagnoses are presented, along with clinically relevant content and CME stylequestions. Malignancies • Plasmacytoma, chondrosarcoma, metastatic disease Benign bone lesions • Osteochondroma,osteochondromatosis, osteopoikilosis, non-ossifying fibroma, and fibrous dysplasia Developmental/Congenital anomalies •Pectus excavatum, carinatum, sternal foramen, cervical ribs, Klippel-Feil syndrome (Sprengel's deformity), ankylosingspondylitis, melorheostosis, rib notching (aortic coarctation), and osteopetrosis Metabolic • Rachitic rosary, Paget disease, sicklecell disease (H/fish mouth vertebrae), and hyperparathyroidism (rugger jersey spine)

CHE176

Gender Matters: The Imaging Spectrum of Thoracic Cardiopulmonary Diseases WhichExclusively or Predominantly Affects Either Females or Males Education ExhibitsLocation: CH Community, Learning Center

ParticipantsCarlos S. Restrepo MD (Presenter): Nothing to Disclose Daniel Vargas MD : Nothing to Disclose Daniel Ocazionez MD : Nothing to Disclose Jorge Carrillo MD : Nothing to Disclose Santiago Martinez-Jimenez MD : Author, Amirsys, Inc Ameya Jagadish Baxi MBBS, DMRD : Nothing to Disclose

TEACHING POINTS1. To identify the thoraciacic cardiopulmonary diseases that exclusively or predominantly affect either females or males. 2. Toreview the pathophysiology, and imaging manifestation of those conditions with a significant difference in distribution by gender.

TABLE OF CONTENTS/OUTLINEThe pathophysiology, clinical and imaging manifestations of the following conditions will be reviewed: Diseases that exclusivelyor predominantly affect women: - Lymphangioleiomyomatosis (LAM), Benign metastatizing leiomyomas, intracardiac uterineleiomyoma, peripartum cardiomyopathy, amniotic fluid embolism, chronic eosinophilic pneumonia, Turner syndrome, Meigssyndrome,Catamenial pneumothorax, Pulmonary endometriosis, Giant cell arteriris, Takayasus arteritis. Diseases whichexclusisvely or predominatly affect men: - Mediastinal seminoma, mediastinal non-seminomatous tumor, Chronicgranulomatous disease, Behcet disease, Hughes-Stovin syndrome, Kaposis sarcoma ,Aortic coarctation, Bicuspid aortic valve,

Plasmacytoma, Young syndrome.

CHE177

Get in on the Act: Optimizing CT Detection of Subtle Pulmonary Nodules and EmphysematousChanges Utilizing MIP and MinIP Images Education ExhibitsLocation: CH Community, Learning Center

ParticipantsJennifer Jaehee Choi MD (Presenter): Nothing to Disclose Kenneth Cooke MD : Nothing to Disclose

TEACHING POINTSThe objective of this exhibit is: 1) To review the principles behind the post processing techniques, maximum intensity projection(MIP) and minimum intensity projection (MinIP). 2) To review current common applications of MIP and MinIP. 3) Tointeractively demonstrate how post processing techniques such as MIP and MinIP can significantly improve CT detection ofsubtle pulmonary nodules and emphysematous changes, respectively. 4) To demonstrate how MIP and MinIP can be easilyintegrated into daily workflow when interpreting CT examinations of the chest.

TABLE OF CONTENTS/OUTLINE-Overview of principles of MIP and MinIP -Current applications of MIP and MinIP -Sample cases demonstrating how using MIPand MinIP can improve CT detection of lung nodules and emphysematous changes -Cases will be presented in a video/PACSsimulation format and the viewer will be asked to detect lung nodules, first on images from a chest CT scan followed bycomplementary MIP images. -Cases will be presented in a video/PACS simulation format and the viewer will be asked to detectsubtle emphysematous changes, first on images from a chest CT scan followed by complementary MinIP images. -Implicationsfor workflow -Summary

CHE178

Getting a Taste for the Pulmonary Cheerio—Imaging Appearance and Differential Diagnosis Education ExhibitsLocation: CH Community, Learning Center


ParticipantsTravis S. Henry MD (Presenter): Spouse, Employee, F. Hoffmann-La Roche Ltd Brent Little MD : Nothing to Disclose Jonathan Hero Chung MD : Research Grant, Siemens AG Royalties, Amirsys, Inc Eugene Aaron Berkowitz MD : Nothing to Disclose Sanjeev Bhalla MD : Nothing to Disclose

TEACHING POINTS1. The pulmonary cheerio is a commonly encountered sign/pattern that was originally described on CT in the context of lungadenocarcinoma (formerly bronchioloalveolar cell carcinoma). Many other entities - both malignant and benign - can presentwith a similar appearance. 2. While the pulmonary cheerio may look similar for different entities, the clinical context, pattern ofcheerio distribution and ancillary lung findings can can often point to a specific diagnosis, or at least narrow the differential asdiscussed in this exhibit.

TABLE OF CONTENTS/OUTLINEIntroduction Cased-Base Review of Causes of Pulmonary Cheerios: Lung adenocarcinoma Metastatic disease (adenocarcinoma ofGI primary; sarcoma; squamous cell carcinoma) Pulmonary Langerhans cell histiocytosis Wegener's granulomatosisTracheobronchial papillomatosis Malignancy treated with VEGF inhibitors Rheumatoid Nodules Pulmonary meningothelial-likenodule Septic emboli Narrowing the differential diagnosis using other clinical and radiologic clues. Conclusion

CHE179

How Does the Blood Get from Here to There? Illustration of Common Collateral PathwaysSeen in the Thorax Education ExhibitsLocation: CH Community, Learning Center

ParticipantsOmar Hasan MD (Presenter): Nothing to Disclose Ashwani Kumar Sharma MD : Nothing to Disclose Abhishek Chaturvedi MD : Nothing to Disclose John C. Wandtke MD : Nothing to Disclose Susan K. Hobbs MD, PhD : Nothing to Disclose

TEACHING POINTS• Review of normal and variant venous anatomy in the thorax • The location of venous occlusion plays a role in development ofcollateral vessels • Arterial collaterals are less common, but can be appreciated on MR and CT

TABLE OF CONTENTS/OUTLINE• Normal and variant venous anatomy of the thorax • Localization of collaterals depends on the level of occlusion. We willreview the collateral pathways associated with the following scenarios: o Axillary or subclavian vein occlusion o Brachiocephalicvein occlusion o Superior vena cava occlusion -Above azygos vein -Below azygos vein -Above and below azygos vein o Inferiorvena cava occlusion -Below the renal veins -Between renal and hepatic veins -Above hepatic veins • Normal and variant arterialanatomy of the thorax • Arterial collaterals of the thorax o Pulmonary artery o Bronchial artery o Aortic diseases

CHE180

How Well Do You Know Lines & Stripes? Review and Quiz for Students, Residents, andBeyond Education ExhibitsLocation: CH Community, Learning Center

ParticipantsJonathan Chung MD (Presenter): Nothing to Disclose Roya Etemad-Rezai MD : Nothing to Disclose Mark Landis MD, FRCPC : Nothing to Disclose

TEACHING POINTSDespite increases in CT use, radiography continues to be an efficacious and cost effective tool to evaluate mediastinal andparenchymal lung disease. This exhibit will revisit the fundamental lines and stripes of chest radiography and reinforce theseconcepts in a quiz format using examples from our teaching center. After completion of this exhibit, the reader will have thetools to detect subtle abnormalities of both the frontal and lateral chest radiograph.

TABLE OF CONTENTS/OUTLINE• Illustrated review of the normal lines and stripes of the chest radiograph. • Series of frontal or lateral chest radiographs, eachwith an abnormality of one or more of the fundamental lines or stripes. These cases will be animated, showing the pertinentabnormality. Correlation with cross sectional imaging will be provided with each case

CHE181

Hyperpolarised Xenon MRI—A New Functional Imaging Technique in Respiratory Medicine Education ExhibitsLocation: CH Community, Learning Center

ParticipantsTahreema Nihad Hashmi Matin MBBS (Presenter): Nothing to Disclose Xiaojun Xu MSc, DPhil : Nothing to Disclose Nassim Parvizi MBBS, BSC : Nothing to Disclose Tom Doel DPhil : Nothing to Disclose Jennifer Lee : Nothing to Disclose Najib Rahman MSc, DPhil : Nothing to Disclose Annabel Nickol : Nothing to Disclose Vicente Grau PhD : Nothing to Disclose Fergus Vincent Gleeson MBBS : Alliance Medical Ltd Consultant

TEACHING POINTSTo describe hyperpolarised xenon MRI (Xe-MRI) at 1.5T, a novel regional functional imaging technique.

TABLE OF CONTENTS/OUTLINEA. Limitations of current lung function assessment tools B: Description of Xe-MRI technique including hyperpolarisation method, choice of sequences and typical examination pathway C: Radiological features of Xe-MRI in healthy volunteers and patients with chronic respiratory disease D: Description of novel Xe-MRI data analysis methodology including regional segmentation and multi-modality co-registration E: Potential utility of Xe-MRI and role in clinical care

Summary: Current methods for assessing lung function are inadequate. Imaging data from 30 prospectively enrolled healthy volunteers,and patients with chronic respiratory disease are used to illustrate the potential of Xe-MRI to offer comprehensive evaluation ofregional lung function. Establishing Xe-MRI will lead to a better understanding of regional lung disease pathophysiology andenable individual-tailored treatments by improved assessment of therapeutic response.

CHE182

Imaging Features of Neoplastic and Non-neoplastic Lesions of the Tracheobronchial Tree;Pictorial Review Education ExhibitsLocation: CH Community, Learning Center

ParticipantsShinsuke Shimoyama MD (Presenter): Nothing to Disclose Hisanobu Koyama MD, PhD : Nothing to Disclose Yoshiharu Ohno MD, PhD : Research Grant, Toshiba Corporation Research Grant, Koninklijke Philips NV Research Grant,Bayer AG Research Grant, DAIICHI SANKYO Group Research Grant, Eisai Co, Ltd Research Grant, Terumo CorporationResearch Grant, Fuji Yakuhin Co, Ltd Research Grant, FUJIFILM Holdings Corporation Research Grant, Guerbet SA Mizuho Nishio MD, PhD : Research Grant, Toshiba Corporation Tatsuya Nishii MD : Nothing to Disclose Shinichiro Seki : Nothing to Disclose Kazuro Sugimura MD, PhD : Research Grant, Toshiba Corporation Research Grant, Koninklijke Philips NV Research Grant,Bayer AG Research Grant, Eisai Co, Ltd Research Grant, DAIICHI SANKYO Group

TEACHING POINTS

Although neoplasm in the tracheobronchial tree are rare, a variety of tumors including primary and secondary malignant tumorsas well as benign tumors are observed in routine clinical practice. On the other hand, many non-neoplastic lesions, e.g. relapsingpolychondritis and infection disease, affect tracheobronchial tree and result in bronchial wall thickening and decreasing of thelumen. The diagnosis is sometimes difficult, however some neoplastic and non-neoplastic lesions of the tracheobronchial tree

have specific findings. Therefore, the knowledge of radiological features of these lesions has a potential of lead to the diagnosis,and therefore the major teaching points of this exhibit are:1. To review the imaging features of neoplastic and non-neoplastic lesions in the tracheobronchial tree at not only CT, but alsoMR imaging and PET or PET/CT.2. To learn the more accurate diagnostic decision making using various modalities in routine clinical practice.

TABLE OF CONTENTS/OUTLINE1. Imaging Features of Neoplasm in the Tracheobronchial Tree 1-1. Primary or Secondary Malignant Tumor 1-2. Benign Tumor2. Imaging Features of Non-neoplasm in the Tracheobronchial Tree 2-1. Relapsing Polychondritis 2-2. Infectious Disorders 2-3.Others 3. Diagnostic Decision Tree of Neoplastic and Non-neoplastic Lesions in the Tracheobronchial Tree

CHE183

Imaging of Classic and Emerging Thoracic Oncologic Emergencies Education ExhibitsLocation: CH Community, Learning Center


ParticipantsThanissara Chansakul MD (Presenter): Nothing to Disclose David M. Jackman : Consultant, F. Hoffmann-La Roche Ltd Consultant, Foundation Medicine, Inc Rachna Madan MD : Nothing to Disclose

TEACHING POINTS

Patients with known primary thoracic malignancy or metastatic disease involving the thorax often experience urgent oremergent complications that are either a direct result of the underlying tumor or an indirect result related to therapy.

1.

A number of novel chemotherapeutic agents are associated with unique thoracic complications.2.Complications are often first identified on imaging studies. Awareness of such complications is crucial in order tominimize morbidity and mortality in oncologic patients.

3.


Discuss potential urgent and emergent thoracic complications in oncologic patients.1.Highlight, using case-based approach, the clinical presentations and imaging findings of thoracic oncologic emergencies.Particular focus is placed on cases in which imaging plays a significant role in diagnosis and guiding clinicalmanagement.

2.

Well known urgent complications such as superior vena cava obstruction, pericardial tamponade, tumoral rupture andhemorrhage, massive hemoptysis as well as malignant airway obstruction due to central mass will be reviewed.

3.

Illustrate examples of emerging oncologic thoracic emergencies related to novel chemotherapeutic agents such asdevelopment of spontaneous pneumothoraces and intratumoral pseudoaneurysms with potential to rupture.

4.

CHE184

Imaging of Lung Transplant— Anatomical Considerations and Complications Education ExhibitsLocation: CH Community, Learning Center

ParticipantsAlessandro Ruggiero MD : Nothing to Disclose Edward Thomas Barden MRCP, FRCR : Nothing to Disclose Katharine Tweed FRCR (Presenter): Nothing to Disclose

TEACHING POINTS1. Delineation of the anatomical considerations for pre-surgical planning. 2. Demonstration of the key imaging findings to aidearly recognition of complications of lung transplantation in the acute post operative phase. 3. Depiction of system basedapproach to the broad spectrum of chronic post lung transplant complications.


1. Bronchial complications, anastomosis dehiscence and ischaemic airway

2. Vascular complications, arterial anastomosis stenosis

3. Infection, CMV and NTM

4. PTLD

5. Single lung transplant complications.

6. Acute and chronic rejection manifestations

7. Drug toxicity

CHE185

Imaging Spectrum of Fluid Containing Thoracic Lesions: An Organized Approach Education ExhibitsLocation: CH Community, Learning Center

Participants

Jay S. Leb MD (Presenter): Nothing to Disclose Yelena Kozirovsky MD : Nothing to Disclose Jay G. Hochsztein MD : Nothing to Disclose David H. Gordon MD : Nothing to Disclose Mark Guelfguat DO : Nothing to Disclose

TEACHING POINTS

This pictorial review of fluid containing thoracic lesions provides a framework for assessment of the various imaging features anddirects integration of observations into a specific diagnosis. Sample cases will illustrate typical and atypical entities. Appropriatepitfalls and complications will be discusses.

TABLE OF CONTENTS/OUTLINEFluid containing thoracic lesions is a diverse group of pathologic conditions. Similar appearing lesions can represent vastlydifferent pathophysiologic processes. This exhibit is highlighting a systematic approach and concepts helpful to formulatefocused differential diagnosis and guide proper management. The lesions are organized in the following groups: Locationrelative to the chest wall, diaphragm, pleura and pericardium; distribution in the lung zones; position in mediastinum; presenceof air-fluid or fluid-fluid levels; presence and appearance of a solid component; occurrence of loculation or septations;distribution of fluid within the lesion; lesion size; fluid characteristics pertinent to the modality (CT density, MRI signal intensity,US echogenicity); appearance of the lesion wall; characteristics of blood flow in the lesion; reactive changes on the neighboringtissues; presence of underlying or predisposing lung disease.

CHE186

Imaging the Central Airways Gently and Wisely by Using MRI Education ExhibitsLocation: CH Community, Learning Center

ParticipantsPierluigi Ciet MD (Presenter): Nothing to Disclose Diana Litmanovich MD : Nothing to Disclose Phillip M. Boiselle MD : Nothing to Disclose Edward Yungjae Lee MD, MPH : Nothing to Disclose Piotr Alfred Wielopolski PhD : Nothing to Disclose Harm Awm Tiddens MD : Nothing to Disclose

TEACHING POINTSCentral airways assessment is routinely performed with bronchoscopy, which requires sedation and does not allow exact airwaymeasurements. Although cine-CT is used as a non-invasive alternative, its use is limited by radiation. MRI, as a radiation-freetechnique, is an attractive alternative for CT. We aim to give a comprehensive overview of MRI capabilities to assess centralairways disease in pediatric and adult patients in order to assist radiologists in "imaging central airways gently and wisely".

TABLE OF CONTENTS/OUTLINEWe will describe and illustrate a practical approach to assess pediatric and adult central airways disease with MRI as follow: 1)central airways mechanics from a radiology perspective; 2) bronchoscopy, CT and MRI of central airways: techniques andpros/cons; 2) 2D vs. 3D MRI; 3) static vs. dynamic MRI; 4) spirometry-guided dynamic MRI; 5) contrast enhanced MRI of thecentral airways and 6) post-processing techniques: clinical and advanced settings. Finally, we will provide and illustratediagnostic algorithms, protocols and clinical scenarios that will facilitate radiologists to 'wisely' select MRI over CT for studyingcentral airway dimensions and dynamics.

CHE187

Is it OK? Non-pathologic or Insignificant Chest CT Findings that Mimic Disease Education ExhibitsLocation: CH Community, Learning Center

ParticipantsJi Hyun Hong MD (Presenter): Nothing to Disclose Jae Sup Jun : Nothing to Disclose Myeong Im Ahn MD, PhD : Nothing to Disclose Jung Im Jung MD, PhD : Nothing to Disclose

TEACHING POINTSThere exist many kinds of non-pathologic or less significant findings that are commonly misread as rather significant diseaseson chest CT scan. The educational goal of this exhibit is to familiarize radiologists to the characteristic CT appearances ofnon-pathologic and insignificant findings and to learn differential diagnostic points of each finding for the improvement ofdiagnostic accuracy when such cases are encountered.

TABLE OF CONTENTS/OUTLINEThe cases are to be presented in a quiz format. Each case has a literature review and differential diagnostic points. Includedcases are as follows: - Contrast material (CM) filling of azygos arch valves - Nonfatal venous air embolism related to IV injectionof CM - Distal thoracic duct - Axillary arch - Pericaval fat collection in IVC - Pericardial recess and sinus - Tracheal diverticulum -Focal fibroatelectasis related to spinal osteophytes - Subpleural tiny "hills" as a minor form of dependent atelectasis - Mucoidpseudotumor in the airway - Pseudothrombosis in SVC by interflowing of opacified and unopacified blood - Motion artifactsmimicking dissection of ascending aorta, bronchiectasis, or rib fracture

CHE188

Lateral Chest Radiography: A Forgotten Art Education ExhibitsLocation: CH Community, Learning Center

Participants

ParticipantsGitanjali Bajaj MBBS : Nothing to Disclose Roopa Ram MD (Presenter): Nothing to Disclose Angela V. Frost MD : Nothing to Disclose Kedar Jambhekar MD : Nothing to Disclose Carey Lee Guidry MD : Nothing to Disclose Sanjaya Viswamitra MD : Nothing to Disclose Tarun Pandey MD, FRCR : Nothing to Disclose

TEACHING POINTS1. Review normal radiographic location of mediastinal, hilar and parenchymal structures on a lateral chest x ray 2. Develop astructured approach to interpreting normal and abnormal lateral chest radiographs. 3. Localize abnormality seen on lateral chestx ray to a specific medistainal compartment and derive a reasonable list of differential diagnosis for each mediastinalcompartment


1. Radiographs showing normal radiographic landmarks including bronchi, vasculature, parenchymal lobes and mediastinalcompartments.

2. Radiographic signs, potential spaces and hidden areas on lateral chest x ray.

3. Case examples showing correlation of imaging findings on lateral chest radiograph with frontal view and CT images.

CHE189

Lung Cancer Mimics: False Positive Fake-outs Education ExhibitsLocation: CH Community, Learning Center

ParticipantsSaurabh Agarwal MD : Nothing to Disclose Carol C. Wu MD (Presenter): Author, Reed Elsevier Matthew David Gilman MD : Nothing to Disclose Sanjeev Bhalla MD : Nothing to Disclose Jo-Anne O. Shepard MD : Consultant, Agfa-Gevaert Group Gerald F. Abbott MD : Author, Thieme Medical Publishers, Inc Author, Amirsys, Inc

TEACHING POINTS

1. Lung cancer has variable imaging manifestations including nodules, masses, focal or diffuse ground-glass opacities andconsolidation

2. A variety of disease entities mimic lung cancer and cause false-positive interpretation of imaging studies

3. Awareness of lung cancer mimics help radiologists provide appropriate differential considerations and guide further diagnosticwork-up

TABLE OF CONTENTS/OUTLINEReview variable imaging appearance of lung cancer o Nodule/Mass o Endobronchial lesion o Consolidation, ground-glass opacityInteractive case-based quiz questions to illustrate lung cancer mimics and distinguishing features, if any o Neoplasm other thanlung cancer Pulmonary lymphoma Carcinoid tumor Metastasis Sarcoma o Infection Pneumonia Abscess Mycobacterial infectionFungal infection o Non-infectious benign entities Hamartoma Amyloidosis Sarcoidosis Necrobiotic Nodule Organizing pneumoniaRounded atelectasis Lipoid Pneumonia Granulomatosis with polyangiitis

CHE190

Minimal-invasive Lung Volume Reduction: Bronchoscopic Techniques and Impact ofQuantitative CT Emphysema Evaluation Education ExhibitsLocation: CH Community, Learning Center


ParticipantsUlrich Grosse MD : Nothing to Disclose Juergen Hetzel : Nothing to Disclose Lutz Guendel : Employee, Siemens AG Sergios Gatidis MD : Nothing to Disclose roland syha : Nothing to Disclose Gerd Grozinger MD : Nothing to Disclose Christoph Schabel MD : Speaker, Siemens AG Claus Detlef Claussen MD : Nothing to Disclose Konstantin Nikolaou MD : Speakers Bureau, Siemens AG Speakers Bureau, Bracco Group Speakers Bureau, Bayer AG Marius Horger MD (Presenter): Nothing to Disclose

TEACHING POINTS

A fundamental knowledge of the pathophysiology of lung emphysema is imperative for understanding the mechanismsof action of the various bronchoscopic lung volume reduction (LVR) techniques.Preinterventional CT imaging of the lung is mandatory to confirm the diagnosis of emphysema, establish the phenotype(heterogeneous vs. homogeneous) as well as to rule out contraindications (for example major fissure gaps forvalve-based LVR therapy as they are an indirect sign of collateral ventilation).Quantitative CT assessment of the lung parenchyma can aid in the preinterventional target lobe/ lobes selection anddifferentiate emphysema from severe bronchial obstruction with hyperinflation (e.g. asthma, bronchiolitis obliterans,etc.).Radiologists should be familiar with the appearance of various LVR-related complications.

Radiologists should be familiar with the appearance of various LVR-related complications.

TABLE OF CONTENTS/OUTLINEDefinition, epidemiology and pathophysiology of emphysema Overview of currently used bronchoscopic LVR techniques Detailedpresentation of the presumed mechanism of action of LVR- coils and valves and effects on lung volume as well as densityQuantification of airflow redistribution

Preinterventional imaging Overview Computed tomography including quantitative lung parenchyma analysis Postinterventional imaging LVR- related complications

CHE191

More Than Node Worthy: Imaging of the Internal Mammary Arteries, Veins and Lymph Nodes Education ExhibitsLocation: CH Community, Learning Center

ParticipantsSheila Kumar Kori MD : Nothing to Disclose Sreevathsan Sridhar MD : Nothing to Disclose Brent Little MD : Nothing to Disclose Sanjeev Bhalla MD : Nothing to Disclose Travis S. Henry MD (Presenter): Spouse, Employee, F. Hoffmann-La Roche Ltd

TEACHING POINTS

1 - While they travel together, the internal mammary veins, arteries and lymph nodes represent three distinct functionalsystems that are affected by a variety of diseases and should be assessed individually. A basic familiarity of normal anatomyand the spectrum of pathology is essential for accurate interpretation of chest CT.

2 - This image-rich educational exhibit will review the diverse pathology that can affect the internal mammary veins, arteriesand lymph nodes including neoplastic, inflammatory/infectious, congenital, traumatic and iatrogenic conditions.

TABLE OF CONTENTS/OUTLINEOutline: Normal anatomy (lymph nodes, arteries, veins) Lymphadenopathy - size criteria for enlargement; discuss exclusionfrom IASLC staging for lung cancer Reactive (infection) - empyema (bacterial, parasites, mediastinitis, other) Malignant (breast,lung/pleural; abdominal with review pathway of drainage from peritoneal cavity/liver) Arteries: -bypass graft (anatomy fromsubclavian, any variants?) -dilated - coarctation, interrupted aortic arch, BT shunt, unilateral vs bilateral -collateral supply tolungs (mycetoma, fibrosis) -traumatic pseudoaneurysm with active extravasation Veins: -dilated - collateral pathways SVCsyndrome, varices -trauma -tumor -iatrogenic - catheter placement in internal mammary vein Conclusion

CHE192

Mounier-Kuhn Syndrome: Radiological Spectrum with Differential Diagnosis Education ExhibitsLocation: CH Community, Learning Center

ParticipantsAmeya Jagadish Baxi MBBS, DMRD (Presenter): Nothing to Disclose Carlos S. Restrepo MD : Nothing to Disclose Amy Laura Mumbower MD : Nothing to Disclose Michael James McCarthy MD : Nothing to Disclose Rashmi S. Katre : Nothing to Disclose Santiago Martinez-Jimenez MD : Author, Amirsys, Inc Ashish Rajendra Khandelwal MD : Nothing to Disclose Aleema Patel MD : Nothing to Disclose

TEACHING POINTS

1. Study the pathophysiology of Mounier-Kuhn Syndrome

2. Study radiological spectrum and differential diagnosis

TABLE OF CONTENTS/OUTLINEMounier-Kuhn syndrome is characterized by tracheobronchial dilation due to atrophy of muscular and elastic tissues in tracheaand main bronchial walls. It usually presents with recurrent pneumonias, fibrosis and other respiratory complications ofpooled/stagnant secretions in dilated airways. Diagnosis of tracheal dilatation is often made by plain radiography although CT ismore sensitive. In adults, the diagnostic criteria are: diameter of the trachea >30 mm; of the right main bronchus >20 mm;and of the left main bronchus >18 mm. MK syndrome has 3 subtypes. In type 1, there is a slight symmetric dilation in thetrachea and main bronchi; in type 2, the dilation and diverticula are distinct; and in type 3, diverticular and saccular structuresextend to distal bronchi.The other conditions which may cause tracheobronchial dilatation include: connective-tissue diseases,ataxia-telangiectasia, ankylosing spondylitis,Ehlers-Danlos syndrome, Marfan's syndrome,Kenny-Caffeysyndrome,Brachmann-de Lange syndrome, and cutis laxa.These diseases differ in epidemiology, clinical outcome, managementand prognosis. Radiologists should be familiar with the imaging appearances of MK syndrome and understand its clinicalsignificance.

CHE193

Multimodality Imaging of Pulmonary Artery Angiosarcoma—An Exhibit On The RadiologicRole of Evaluation and Palliation Education ExhibitsLocation: CH Community, Learning Center

ParticipantsZachary R. Laste MD (Presenter): Nothing to Disclose Rahul N. Sawlani MD : Nothing to Disclose Kaushik S. Shahir MD : Nothing to Disclose Dhiraj Baruah MD : Nothing to Disclose Sushilkumar K. Sonavane MD : Nothing to Disclose Lawrence R. Goodman MD : Nothing to Disclose

TEACHING POINTSAngiosarcoma is a rare disease associated with significant morbidity and mortality. When localized in the pulmonary arteries,this disease can mimic pulmonary embolism in both clinical and radiologic presentation, delaying proper therapy. The aim of thisexhibit is to demonstrate the role of CT, MRI, and PET imaging to distinguish these disease entities, as well as describe the rolethat interventional radiology can play in the palliative care of these patients. This review will increase radiologist's awareness ofthe common imaging findings of pulmonary artery angiosarcoma as well as their potential role in these patients' care.


a. Brief overview of pathophysiology of angiosarcomab. Overview of the imaging of findings of CT, MRI, and PET with multiple case examplesc. Description of the palliative measures interventional radiology can offer to these patients with case examples

CHE194

Need-to-Know CT Anatomy of the Upper Thorax Education ExhibitsLocation: CH Community, Learning Center

ParticipantsSeul Ki Lee MD (Presenter): Nothing to Disclose Dae Hee Han MD, PhD : Nothing to Disclose

TEACHING POINTS1) In this exhibit, CT anatomy of several less-known yet critically important structures of the upper thorax is shown. 2)Relevent anatomical knowledge is also given

TABLE OF CONTENTS/OUTLINEAnatomic structures Thoracic duct Vertebral vein Internal mammary vessels above the parasternal level: Relation to the lateralmargins of the costal cartilage and the brachicephalic veins Soft-tissue density of the sternoclavicular joint projected below theclavicle with correlation with cryosection anatomy Cervical extension of the thymus: CT density in adolescent and adults Thelocations of the phrenic, vagus, and recurrent laryngeal nerves on axial CT scans

CHE195

Past, Present and New Era of Imaging of Chronic Obstructive Pulmonary Disease Education ExhibitsLocation: CH Community, Learning Center


ParticipantsBrian Daneshvar : Nothing to Disclose Jadranka Stojanovska MD, MS (Presenter): Nothing to Disclose Craig J. Galban PhD : Inventor, ImBio, LLC Brian Dale Ross PhD : Co-founder, ImBio, LLC Shareholder, ImBio, LLC Advisor, ImBio, LLC Ella A. Kazerooni MD : Nothing to Disclose

TEACHING POINTS1. Review classification, clinical and imaging features of severity and phenotypes of Chronic Obstructive Pulmonary Disease(COPD) 2. Review COPD imaging techniques used to evaluate COPD patients in the past (chest x-ray, chest CT) and in thepresence (chest CT and CT density mask) with an emphasis on technical advances (Parametric Response Map) to improve COPDoutcome 3. Discuss the clinical potential of COPD phenotype imaging in evaluating these patients and to correlate clinical andimaging findings

TABLE OF CONTENTS/OUTLINEThe spectrum of COPD phenotypes in different Global Obstructive Lung Disease (GOLD) stages with correlation between thecurrent techniques and recent advancements such as Parametric Response Map (PRM) will be presented as clinical case serieswhere PRM can solve the clinical conundrum. The following will be discussed: 1. Clinical significance, treatment and prognosis 2.Computed Tomography evaluation (protocols, imaging findings, and current post-processing technique) 3. Recent advances inpost-processing Current CT quantitative imaging for COPD is an important tool for providing more accurate assessment ofdisease severity that guides clinical management. Bringing PRM into future practice may identify a patient's specific COPDphenotype to direct targeted and personalized therapy.

CHE196

Pipe Trouble: Pathology of the Tracheobronchial Tree Education ExhibitsLocation: CH Community, Learning Center

Participants

Minesh Patel MD (Presenter): Nothing to Disclose Anna Knobel MD : Nothing to Disclose Maciej Walczyszyn : Nothing to Disclose Palka Wojciech MD : Nothing to Disclose Robert William Perone MD : Nothing to Disclose

TEACHING POINTSReview the anatomy of the tracheobronchial tree. Discuss the spectrum of anatomic variants and pathology associated with thetracheobronchial tree with radiologic and bronchoscopic correlation. Emphasize the importance of correlating radiologic findingswith clinical history, bronchoscopy and in some cases, tissue sampling.


Normal anatomy and variants.1.Imaging techniques.2.Discuss and present cases of focal diseases and provide correlation with virtual and/or fiber-optic bronchoscopyincluding: Tracheal stricture/stenosis, benign neoplasms, primary malignant neoplasms, secondary malignant neoplasms,tracheoesophageal fistula, tracheal diverticulum, trauma, foreign bodies.

3.

Discuss and present cases of diffuse disease processes and provide correlation with virtual and/or fiber-opticbronchoscopy of the trachea including: Mounier-Kuhn disease (tracheobronchomegaly), relapsing polychondritis,amyloidosis, tracheopathia osteoplastica, saber-sheath trachea, tracheobronchomalacia, infectious disorders.

4.

Summary5.

CHE197

Pitfalls in Interpretation of Oncologic Thoracic PET/CT Education ExhibitsLocation: CH Community, Learning Center

ParticipantsGustavo S.P. Meirelles MD, PhD (Presenter): Partner, DICOM Grid Stockholder, Fleury Group Julia Capobianco MD : Nothing to Disclose Marco Oliveira : Nothing to Disclose

TEACHING POINTSThe main teaching points of this exhibit are: - To describe and illustrate the main pitfalls and artifacts in the interpretation ofoncologic thoracic PET/CT examinations, including false-negative and false-positive findings; - To present strategies for avoidingmisinterpretation of common pitfalls and artifacts in oncologic thoracic PET/CT examinations.

TABLE OF CONTENTS/OUTLINE1. Physiologic uptake of FDG 2. Normal variants 3. Artifacts: misregistration, truncation, FDG embolism and extravasation 4.Potential pitfalls 4.1 Brown-fat FDG uptake 4.2 Lipomatous hipertrophy of the interatrial septum 4.3 Pleural uptake related totalc pleurodesis 4.4 Teflon injection of the vocal cord 4.5 Radiation-induced injuries 4.6 Iatrogenic causes of FDG uptake 4.7Muscular FDG uptake 4.8 G-CSF FDG uptake 5. False-negative results 5.1 Small lesions 5.2 Mucinous tumors 5.3Adenocarcinomas in situ and minimally invasive (previously referred as bronchoalveolar carcinoma) 6. False-positive results 6.1Infectious diseases 6.2 Atherosclerosis 6.3 Granulomatous diseases (sarcoid) 7. Summary

CHE198

Proton Therapy: What the Diagnostic Radiologist Needs to Know Education ExhibitsLocation: CH Community, Learning Center

ParticipantsMarcelo Kuperman Benveniste MD (Presenter): Nothing to Disclose Daniel Richard Gomez MD : Nothing to Disclose Brett Wilson Carter MD : Author, Reed Elsevier Consultant, St. Jude Medical, Inc Sonia Liliana Betancourt Cuellar MD : Nothing to Disclose Patricia Monique de Groot MD : Nothing to Disclose Edith Michelle Marom MD : Nothing to Disclose

TEACHING POINTS1- Radiotherapy plays a central role in the management of intrathoracic malignancies including lung, esophageal and breastneoplasms as well as thymic epithelial neoplasm, malignant pleural mesothelioma and lymphoma. 2- Different radiationtechniques have been used to plan and deliver radiation to the tumor including 3D conformal radiation therapy (3D-CRT),intensity-modulated radiotherapy (IMRT) and stereotactic body radiotherapy (SBRT). 3- Advances in radiation technique haveled to the use of proton therapy to treat thoracic malignancies. By exploiting the unique way in which protons deliver radiation,in select cases a high dose to the target volume can be maintained while reducing dose to surrounding structures, aphenomenon known as improving the therapeutic ratio. 4- We will review the different radiation delivery techniques and willfocus on proton therapy delivery technique, its advantages and CT appearance at follow-up.


Discuss the physical basis of the potential advantages of proton therapy. Describe the indications and benefits of proton therapy. Describe the role of the diagnostic radiologist in evaluating images based on treatment modality. Discuss radiologic manifestations of radiation-induced lung disease in proton therapy.

CHE199

Pulmonary Complications in Pregnancy: What Every Radiologist Should Know Education Exhibits

Location: CH Community, Learning Center

ParticipantsNik Kolicaj MD (Presenter): Nothing to Disclose David L. Spizarny MD : Nothing to Disclose

TEACHING POINTSThe major teaching points of the educational exhibit are as follows: 1. Radiologists will be familiar with the clinical features andthe multimodality imaging findings in amniotic fluid emboli, venous thromboembolism, tocolytic pulmonary edema,preeclampsia-pulmonary edema, primary spontaneous coronary dissection, pulmonary hemorrhage, peripartumcardiomyopathy, asthma, and trophoblastic emboli causing edema and aspiration pneumonia. 2. Fetal radiation exposure. 3. Theunique physiology of pregnancy which contributes to the pathophysiology of the pulmonary complications of pregnancy as seenon imaging.

TABLE OF CONTENTS/OUTLINEPhysiologic changes in pregnancy (i.e. respiratory rate, increased cardiac output, etc.) Fetal radiation exposure with differentdiagnostic procedures/imaging. Sample Cases(10 common/uncommon complications): Imaging findings Timing of complicationsPathophysiology Clinical features Summary

CHE200

Pulmonary Disease in Dermatologic Disorders Education ExhibitsLocation: CH Community, Learning Center

ParticipantsAshley Marie Stanley MD (Presenter): Nothing to Disclose Mohammad Sarwar MD : Nothing to Disclose Alfred Wang : Nothing to Disclose Arturo Dominguez : Nothing to Disclose Nagina Malguria MBBS : Nothing to Disclose Suhny Abbara MD : Research Consultant, Radiology Consulting Group

TEACHING POINTS1. Understand that dermatologic diseases, which include genetic, inflammatory, infectious, and connective tissue disorders,often have simultaneous cardiopulmonary manifestations. 2. Through case presentation, we will systematically review thespectrum of thoracic findings on cross-sectional imaging that are associated with common dermatologic disorders. 3. Discuss amultidisciplinary approach to diagnosis: understand that the differential diagnosis of these thoracic findings is broad, but canoften be narrowed when clinical findings are considered.

TABLE OF CONTENTS/OUTLINECases will include: • Infectious o Kaposi Sarcoma o Disseminated Coccidiomycosis o Disseminated Varicella o Staph Scaldedskin syndrome secondary to mediastinitis o Bacillary Angiomatosis • Connective Tissue Disease o SLE o Dermatomyositis oScleroderma • Inflammatory o Sarcoidosis • Genetic o Tuberous Sclerosis o Neurofibromatosis type 1 o Sturge Weber Syndrome

CHE201

Pulmonary Edema: Key Radiologic Features & Pathophysiology that Radiologists Need toKnow Education ExhibitsLocation: CH Community, Learning Center

ParticipantsMasaki Matsusako MD, PhD (Presenter): Nothing to Disclose Yasuyuki Kurihara MD : Nothing to Disclose Takeshi Hara PhD : Nothing to Disclose Yuka Okajima MD, MPH : Nothing to Disclose Mariko Okura : Nothing to Disclose Tomoya Nishiyama MD : Nothing to Disclose Takeshi Wada MD : Nothing to Disclose Kazuhiko Hosoya : Nothing to Disclose Tsutomu Nihei : Nothing to Disclose

TEACHING POINTSThe purposes of this exhibit are: 1. To illustrate how to interpret imaging findings of pulmonary congestion and cardiogenicedema on chest radiographs. 2. To learn differences of pathophysiology and radiologic features between increased hydrostaticpressure edema and permeability edema. 3. To review clinical and radiologic manifestations of various types of pulmonaryedema.

TABLE OF CONTENTS/OUTLINE1. Key points to interpret imaging findings of pulmonary congestion and pulmonary edema on chest radiographs i. Hypoxicpulmonary vasoconstriction ii. Pulmonary blood flow distribution iii. Vascular pedicle width ( - as an indicator of changes insystemic blood volume - ) iv. Patterns of interstitial pulmonary edema v. Regional distribution of pulmonary edema 2.Differences in pathophysiology between increased hydrostatic pressure edema and permeability edema i. Function of endothelialand epithelial barrier ii. Characteristics of edema fluid iii. Mechanism of clearance of edema fluid iv. Role of lymphatic drainagein the interstitium 3. Various types of pulmonary edema i. Neurogenic pulmonary edema ii. Reexpansion pulmonary edema iii.High altitude pulmonary edema iv. Near-drowning or drowning v. Peripartum cardiomyopathy vi. Pulmonary edema induced bymarathon running

CHE202

Pulmonary Micronodules: New Entities Come into Play

Education ExhibitsLocation: CH Community, Learning Center

ParticipantsSarah Lafond MD (Presenter): Nothing to Disclose Juliana Marcela Bueno MD : Co-author, Oxford University Press

TEACHING POINTSThe purpose of this exhibit is to help the learner: Review the basic anatomy of the lung parenchyma as seen on HRCT. Gainunderstanding on pathophysiology of the different entities that manifest with pulmonary micronodules. Be able to apply aneffective, up to date, diagnostic algorithm when approaching these entities based on imaging findings. This is important tore-evaluate since the last comprehensive review was performed nearly 10 years prior. Identify new pulmonary pathologies thatshould be included in the differential diagnosis of micronodules, including establishing the novel term 'arterial tree-in-bud' as adiagnostic consideration.

TABLE OF CONTENTS/OUTLINEReview of the anatomic components of the lung parenchyma, specifically emphasizing the secondary pulmonary lobule, as seenon HRCT. Diagrams HRCT images Anatomic-pathologic correlations of micronodular lung diseases. Examples of HRCT findings ofeach entity. Updated diagnostic algorithm to micronodular diseases.

CHE203

Quantification of Regional Lung Parenchyma Movement using Dynamic Respiratory CT Education ExhibitsLocation: CH Community, Learning Center

ParticipantsHiroshi Moriya MD (Presenter): Nothing to Disclose Manabu Nakagawa : Nothing to Disclose Koutarou Sakuma : Nothing to Disclose

TEACHING POINTSTo visualize the quantified images of lung parenchyma movement by dynamic respiratory CT and 4D voxel-tracking method. Todisplay the regional respiratory movement of cases with typical respiratory diseases.

TABLE OF CONTENTS/OUTLINE[Objective] A range of 16 cm can be scanned in a single rotation with 320-row ADCT. Dynamic motion images are obtained byusing continuous scanning. The purpose of this presentation is to visualize the quantified images of regional lung parenchymamovements. [CT scan] 320-row ADCT (Aquilion ONE), continuous dynamic volume scanning. [4D voxel-tracking method]PhyZiodynamics; the 3-dimensional structures are tracked from dynamic volume data (voxel-to-voxel mapping). [Methods] Therespiratory phases are obtained from the motion of the diaphragm, and the temporal changes of the points, areas, and volumesassociated with the respiratory phases are analyzed. [Cases] Lung cancer or mediastinum tumor patients with respiratorydisorder (COPD, IPF, tracheobronchimalacia, etc.). [Conclusion] The difference in movement can be displayed by using dynamicvolume scanning. These dynamic movements may be correlated with the regional lung function.

CHE204

Quantitative Computed Tomography Evaluation in Emphysema and Airway Diseases Education ExhibitsLocation: CH Community, Learning Center

ParticipantsMarcel Koenigkam Santos MD, PhD (Presenter): Nothing to Disclose Valdair Francisco Muglia MD, PhD : Nothing to Disclose Marcelo Bezerra Menezes : Nothing to Disclose Elcio dos Santos Oliveira Vianna : Nothing to Disclose Jose Baddini Martinez : Nothing to Disclose Jorge Elias MD, PhD : Nothing to Disclose

TEACHING POINTS1. To understand the principles and techniques for quantitative computed tomography evaluation of emphysema and airwaydiseases 2. To review the role of the method as a biomarker in disorders such as chronic obstructive pulmonary disease(COPD), asthma and cystic fibrosis

TABLE OF CONTENTS/OUTLINEA. Introduction B. Principles of CT quantification of emphysema and airway abnormalities C. Technical aspects of the method D.COPD E. Asthma F. Cystic fibrosis G. Summary

CHE205

Radiologic Review of Primary Mediastinal Nonseminomatous Germ Cell Tumors: ThreeDecades of Experience from a Large Referral Center with Emphasis on Surgical Management Education ExhibitsLocation: CH Community, Learning Center

Cum Laude

Participants

Darel Edward Heitkamp MD (Presenter): Nothing to Disclose Wahida Tania Rahman MD : Nothing to Disclose Shawn D. Teague MD : Nothing to Disclose Karen M. Rieger MD : Nothing to Disclose Kenneth A. Kesler MD : Nothing to Disclose

TEACHING POINTS1. Primary mediastinal nonseminomatous germ cell tumor (PMNSGCT) typically occurs in a predictable location within thethorax. This exhibit will familiarize the radiologist with the appearance of classic and atypical PMNSGCTs. 2. Radiology plays avital role in the diagnosis and pre-surgical planning of these patients, as well as the post-surgical evaluation of potentialcomplications and disease recurrence. 3. PMNSGCT represents a challenging subgroup of malignant germ cell tumors andsurvival depends on both sucessful chemotherapy and surgical resection. 4. An aggressive multidisciplinary approach thatincludes surgery after cisplatin-based chemotherapy can result in long-term survival, even in patients with persistent germ cellor non-germ cell cancer.

TABLE OF CONTENTS/OUTLINE1. Introduction: basic information related to PMNSGCT. 2. Current treatment paradigm (chemotherapy + surgery). The crucialrole of radiology in diagnosis and treatment planning. Review of surgical approach and how it affects imaging appearance. 3.Imaging review of classic and atypical cases. Pretherapy and posttherapy appearance. Recurrence and posttherapy salvagecases. Imaging of surgical devices and common complications. 4. Review of extensive single institution data includingindependent predictors of survival.

CHE206

Reduced Dose, Low Dose, Ultra-low Dose… Can We Get Any Lower? A Practical Guide toOptimize the Radiation Dose Delivered in Chest Computed Tomography Education ExhibitsLocation: CH Community, Learning Center


ParticipantsMarysa Schaal MD (Presenter): Nothing to Disclose Mickael Ohana MD, MSc : Nothing to Disclose Mi-Young Jeung MD : Nothing to Disclose Aissam Labani MD : Nothing to Disclose Catherine Roy MD : Nothing to Disclose

TEACHING POINTSDetermine the actual optimal radiation dose levels for chest CT. Learn how to efficiently use the dose reduction techniques. Beable to adapt the radiation dose delivered according to the indication and the patient's morphology. Become familiar withultra-low dose (ULD) chest CT and be aware of its current and future applications.

TABLE OF CONTENTS/OUTLINE1. Chest CT in 2014: what are the different radiation levels? 1.1. A little bit of physics: how to measure the radiation dose? 1.2.Current optimal radiation dose 1.2.1. Unenhanced chest CT 1.2.2. Enhanced chest CT 1.2.3. Chest CTA with ECG gating 1.3.Reduced dose and low dose chest CT 1.4. ULD chest CT 2. Dose reduction techniques: how to use them? 2.1. Iterativereconstruction 2.2. kV and tube current modulation 2.3. Others 3. Practical approach to radiation dose reduction in chest CT 3.1.Based on patient's morphology 3.2. Based on the indication 3.3. Practical examples 4. ULD chest CT today and in the nearfuture 4.1. Nodule detection and follow-up 4.2. Screening 4.2.1. Lung cancer 4.2.2. Asbestos related disease 4.2.3. Tuberculosis4.3. Other future applications 4.4. Actual limitations

CHE207

Resident’s Guide to Post-therapy Changes in the Chest Education ExhibitsLocation: CH Community, Learning Center

ParticipantsRydhwana Hossain MD (Presenter): Nothing to Disclose Alan Clint Legasto MD : Nothing to Disclose

TEACHING POINTSAs post-therapy chest imaging is extremely common, it is imperative for radiologists in training to understand the post-surgicaland post-radiation changes. Knowledge of the different types of surgeries as well as different manifestations of post radiationchanges in the acute, transient and chronic stages, as well as its' differential diagnosis is also very important. Our exhibit willhighlight the concept of post-therapy changes in the chest-both post-surgical and post-radiation.

TABLE OF CONTENTS/OUTLINE1. Review various surgical options including- wedge resection, lobectomy, pneumonectomy, thoroacoplasty, sleeve resectionetc. 2. Review various radiation portals and beam arrangements for the treatment of thoracic malignancies. 3. Review thedifferent manifestations of radiation induced lung disease in the acute, transient and chronic phases. 4. Differential diagnosis forpost radiation changes of the chest.

CHE208

Spectral Detector Computed Tomography (Dual-layer CT): Clinical Applications in ThoracicImaging Education ExhibitsLocation: CH Community, Learning Center

ParticipantsRong Rong MD : Institutional Grant support, Koninklijke Philips NV Prabhakar Rajiah MD, FRCR : Institutional Research Grant, Koninklijke Philips NV Luis Alberto Landeras MD (Presenter): Institutional Grant support, Koninklijke Philips NV

TEACHING POINTS- To gain awareness of the basic principles of spectral computed tomography (CT) - Understand the essentials of spectraldetector CT technology compared to other available spectral CT solutions - Demonstrate different applications of spectraldetector CT imaging in the thorax

TABLE OF CONTENTS/OUTLINE1. Introduction 2. Principles of Spectral CT 3. CT Image reconstruction 4. Clinical applications: - Lung perfusion - VirtualNonenhanced Imaging - Metallic artifact reduction - Rescuing of the suboptimal pulmonary embolism CTA - Nodule and softtissue mass characterization - Lymph node assessment - Post treatment evaluation. 5. Radiation dose

CHE209

State-of-the-Art Thoracic CT Imaging Techniques with 3rd Generation Dual Source CT Education ExhibitsLocation: CH Community, Learning Center

ParticipantsMarcel L. Dijkshoorn RT (Presenter): Consultant, Siemens AG Ronald Booij RT : Nothing to Disclose Arlette Odink MD, PhD : Nothing to Disclose Marcel Van Straten PhD : Research collaboration, Siemens AG

TEACHING POINTS1. To explain the application, benefits and pitfalls of spectral shaping with tin filtration. 2. To understand how detector combfiltering influences spatial resolution and noise. 3. To discuss dose reduction potential of organ based angular tube currentmodulation. 4. To demonstrate how ultrafast scan protocols minimize breathing and pulsation artifacts. 5. To understandimprovements in dual energy application and be able to interpret specific dual energy artifacts.

TABLE OF CONTENTS/OUTLINEIntroduction Spectral shaping with tin filtration Detector comb filtering Ultrafast scan protocols Organ based angular tubecurrent modulation Sub-second full thorax imaging Dual Energy scanning and analysis Summary: Third generation dual SourceCT has a number of dedicated techniques to facilitate state-of-the-art thoracic imaging. The availability of these techniquesprovides solutions for optimizing image quality and reducing radiation dose. This exhibit will explain the individual scantechniques, pitfalls and illustrate which patient group or clinical questions benefit most per technique.

CHE210

The ABC’s on CT: Ancillary Breast & Chest Masses Education ExhibitsLocation: CH Community, Learning Center

ParticipantsGabriela Gayer MD (Presenter): Nothing to Disclose Amsalu Dabela-Biketi MD : Nothing to Disclose

TEACHING POINTS1. Review the spectrum of common and unusual CT findings in the breast and chest wall. 2. Refine the diagnostic approach toincidental breast and chest wall lesions on CT using attenuation characteristics and patient history. 3. Learn what to recommendfor incidental breast and chest wall lesions on CT.

TABLE OF CONTENTS/OUTLINE1. Incidental breast masses 2. Incidental chest wall masses 3. Diagnostic approach based on CT imaging features and pertinenthistory 4. Imaging algorithm for further workup 5. Challenge cases: congenital, infectious/inflammatory, neoplasm, iatrogenic 6.Summary

CHE211

The Dozen Key Imaging Signs of HRCT in Focal and Diffuse Lung Disease Every RadiologyResident Must Know Education ExhibitsLocation: CH Community, Learning Center

ParticipantsRammohan Vadapalli MD (Presenter): Nothing to Disclose Harshavardhan KR MD : Nothing to Disclose Abhijit Roychowdhury MD : Nothing to Disclose Pramod Kumar Reddy Kaila MD : Nothing to Disclose Abhinav Sriram Sriram Vadapalli : Nothing to Disclose

TEACHING POINTSTo list all the key imaging signs in HRCT useful for characterization of Focal and Diffuse Lung Disease and briefly explain theunderlying Pathological Correlates-Every Resident must know The Differential diagnosis of each of these signs,what they standfor and theeir specificity is highlighted. with Differential Diagnosis is discussed. A symptom or Clinical scenario specific Checklist

approach every resident must follow when interpreting HRCT studies and observing these signs is showcased.

TABLE OF CONTENTS/OUTLINE1.Halo sign 2.Reverse Halo sign 3.fairy Ring sign 4.Dark Bronchus sign 5.CT Angiogram sign 6.GLOVED Finger sign 7.CrazyPaving Pattern 8.Tree in Bud sign 9.Signet ring sign 10.Split Pleura sign 11.Comet tail Sign 12.Feeding Vessel Sign Each sign isdefined its components clearly outlined by Diagramatic reprentation and Clinical illustrative HRCT images. The pathologicalCorrelates of Every Imaging sign are highlighted The Common and Uncommon pathologies which show the sign and Particularpattern are listed.

CHE212

The Paratracheal Pseudomass: An Atypical Appearance of Tracheal Diverticulum. Education ExhibitsLocation: CH Community, Learning Center

ParticipantsTamara Y. Carroll MD (Presenter): Nothing to Disclose Gregory Kicska MD, PhD : Nothing to Disclose Sudhakar N. Pipavath MD : Nothing to Disclose Moira Aitken MD : Nothing to Disclose J. David Godwin MD : Shareholder, Cardiac Insight

TEACHING POINTS1. Definition of tracheal diverticula and types. 2. The epidemiology and pathophysiology of tracheal diverticula. 3. Awareness ofthe atypical appearance of infected or fluid filled tracheal diverticula in order to avoid misdiagnosis of neoplasm orlymphadenopathy and prevent unnecessary invasive work-up.

TABLE OF CONTENTS/OUTLINE1. Brief review of the pathophysiology of tracheal diverticula. 2. Brief discussion of epidemiology. 3. Typical CT appearance oftracheal diverticulum. 4. Cases mimicking adenopathy or neoplasm 4.1. CT and other modality imaging (e.g. ultrasound andFDG-PET) appearance of filled tracheal diverticula 4.2. Patient symptomatology and presentation with filled tracheal diverticula.

CHE213

"The Pomegranate Sign: A Useful CT Finding for Diagnosing Intrathoracic Exudates" Education ExhibitsLocation: CH Community, Learning Center

ParticipantsTomas C. Franquet MD (Presenter): Nothing to Disclose Sanjeev Bhalla MD : Nothing to Disclose Marvin H. Chasen MD : Nothing to Disclose Ana M. Gimenez MD : Nothing to Disclose Alberto Hidalgo MD : Nothing to Disclose

TEACHING POINTS1. To recognize the morphologic characteristics of Pomegranate sign. 2. To understand the physical basis that may form a wavyline interface in intrathoracic exudates. 3. To illustrate this sign in different intrathoracic exudates related to infections,malignancies, congenital malformations, iatrogenic disorders and trauma.

TABLE OF CONTENTS/OUTLINEThe 'Pomegranate sign' is a useful CT finding based on the appearance of intrathoracic pathologic gas-fluid levels. This signconsist on the presence of a wavy air-fluid interface occurring after the complication of a cavity or space containing fluid(exudate). When the imaging plane is parallel to the wavy gas-fluid interface, a pomegranate-like appearance will be visible. Wediscuss and illustrate this previously non-described CT finding in diverse complicated intrathoracic disorders (Table 1). Table 1.Gas-Fluid Levels in Complicated Intrathoracic Exudates (Pomegranate Sign) A) Infectious processes with parenchymal, pleuralor mixed involvement such as bronchopleural fistula, empyema, and lung abscess. B) Congenital disorders: Bronchogenic cyst;Bronchial atresia; Congenital pulmonary airway malformation (CPAM). C) Malignant: Malignant pleural effusion D) Iatrogenicdisorders E) Traumatic thoracic injuries: Hydropneumothorax, Lung contusion

CHE214

Thoracic Applications of Magnetic Resonance Imaging Education ExhibitsLocation: CH Community, Learning Center


ParticipantsLucia Flors MD (Presenter): Nothing to Disclose Carlos Leiva-Salinas MD : Nothing to Disclose Patrick T. Norton MD : Nothing to Disclose Talissa A. Altes MD : Research Grant, Vertex Pharmaceuticals Incorporated Research Grant, Novartis AG Speaker, KoninklijkePhilips NV Speaker, Guerbet SA Klaus D. Hagspiel MD : Research Grant, Siemens AG

TEACHING POINTS• Review the protocol to study thoracic pathology with MRI • Summarize the different applications of thoracic MRI

TABLE OF CONTENTS/OUTLINE• Thoracic MR: advantages and limitations • Protocol - Morphology - Function (diffusion, perfusion, respiratory dynamics) - New

• Thoracic MR: advantages and limitations • Protocol - Morphology - Function (diffusion, perfusion, respiratory dynamics) - Newcontrast materials: Hyperpolarized gases, O2 enhanced MRI - Common artifacts • Applications - Vascular pathology: aorta,pulmonary embolism and hypertension, congenital pathology - Mediastinal masses - Lung cancer: Pancoast tumor, TNMstaging, response to therapy - Pleura: effusion, benign vs maligant pathology, mesothelioma - Chest wall lesions - Pulmonaryparenchyma: nodules, masses, cystic fibrosis, interstitial lung disease • Main clinical indications

CHE215

Thoracic Applications of Minimum Intensity Projection Reformatting: The Airways andBeyond Education ExhibitsLocation: CH Community, Learning Center

ParticipantsJabi E. Shriki MD (Presenter): Nothing to Disclose

TEACHING POINTS

The following teaching points will be emphasized:

Minimum intensity projection (MinIP) reformatting is a technique for depicting low attenuation or low signal intensity structureswithin a volume of tissue. This technique has particular utility in thoracic imaging in depicting a wide range of pathology, andcan be applied to CT or MRI.

MinIP is commonly useful in depicting airways in order to show normal bronchi, variants of normal anatomy, and pathologicalconditions affecting the airways. Normal and variant anatomy and disease states of the bronchi will be reviewed.

MinIP is also useful in evaluating the pulmonary parenchyma in demonstrating areas of lucency or low signal intensity, whichcan either be due to air trapping or decreased perfusion. Various diseases which can result in oligemia or air trapping will bediscussed.

MinIP can also be used to demonstrate other structures which are low in signal intensity or attenuation within a background ofhyperattenuation or high signal, such as dissection flaps within a contrast-filled lumen.

TABLE OF CONTENTS/OUTLINETechniques for MinIP reformatting of imaging studies: the basics of MinIP. MinIP in the depiction of the airways. MinIP in theevaluation of the lung parenchyma. MinIP for demonstration of low attenuation or low signal intensity structures within a 'bright'background.

CHE216

Thoracic Manifestations of Hepatobiliary and Pancreatic Malignancies: How Do They Differfrom Other Tumors? Education ExhibitsLocation: CH Community, Learning Center

ParticipantsRoss Holwerda MD (Presenter): Nothing to Disclose Christopher Walker MD : Author, Amirsys, Inc Author, Reed Elsevier Melissa L. Rosado De Christenson MD : Author, Thieme Medical Publishers, Inc Author, Amirsys, Inc Author, American Registryof Pathology Author, Oxford University Press Santiago Martinez-Jimenez MD : Author, Amirsys, Inc Jeffrey Russell Kunin MD : Investigator, Oncimmune LLC Paul P. Pettavel MD : Nothing to Disclose

TEACHING POINTS

1. Metastases from hepatobiliary and pancreatic neoplasms often follow predictable patterns of spread in the thorax.

2. Knowledge of classic and atypical imaging appearances allows the radiologist to tailor his/her search pattern based on thespecific malignancy, better evaluate disease progression, and avoid misdiagnosis of concurrent benign conditions.

TABLE OF CONTENTS/OUTLINE1. Thoracic metastases from hepatobiliary and pancreatic neoplasms. 2. Typical and atypical patterns of metastatic spread androle of biomarkers in diagnosis and follow-up (e.g. AFP, CA19-9, CgA) - Hepatocelluar carcinoma - intracardiac tumorthrombus/tumor emboli, lymphadenopathy, hematogenous dissemination, diaphragm invasion - Hepatic angiosarcoma - noduleswith surrounding ground glass opacity (CT halo sign) - Pancreatic adenocarcinoma - pulmonary nodules with or withoutcavitation, tumor emboli, consolidation, ground-glass opacities (lepidic tumor growth), and CT halo sign - Pancreaticneuroendocrine tumor - hypervascular metastases - Cholangiocarcinoma/gallbladder cancer - cavitary and noncavitarypulmonary nodules 3. Incidence of intrathoracic complications (e.g. pulmonary embolism incidence higher in hepatobiliary andpancreatic malignancies compared to other malignancies).

CHE218

Unilateral Pulmonary Edema Education ExhibitsLocation: CH Community, Learning Center

ParticipantsKathleen Elizabeth Jacobs MD (Presenter): Nothing to Disclose Paul Stark MD : Nothing to Disclose

TEACHING POINTS

Unilateral pulmonary edema is a common cause of uniteral lung opacification and recognition of this entity is importantfor determining patient managementThis presentation will review the etiologies of unilateral pulmonary edema and underlying pathophysiologySelect cases will be shown to highlight the radiologic appearance and natural progression of unilateral pulmonary edemaAdditional differential considerations for unilateral lung opacification will also be discussed


1. Objectives

Explore etiologies of unilateral pulmonary edemaDiscuss pathogenesis and natural progression of each entityReview differential considerations for unilateral lung opacification

2. Pulmonary Edema Ispilateral to Abnormality

Reexpansion pulmonary edemaAcute rejection post lung transplantationReimplantation response post lung transplantationUnilateral pulmonary vein occlusionPulmonary contusionAspirationBronchial obstructionProlonged lateral decubitus positionAcute mitral regurgitation

3. Pulmonary Edema Contralateral to Abnormality

Left ventricular failure and unilateral lung diseasePulmonary thromboembolismProximal interruption of the pulmonary arteries

4. Differential: Unilateral Diffuse Lung Opacification

CHE219

What Could Happen after Lung Transplantation: Complications That Radiologists Should Know

Education ExhibitsLocation: CH Community, Learning Center

ParticipantsIsaac Daimiel MD (Presenter): Nothing to Disclose Gerardo Ayala Calvo : Nothing to Disclose Sergio Alonso Charterina MD : Nothing to Disclose

TEACHING POINTS

- To review the main complications of pulmonary transplantation surgery depending on the time passed after the procedure.

- To illustrate radiological appearance of these complications and correlate them with clinical findings.


Nowadays lung transplantation is suggested as the best option of treatment for end stage pulmonary conditions such asidiopathic pulmonary fibrosis, chronic obstructive pulmonary disease, cystic fibrosis or pulmonary hypertension. The increasingsurvival in these patients is related to better immunosuppressive therapies, donor organ preservation and the improvement ofsurgical technique. Nevertheless, this is still susceptible to complications that must be detected early.

Depending on elapsed time after surgery different complications should be considered.

Acute conditions are within two months after surgical procedure and include pleural complications, reperfusion edema, acuterejection and bronchial anastomosis dysfunction.

After 2 months, we will consider entities such as cryptogenic organizing pneumonia, posttransplantation lymphoproliferativedisorder, progressive upper lobe fibrosis or chronic lung allograft dysfunction.

Events related to immunosuppressive therapy like infections, recurrence of primary disease or pulmonary embolism can occurat anytime in the postoperative period.

CHE220

When a Harmonious Relationship Goes Wrong: Chest Manifestations in Disorders ofHepatopulmonary Axis Education ExhibitsLocation: CH Community, Learning Center

ParticipantsRahul Dinkar Renapurkar MD (Presenter): Nothing to Disclose Joseph Thomas Azok MD : Nothing to Disclose Jason K. Lempel MD : Nothing to Disclose Ruchi Yadav MD : Nothing to Disclose Ahmed El-Sherief MD : Nothing to Disclose Charles T. Lau MD : Nothing to Disclose

TEACHING POINTS

The purpose of this exhibit is:

1) To discuss the general thoracic manifestations in chronic liver disease.

2) To highlight specific disorders which involve the hepatopulmonary axis.

3) To understand the role of imaging in evaluation of chest manifestations of disorders of hepatopulmonary axis.

TABLE OF CONTENTS/OUTLINEA) General manifestations in chronic liver disease 1) Chest wall-Gynecomastia and collaterals 2) Mediastinum -Dilation of azygossystem -Diaphragmatic lymphadenopathy -Transthoracic migration of ascitic fluid -Varices 3) Pulmonary and pleural -Pleuraleffusions -Pulmonary infections -Pulmonary Edema 4) Vascular -Portopulmonary hypertension -Hepatopulmonary syndrome B)Chest manifestations in specific diseases involving the hepatopulmonary axis 1) Hepatitis C associated lung disease -Pulmonaryfibrosis 2) Alpha 1 antitrypsin deficiency -Emphysema and bronchiectasis 3) Cystic fibrosis -Bronchiectasis 4) Hereditaryhemorrhagic telangiectasia -Pulmonary AVMs 5) Sarcoidosis and other granulomatous diseases -Pulmonary nodules andlymphadenopathy 6) Infections such as Echinococcosis and E. histolytica -Pulmonary and pleural involvement 7)Neoplasticdiseases such as Hepatocellular carcinoma and lymphoma 8) Drug reactions -Amiodarone -Complications of antiviral therapy

CHE221

When You See More Than What You Want to See: Management of Incidental Findings on CTor PET/CT of the Thorax Education ExhibitsLocation: CH Community, Learning Center


ParticipantsBrett Wilson Carter MD (Presenter): Author, Reed Elsevier Consultant, St. Jude Medical, Inc Myrna Cobos Barco Godoy MD, PhD : Nothing to Disclose Gerald F. Abbott MD : Author, Thieme Medical Publishers, Inc Author, Amirsys, Inc Matthew David Gilman MD : Nothing to Disclose Edith Michelle Marom MD : Nothing to Disclose Jane P. Ko MD : Editor, Reed Elsevier Reginald F. Munden MD, DMD : Nothing to Disclose Carol C. Wu MD : Author, Reed Elsevier

TEACHING POINTS1. Unsuspected incidental findings in the chest and upper abdomen are frequently detected on CTs performed for lung cancerscreening, coronary artery screening, and unrelated clinical indications or PET/CT performed for staging of malignancy. 2.Radiologists play an important role in reporting and assigning appropriate clinical significance to incidental findings. 3.Familiarity with up-to-date evidence and management guidelines for incidental findings involving the lungs, mediastinum, chestwall, and upper abdominal structures helps radiologists improve recommendations and clinical practice. 4. Appropriaterecommendations for management of incidental findings can help facilitate timely evaluation and treatment of significantfindings and prevent unnecessary diagnostic evaluations.

TABLE OF CONTENTS/OUTLINEInteractive case-based quiz questions with chest CT or PET/CT images will be presented to illustrate incidental findings in thelungs, mediastinum, chest wall, and upper abdomen. For each incidental finding, the following will be discussed and reviewed:Important imaging features and clinical information to consider in characterizing the incidental finding. Latest literatureregarding frequency and clinical significance of the incidental finding. Management guidelines from the ACR and/or otherprofessional organizations.

CHE222

Where, Oh Where, is the Air? A Quiz-based Primer for Every Radiologist on Abnormal AirSeen on Chest Radiography Education ExhibitsLocation: CH Community, Learning Center


ParticipantsDaniel Robert L'Heureux MD (Presenter): Nothing to Disclose Maria Daniela Martin MD : Nothing to Disclose Palmi Nitin Shah MD : Nothing to Disclose

TEACHING POINTSA diverse, multi-system spectrum of pathologies can be diagnosed or suspected by identifying abnormal air and its location onchest radiographs. The goal of this presentation is to expose the learner to many of the different manifestations of abnormal airseen on chest radiography to improve the learner's diagnostic ability. The importance of maintaining a rigorous, systematicsearch pattern will also be reinforced, both by providing the search pattern followed by the authors and through thecategorization of the diagnoses discussed.

TABLE OF CONTENTS/OUTLINEa. Introduction to topic/goals. b. Reinforcement of search pattern with brief demonstration. c. Cases- majority of thepresentation will follow a quiz-based format where the learner will be prompted with a question that is followed by the answer,the radiographic findings, and a teaching point. Correlation with advanced imaging, as indicated, will accompany the answer.Case examples will be categorized by location and will include, but are not restricted to: Mediastinum (pneumomediastinum,pneumopericardium, esophageal diverticulum), Lungs (pneumothorax, Macklin effect, empyema), Abdomen (portal venous gas,pneumoperitoneum, intramural gastric air, retroperitoneal air), MSK (vacuum phenomenon, paraspinal abscess), and SoftTissues (subcutaneous emphysema, sternal dehiscence).

CHE223

Xenon Ventilation CT: Ventilation Changes After Treatment in Patients With Emphysema

Xenon Ventilation CT: Ventilation Changes After Treatment in Patients With Emphysema Education ExhibitsLocation: CH Community, Learning Center

ParticipantsRex Kim Ping Wong MBBS, FRCR (Presenter): Nothing to Disclose Gladys G. Lo MD : Nothing to Disclose Bing Lam : Nothing to Disclose

TEACHING POINTSTo understand the indications, preparations, techniques, image reading and interpretation strategy and data post-processingtechniques of Xenon ventilation CT. To demonstrate how this technique can provide a visual and quantitative assessment oflung ventilation on a regional basis.

TABLE OF CONTENTS/OUTLINEA. Introduction Review the principle behind Xenon ventilation CT using dual energy technique. B. Technical ConsiderationPatient preparation, positioning, image acquisition parameters and data postprocessing. C. Image Interpretation Practicalapproach to interpretation of CT data sets. D. Image Gallery Illustrative cases of ventilation changes in patients withemphysema before and after treatment.

CHE224

Functional Imaging of the Pleura: Applications in Oncology Education ExhibitsLocation: CH Community, Learning Center

ParticipantsJordi Broncano MD (Presenter): Nothing to Disclose Antonio Luna MD : Nothing to Disclose Maria Jose Garcia-Velloso : Nothing to Disclose Roberto Garcia Figueiras MD : Nothing to Disclose Teodoro Martin MD : Nothing to Disclose Javier Sanchez MD, PhD : Research Consultant, Koninklijke Philips NV Antonio Alvarez-Kindelan : Nothing to Disclose

TEACHING POINTS

To analyze the current functional imaging techniques available (18FDG PET/CT, CT perfusion and DWI and DCE-MRI) forthe evaluation of pleural diseases, with a focus in their correct acquisition and post-processing.

1.

To review the clinical applications of these techniques, for the evaluation of malignant pleural diseases and its mimics.2.

TABLE OF CONTENTS/OUTLINE1. Introduction 2. Imaging techniques optimization 2.a. Diffusion-weighted MRI 2.b. Perfusion-weighted MRI 2.c. Perfusion CT2.d. 18FDG - PET/CT 3. Clinical applications 3.a. Malignant pleural mesothelioma Characterization of pleural disease and stagingTreatment selection and follow-up Detection of recurrence and prognostic factors 3.b. Metastatic pleural disease Characterizationand staging Treatment monitoring 3.c. Benign pleural tumors 3.d.Pitfalls 4. Conclusions

CHE225

Got Milk? Role of Radiology in Diagnosis and Management of Chylothorax Education ExhibitsLocation: CH Community, Learning Center


ParticipantsXue Susan Bai MD : Nothing to Disclose Sana Parsian MD (Presenter): Nothing to Disclose Sandeep Vaidya MD : Nothing to Disclose Gregory Kicska MD, PhD : Nothing to Disclose Sudhakar N. Pipavath MD : Nothing to Disclose J. David Godwin MD : Shareholder, Cardiac Insight

TEACHING POINTS1. Review relevant anatomy and physiology of the lymphatic system. 2. Discuss the etiology of Chylothorax. 3. Illustrate thediagnosis of thoracic duct injuries specifically via lymphaniography and highlight percutaneous thoracic duct embolization formanagement of Chylothorax.

TABLE OF CONTENTS/OUTLINE1) Anatomy and Physiology of the lymphatic system. 2) Etiologies of Chylothorax: -Nontraumatic -Malignant (lymphoma,Kaposi's sarcoma, Metastatic disease) -Nonmalignant (Idiopathic, benign tumors, Lymphangioleiomyomatosis, systemic lupuserythematosus) -Traumatic -Iatrogenic 3) Diagnosis of thoracic duct injuries via lymphangiography and highlight percutaneousthoracic duct embolization for management of chylothorax. 4. Outline an efficient radiology approach to manage chylothorax.

CHE226

Mesothelioma: Radiologic Features, Differential Diagnosis and Management Education ExhibitsLocation: CH Community, Learning Center

Location: CH Community, Learning Center

ParticipantsDaniel Barnes MD (Presenter): Nothing to Disclose Marcelo Antonio Sanchez Gonzalez MD : Nothing to Disclose Mariana Nelida Benegas Urteaga MD : Nothing to Disclose Oscar Sabino Chirife Chaparro MD : Nothing to Disclose Teresa Maria Caralt : Nothing to Disclose Rosario Jesus Perea MD, PhD : Nothing to Disclose

TEACHING POINTS-Pleural mesothelioma is a rare neoplasm with high mortality. Asbestos exposure is decreasing but the incidence is expected toincrease due to past expositions. -Radiologists must be aware detecting and managing malignant pleural thickening or effusionto avoid delays in diagnosis and treatment. - We observed that sarcomatoid mesothelioma is more aggressive that epithelioidmesothelioma, as different clinical studies suggests, and they have different radiological appearances -CT-guided biopsy is agood diagnostic technique, with similar performance to VTC with lower rate of track seeding. -New TNM allows some patientswho would had received a palliative treatment before, at the present time may opt for a treatment with curative intent.

TABLE OF CONTENTS/OUTLINE1) Introduction 2) Asbestos and mesothelioma Pleural plaques Prevalence of exposure Non exposed patients 3) Histologicalclassification Epithelioid Sarcomatoid 4) Imaging techniques MDCT PET-CT 5) Differential diagnosis Diffuse pleural thickening:metastases, tuberculosis, sarcoidosis, chronic pleuritis, limfoma Other pleural lesions 6) Histological analysis Cytology CT-guidedbiopsy Surgical biopsy (VTC) 7) Pleural thickening, Diagnostic and management algorythm 8) New TNM classification 9)Therapeutic approach and upcoming challenges

CHE227

Pleural Lesions: A Pictorial Review of Common and Not So Common Pleural Lumps andBumps Education ExhibitsLocation: CH Community, Learning Center


ParticipantsElena Scali MD : Nothing to Disclose Anto Sedlic MD (Presenter): Nothing to Disclose

TEACHING POINTS1. To present an overview of thoracic pathology presenting as pleural lesions 2. To review the radiographic and cross-sectionalimaging findings of common and uncommon pleural lesions including neoplastic, infectious, and post-traumatic etiologies. 3. Todescribe the imaging appearances that favor a pleural location for lesions identified on radiography

TABLE OF CONTENTS/OUTLINE• Radiographic patterns that aid in localization of lesions to the pleura • Differentiating pleural from chest wall lesions andpulmonary mimics of pleural lesions • Common traumatic findings, including pleural hematoma and extrapleural thoracic injuriessuch as rib fractures, soft tissue hematomas, and splenosis that may mimic pleural lesions • Non-traumatic pleural lesionsincluding primary pleural neoplasm, metastatic pleural lesions, acute and chronic pleural findings in infection, and pleural lesionsseen in occupational diseases such as asbestos related pleural plaques. • Role of the radiologist in the interdisciplinary approachin the diagnosis of pleural lesions, identifying suspicious lesions with aggressive features suggesting chest wall invasion or bonedestruction as well as benign lesions in avoiding unnecessary biopsy

CHE228

Chronic Thromboembolic Pulmonary Hypertension (CTEPH): Radiological Approach withDual-energy CT Pulmonary Angiography. A One-stop Assessment Education ExhibitsLocation: CH Community, Learning Center


ParticipantsMariana Nelida Benegas Urteaga MD (Presenter): Nothing to Disclose Marcelo Sanchez MD : Nothing to Disclose Marta Burrel MD, PhD : Nothing to Disclose Josep Guitart MD : Nothing to Disclose Marta Barrufet MD : Nothing to Disclose Teresa Maria de Caralt : Nothing to Disclose Rosario Jesus Perea MD, PhD : Nothing to Disclose

TEACHING POINTS1. To describe the CT findings of chronic thromboembolic disease at Dual CT angiography 2. To provide a differential diagnosisof pulmonary embolism and focal iodine defects in perfusion maps of dual CT 3. To explain that Dual-energy CT offers a"one-stop" assessment of anatomy and perfusion in CTEPH

TABLE OF CONTENTS/OUTLINE1. Introduction 2. Dual energy CT pulmonary angiography technique 3. CT angiography features a. Direct signs b. Indirect signsi. Related to pulmonary hypertension ii. Related to systemic collateral supply 4. Dual-Energy CT imaging a. Parenchymal findingsb. Virtual non contrast findings i. Calcifications ii. Tumoral uptake c. Iodine maps of dual CT 5. Other imaging techniques a.Digital Angiography. Correlation with dual source pulmonary angiography b. Pulmonary scintigraphy. Correlation with iodinemaps 6. Differential Diagnosis a. CT angiography i. Acute embolism ii. Proximal interruption of the pulmonary artery iii. Nonthrombotic embolism iv. Arteritis v. Pulmonary artery sarcomas b. Iodine maps i. Artifacts ii. Non thrombotic iodine defects:emphysema, constrictive bronchiolitis. 7. Pre and post thromboendarterectomy evaluation 8. Conclusions

CHE229

Physiological Variation in Lung Density: Potential Limitation for CT Lung Perfusion Education ExhibitsLocation: CH Community, Learning Center

ParticipantsShabnam Homampour (Presenter): Nothing to Disclose Laura Jimenez-Juan MD : Nothing to Disclose Chris Dey MD, FRCR : Nothing to Disclose Hatem Mehrez PhD : Employee, Toshiba Corporation Narinder S. Paul MD : Research funded, Toshiba Corporation

TEACHING POINTS

1. Different approaches to perform CT lung perfusion2. Emerging role of CT lung perfusion in assessing lung physiology and pathological changes3. Physiological confounders in assessing CT lung perfusion4. The critical influence that changes in lung density with breathing have on CT lung perfusion

TABLE OF CONTENTS/OUTLINE1. Review different models used in CT lung perfusion 2. Present a synopsis of current literature outlining clinical utility of CTlung perfusion 3. Demonstrate the importance of lung parenchyma density in lung analyses using animal (swine) and humandata with qualitative and quantitative evaluation displayed on perfusion maps as illustrated in the attached images

CHE230

Pulmonary Angiography for Pulmonary Embolism with Computed Tomography: MaximizingClinical Value Education ExhibitsLocation: CH Community, Learning Center

ParticipantsClaude Emmanuel Guerrier MS (Presenter): Nothing to Disclose Han Kim MD : Nothing to Disclose Barun Aryal BS : Nothing to Disclose Danh Truong : Nothing to Disclose Weonpo Yarl : Nothing to Disclose edward prevatt : Nothing to Disclose Matthew Kahari : Nothing to Disclose Andre J. G. Duerinckx MD, PhD : Nothing to Disclose Genelle Gittens-Backus : Nothing to Disclose Faezeh Razjouyan MS : Nothing to Disclose Kamyar Sartip MD : Nothing to Disclose Bonnie Clarissa Davis MD : Nothing to Disclose

TEACHING POINTS• Optimized pulmonary computed tomography angiography (PCTA) for pulmonary embolism detection is a complex undertakinginvolving selection of contrast volume, injection timing, scanning parameters, and interaction with patient (breath-holding). •Breathing techniques and cardiac gating can optimize CTA image quality by decreasing various respiratory and motion artifacts.• The controversial clinical significance of small subsegmental pulmonary emboli. • The prognostic value of right ventricularfunction assessment. • The emerging technology of lung perfusion imaging using dual energy computed tomography. • Newimaging techniques play an important role in guiding treatment decisions as well as future research investigations.

TABLE OF CONTENTS/OUTLINE• Review how to optimize CTA image quality with the strategic use of intravenous contrast, scanning parameters, breathingtechniques, and electrocardiographic gating. • Review the value of different treatment possibilities of small subsegmentalpulmonary embolism and recommendations to initiate anticoagulation. • Review approaches to right ventricular functionevaluation. • Review the ability of new CT technologies to add new information (lung perfusion), improve spatial resolution, andreduce radiation dosage.

CHE231

Pulmonary Ischemia and Pulmonary Infarction in Non-contrast and Non-vascular Chest CT:The "Bubbly" Lung Sign Education ExhibitsLocation: CH Community, Learning Center

ParticipantsHannes Kroll MD (Presenter): Nothing to Disclose Patrick T. Norton MD : Nothing to Disclose Michael Hanley MD : Nothing to Disclose Juliana Marcela Bueno MD : Co-author, Oxford University Press

TEACHING POINTSAfter viewing this exhibit, the learner will: 1 Recognize the typical appearance of pulmonary ischemia and pulmonary infarctionin CT studies of the chest non targeted to pulmonary artery assessment 2 Know when to suspect an occult pulmonary embolismin non-contrast and non-CTPA studies, by recognition of main imaging characteristics of lung ischemia/infarction 3 Differentiatealveolar occupation seen in non-ischemic entities, from that seen in lung parenchymal ischemia/infarction. The "bubbly lung"sign. 4 Understand the importance of early recognition of these imaging findings in the non-angiographic chest CT of patientswho present with non-specific respiratory symptoms and misleading clinical signs

who present with non-specific respiratory symptoms and misleading clinical signs

TABLE OF CONTENTS/OUTLINE1 Anatomy of the lung, emphasizing why it is easily prone to ischemia 2 Radiologic-pathologic correlation of lung parenchymalischemia 3 Main imaging findings of lung ischemia/infarction in non-contrast chest CT: how to recognize it. 3' The "bubbly lung"sign 4 Case examples

CHE232

The Post Surgical Lung: A Pictorial Review of Frequent Surgical Techniques in the Treatmentof Lung Cancer Education ExhibitsLocation: CH Community, Learning Center

ParticipantsJoshua F. Smith MD (Presenter): Nothing to Disclose Sarah Lafond MD : Nothing to Disclose Juliana Marcela Bueno MD : Co-author, Oxford University Press

TEACHING POINTSMultiple reviews of pulmonary surgical techniques have been published for surgeons, but very few recent articles in theradiologic literature are dedicated to explain the basic surgical techniques used in the treatment of lung cancer to radiologists.After viewing this exhibit, the learner will: 1 Learn the most frequent surgical techniques used in the treatment of lung canceraccording to the stage of disease 2 Understand the importance of time in the interpretation of post surgical images and how itinfluences the radiographic appearance of the surgical bed 3 Recognize normal and abnormal findings after surgery on atimeline review 4 Recognize the most common post surgical complications, according to time elapsed after surgery

TABLE OF CONTENTS/OUTLINE1. Most common surgical techniques used in the treatment of lung cancer (wedge resection, segmentectomy, sleeve lobectomy,lobectomy, pneumonectomy) 1'. Anatomic illustration and imaging correlation of these techniques 2. Timeline review of imagingfindings: what to expect over time 3. Sample cases: expected and unexpected findings. Main complications.

CHE233

Tubes, Lines and Medical Devices in the Intensive Care Unit (ICU). What Should We Know foran Accurate Interpretation? Education ExhibitsLocation: CH Community, Learning Center

ParticipantsSimon Long MD (Presenter): Nothing to Disclose David Hilton Ballard MS : Nothing to Disclose Luciana Previgliano MD : Nothing to Disclose Carlos Humberto Previgliano MD : Nothing to Disclose Alberto Andres Simoncini MD : Nothing to Disclose Guillermo P. Sangster MD : Nothing to Disclose Eduardo C. Gonzalez-Toledo MD : Nothing to Disclose

TEACHING POINTSFollowing completion of this educational activity the learner will be able to: 1. Recognize different types of lines, tubes andmedical devices used in ICU patients. 2. Identify the correct and incorrect positioning of these devices for a prompt report 3.Discuss ACR practice guidelines for daily portable Chest Radiograph

TABLE OF CONTENTS/OUTLINEChest radiograph is a crucial tool for diagnosis and follow up of critically ill in the ICU. In addition, allows to evaluate a broadrange of monitoring and support equipment and to detect complications. Medical devices malpositioning is a serious condition,and often unrecognized. A collective of patients with adecuated and malpositioned medical devices encountered in clinicalpractice form the basis of this pictorial essay. The following imaging findings are depicted: 1. Normal appearance, function andposition of: a. Airway b. Vascular c. Pleural d. Cardiac e. Gastrointestinal f. Miscellaneous medical devices 2. Malpositioning andpotential complications

EDE003-b

Chest Case of the Day Education ExhibitsLocation: NA

ParticipantsModeratorAlvaro Huete Garin MD Nothing to Disclose Nicole L. Restauri MD : Nothing to Disclose Peter B. Sachs MD : Advisor, Koninklijke Philips NV Daniel Vargas MD : Nothing to Disclose Thomas Dale Suby-Long MD : Nothing to Disclose Kristopher W. Cummings MD : Research Consultant, Biomedical Systems Research Consultant, Medtronic, Inc Maria Jose Baladron MD : Nothing to Disclose Santiago E. Rossi MD : Advisory Board, Koninklijke Philips NV Speaker, Pfizer Inc Royalties, Springer Science+Business MediaDeutschland GmbH Nadeem Parkar MD : Nothing to Disclose Talha S. Allam MD : Nothing to Disclose Hilary L. Purdy MD : Nothing to Disclose Sanjeev Bhalla MD : Nothing to Disclose

TEACHING POINTS

1) To analyze interesting chest cases. 2) To understand appropriate differential diagnosis. 3) To understand the clinicalsignificance of the diagnosis presented.

EDE100

Image Interpretation Exhibit in Digital Format Education ExhibitsLocation: NA

ParticipantsJeffrey C. Weinreb MD : Nothing to Disclose

TEACHING POINTS

This is the companion electronic exhibit to the Image Interpretation Session, scheduled for Sunday, November 30, 4:00 - 5:45pm, in Arie Crown Theater. Several of the case histories to be discussed in the Sunday session will be on display electronicallybeginning Sunday at 8:00 am. After the session concludes, the accompanying discussion for each case will be revealed. Theexhibit will remain on display for self-study until 12:30 pm, Friday, December 5.

The learning objectives for this presentation are: 1) Identify key abnormal findings on radiologic studies that are critical tomaking a specific diagnosis. 2) Construct a logical list of differential diagnoses based on the radiologic findings, focusing on themost probable differential diagnoses. 3) Determine which, if any, additional radiologic studies or procedures are needed in orderto make a specific final diagnosis. 4) Choose the most likely diagnosis based on the clinical and the radiologic information.

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The Great Pretender—How Sarcoidosis Gained Its Reputation as the Mimic of Other Pathology Education ExhibitsLocation: MS Community, Learning Center

ParticipantsThomas Robert Semple MBBS, BSC (Presenter): Nothing to Disclose Susan Jane Buckingham MBChB : Nothing to Disclose

TEACHING POINTS

The aim of this exhibit is to

Review the pathophysiology of sarcoidosis1.Demonstrate the typical radiological features of sarcoid within the chest, abdomen and central nervous system2.Share some particularly good cases of sarcoid mimicking other conditions and the key features that suggest sarcoidcould be the underlying cause

3.


The Pathophysiology of SarcoidosisTypical Radiological Features (radiography, CT, MRI)

ChestAbdomenCentral Nervous System

Sarcoid as mimic of other pathology - illustrative cases and tell tale signs all is not what it seems

(Including, amongst others, cases of sarcoid masquerading as metastatic bowel cancer (granulomatous colitis with necroticlymphadenopathy and multiple pulmonary lesions) and mimicking high grade lymphoma with extensive bone marrowinvolvement (lymphadenopathy and diffuse bone FDG avidity on PET-CT). All cases presented were subsequently biopsy provento represent sarcoidosis)

Summary

MSE101

Cardiopulmonary and Gastrointestinal Manifestations of Eosinophilic Diseases (ED) andIdiopathic Hypereosinophilic Syndromes: Radiological Spectrum with Emphasis on CrossSectional Imaging Education ExhibitsLocation: MS Community, Learning Center


ParticipantsRashmi S. Katre (Presenter): Nothing to Disclose Carlos S. Restrepo MD : Nothing to Disclose Abhijit Sunnapwar MD : Nothing to Disclose Venkata S. Katabathina MD : Nothing to Disclose Sushilkumar K. Sonavane MD : Nothing to Disclose Ameya Jagadish Baxi MBBS, DMRD : Nothing to Disclose

TEACHING POINTS1. ED are a diverse group of disorders associated with peripheral or tissue eosinophilia. System involvement can be due toprimary ED with no known cause or secondary due to underlying condition or known cause. Diagnosis of ED is established byclinical, laboratory and imaging findings 2. CT and MR play important role to assess the extent of disease and end organdamage. Delayed gadolinium enhancement on cardiac MRI is particularly helpful in confirming myocarditis or pericarditis

TABLE OF CONTENTS/OUTLINE• Pulmonary manifestations of ED: simple eosinophilic pneumonia, chronic eosinophilic pneumonia, allergic bronchopulmonaryaspergillosis, parasitic infections, drug reactions, Churg-Strauss syndrome and primary hypereosinophilic syndromes -radiographic and CT findings • Cardiac involvement: typically seen as endomyocarditis and rarely pericarditis - role of CT andpost gadolinium MRI • Eosinophilic gastrointestinal disorders: esophagitis, gastritis, enteritis and colitis - conventionalradiography and CT findings Chest radiograph may be the first screening tool to suggest ED along with patient symptoms.Correlation between CT/ MR findings and the results of careful clinical evaluation may be helpful in developing a differentialdiagnosis for eosinophilic disease. Radiologists should be aware of these entities and their imaging appearances

SPSP01

Nuevos Horizontes en Diagnostico por Imagen Desde el CIR: Sesión del ColegioInteramericano de Radiología (CIR) en Español/New Horizons in Diagnostic Imaging fromCIR: Session of the Interamerican College of Radiology (CIR) in Spanish Special Courses

NM MR CT VA NR MK GU GI CH BR

AMA PRA Category 1 Credits ™: 3.75

ARRT Category A+ Credits: 4.00

Sat, Nov 29 1:00 PM - 5:00 PM Location: E451A

LEARNING OBJECTIVES

1) To review advances or new horizons in imaging in major subspecialties from experts from different CIR (InteramericanCollege of Radiology) countries. 2) To use a practical approach including case-based learning. 3) To seek audience participationwith presentation of unknown clinical examples related to the organ system presentations.

Sub-Events Introducción/Opening Remarks

Gloria Soto Giordani MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

View learning objectives under main course title.

Primera Parte/Part 1

Moderator Pablo Riera Ros MD, PhD : Medical Advisory Board, Koninklijke Philips NV Medical Advisory Board,KLAS Enterprises LLC Medical Advisory Committee, Oakstone Publishing Departmental Research Grant, SiemensAG Departmental Research Grant, Koninklijke Philips NV Departmental Research Grant, Sectra AB DepartmentalResearch Grant, Toshiba Corporation

LEARNING OBJECTIVES


Sistema Nervioso Central: Correlación Entre Marcadores Genéticos e Imágenes enAstrocitomas/Central Nervous System: Imaging-Genetic Markers Correlation in Astrocytomas

Mauricio Castillo MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) To become familiar with the traditional biochemical/genetic markers of astrocytomas and how their presenceor absence correlate with imaging findings. 2) To understand the biological changes, as reflected by MRadvanced imaging techniques, that astrocytomas go through when malignant transformation occurs.

ABSTRACT

In this lecture we will use advanced MR imaging techniques, perfusion (both contrast enhanced and arterial spinlabelled), permeability, diffusion, and spectroscopy to understand the biological behavior of astrocytomas. Lowgrade astrocytomas may not show high choline on MRS but show high myoinositol which correlates with lowperfusion values. Anaplastic astrocytomas produce metalloproteases and thus VEGF and PDGF can stimulateangiogenesis resulting in high perfusion with gadolium and ASL. Lastly, hypoxia induces formation ofpermeability factors leading to edema and contrast enhancement in glioblastomas. Necrosis, seen as lipids onMRS is a marker of glioblastoma. Presence of MGMT promoter and alterations in the IDH1 gene (present in mostsecondary glioblastomas) confer a better survival pattern to glioblastoma patients and these findings are seenpredominantly in temporal and deep tumors and in those with little contrast enhancement and high signal on T2and DWI images. Thus, the intial transformation in all low grade astrocytomas is ischemia that can be seen asthe presence of lactate on MRS, while markers of higher grades such as angiogenesis, permeability, and

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the presence of lactate on MRS, while markers of higher grades such as angiogenesis, permeability, andnecrosis can be identified with perfusion, K-trans maps, and MR spectroscopy. Lack of myoinositol on MRSindicates its consumption for production of metalloproteases and thus it is also an early marker of angiogenesis.Many of these changes occur before anatomical images may suggest them.

URL

https://sites.google.com/site/castilloneuroradiology/

Active Handout

http://media.rsna.org/media/abstract/2014/14002958/SPSP01C sec.pdf

Cardiovascular: Cambios Desde el TAC y RM Hacia la Imagen Funcional y Molecular/Cardiovascular:CT and MRI Changes towards Functional and Molecular Imaging

Antonio Luna MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) Revisar las indicaciones actales del TC y RM en el diagnóstico cardiovascular. 2) Ensalzar las nuevasaproximaciones técnicas en TC y RM del sistema cardiovascular. 3) Esbozar el papel potencial de la imagenfuncional y molecular en enfermedades cardiovasculares. 1) Review the current clinical indications of CT andMRI in cardiovascular diagnosis.2) Highlight the new technical approaches in CT and MRI of the cardiovascularsystem. 3) Outline the potential role of functional and molecular imaging in the management of cardiovasculardiseases.

Mama: Integración de Medicina Nuclear en las Imágenes Diagnósticas de Mama/Breast: NuclearMedicine Integration in Breast Imaging

Maria Victoria Velasquez MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) Present the current indications for Molecular Breast Imaging and Positron Emission Mammography. 2)Describe imaging protocols, radiation exposure and benefits for both techniques. 3) Outline the most commonfindings of benign and malignant breast lesion on MBI and PEM with correlation with other breast imagingstudies. 4) Navigate through the different steps of PEM guided biopsy. 5)Describe alternative management andfollow up with these techniques.

ABSTRACT

Integration of Nuclear Medicine in Breast Imaging In the last decade the introduction of Nuclear medicine asMolecular imaging of the breast had a significant development in the diagnosis of breast abnormalities. PositronEmission Mammography (PEM) and Molecular Breast Imaging (MBI) have been successful in the detection ofbenign, atypical and malignant breast conditions. PEM have been proven to represent a very helpful staging toolin patients with contraindications to breast MRI. MBI is a valuable technique for screening of high risk patientsand as for problem solving for patients with inconclusive clinical or imaging findings. This presentation willreview the main indications of these Nuclear Medicine studies and will detail the findings and the correlationwith conventional breast imaging. The breast imager will have a better understanding of the anatomic,functional and molecular breast imaging techniques.

Tórax: Hallazgos de la Resonancia Magnética en Enfermedades del Parénquima/Chest: MagneticResonance Findings in Lung Parenchymal Disease

Arthur Soares Souza MD, PhD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) To show the value of thoracic MRI for assessment of parenchymal lung disease. 2) To demonstrate the valueof diffusion weighted MRI (DWI) for differentiating benign from malignant lung neoplasms.

ABSTRACT

In this lecture we will show the clinical ability of thoracic MRI to depict the most common patterns ofparenchymal lung diseases, and do the correlation with CT findings. MRI seems to be a valuable tool, withoutradiation exposure, for management of parenchymal lung disease. We will, also, address the importance ofdiffusion weighted MRI (DWI) for differentiating benign from malignant lung lesions.

URL

http://www.ultrax.com.br/chest

Conferencia del Colegio Interamericano de Radiología/Interamerican College of Radiology Lecture

Dante R. Casale Menier MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

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Segunda Parte/Part II

Moderator Miguel E. Stoopen MD : Nothing to Disclose

LEARNING OBJECTIVES


ABSTRACT

N/a

URL

www.webcir.org

Musculoesqueletico: Imágenes Avanzadas del Cartílago Articular y "Chemichal Shift" de MédulaÓsea/Musculoskeletal: Advanced Imaging of the Articular Cartilage and Bone Marrow Chemical ShiftImaging

Gonzalo Javier Delgado MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES


Abdomen e Hígado: Contrastes Hepatoespecíficos y Elastografia por ResonanciaMagnética/Abdomen and Liver: Liver Specific Contrast Agents and Hepatic MR Elastography

Luis Antonio Sosa MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES


Próstata: Resonancia Magnética de 3T y PET/CT con Colina/Prostate: 3T MRI and Choline PET/CT

Daniela Stoisa MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES


Handout:Daniela Stoisa

http://media.rsna.org/media/abstract/2014/14002966/cap chicago 2014.ppt

Clausura/Closing Remarks

Dante R. Casale Menier MD (Presenter): Nothing to Disclose , Pablo Riera Ros MD, PhD (Presenter): MedicalAdvisory Board, Koninklijke Philips NV Medical Advisory Board, KLAS Enterprises LLC Medical AdvisoryCommittee, Oakstone Publishing Departmental Research Grant, Siemens AG Departmental Research Grant,Koninklijke Philips NV Departmental Research Grant, Sectra AB Departmental Research Grant, ToshibaCorporation , Miguel E. Stoopen MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES


SSA04

Chest (Lung Cancer Screening) Scientific PapersCT CH

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Sun, Nov 30 10:45 AM - 12:15 PM Location: S404CD

ParticipantsModeratorMark L. Schiebler MD : Shareholder, Cellectar Biosciences, Inc ModeratorCaroline Chiles MD : Nothing to Disclose

Sub-Events Lung Cancer Screening in a Predominantly Poor, Overweight, Inner-city Minority Population: InitialExperience

Alla Godelman MD : Nothing to Disclose , Hannah Milch MD (Presenter): Nothing to Disclose , Mark Kaminetzky : Nothing to Disclose , Anna Shmukler MD : Nothing to Disclose , Tova C. Koenigsberg MD : Nothing to Disclose , Linda Broyde Haramati MD, MS : Investor, OrthoSpace Ltd Investor, Kryon Systems LtdSpouse, Board Member, Bio Protect Ltd Spouse, Board Member, OrthoSpace Ltd Spouse, Board Member, KryonSystems Ltd

PURPOSE

To evaluate the applicability of the National Lung Screening Trial (NLST) results to a predominantly poor,overweight, inner-city minority population.

METHOD AND MATERIALS

We examined the data for all 198 patients who underwent low dose chest CT as part of our inner-city academicmedical center's lung cancer screening program from its inception in 12/2012 till 2/2014. All met NLSTeligibility criteria. A screening coordinator worked closely with patients and tracked follow-up. CTs wereinterpreted clinically by 1 of 4 cardiothoracic radiologists. Results were reported as 5 standardized categories:1. No evidence of lung cancer, normal chest; 2. No evidence of lung cancer, benign pulmonary findings; 3.Small nonspecific pulmonary nodules; 4. Small spiculated nodule (4a) or ground glass nodule (4b); 5.Pulmonary mass (5a) or metastatic disease (5b). Routine screening in 1-year was recommended for categories1 and 2. Shorter follow up (Fleischner criteria) was advised for categories 3 and 4. Tissue correlation wasadvised for category 5. Calcium score (Shemesh et al. range 0-12) was reported. Additional data includeddemographics, smoking history, BMI, dose length product (DLP), and lung biopsy/resection pathology.

RESULTS

Of 198 patients, 54% were men, 72% current smokers, 69% non-white (35% black, 31% Hispanic, 3% other).Mean age was 64 yrs, mean BMI 31 (range 20-39). Mean calcium score was 3/12 (range 0-12), mean DLP 107(range 71-223). 73% results were categories 1 and 2, 22% category 3, 2% category 4 and 3% category 5. 4of 5 category 5 patients had resections confirming the diagnosis of lung carcinoma, ranging from stage IA toIIIA. One category 5 patient awaits biopsy. One category 4 had ongoing suspicion for cancer on follow up CTbut biopsy results were benign.

CONCLUSION

Low dose CT lung cancer screening using NLST criteria is feasible in a predominantly poor, overweight,inner-city minority population. The screening coordinator plays a crucial role. In the first 15 months, lungcancer was diagnosed in 2%. Interpretation yielded a high specificity with sensitivity to be determined withongoing follow-up.

CLINICAL RELEVANCE/APPLICATION

Successful initiation of a lung cancer screening program is feasible in a predominantly poor, overweight,inner-city minority population. NLST results require validation in understudied populations.

Invited Speaker: Demographic Characteristics and Results of National Comprehensive CancerNetwork High-risk Group 2 in a Clinical CT Lung Screening Program

Brady John McKee MD (Presenter): Nothing to Disclose , Jeffrey Alexander Hashim MD : Nothing to Disclose , Robert James French MD : Nothing to Disclose , Andrea Bertram McKee MD : Nothing to Disclose , Christoph Wald MD, PhD : Radiology Advisory Committee, Koninklijke Philips NV , Sebastian Flacke MD : Research Consultant, Pluromed, Inc Speaker, Nordion, Inc

PURPOSE

To compare the demographic characteristics and screening results of NCCN high-risk Group 2 (>50y, >20pack-years, 1 additional risk factor) to NCCN high-risk Group 1 (55-74y, current or former smoker quit 30pack-years) in a clinical CT lung screening program.


We retrospectively reviewed results of all CT lung screening exams performed from 1/2012 through 12/2013.Those screened had to fulfill the NCCN high-risk criteria and have an MD order for screening. All exams wereperformed on 64+ MDCT scanners at 100 kV and 30-70 mA. Image interpretation was performed bycredentialed radiologists using the structured reporting system, "LungRADS". A positive exam was defined as a

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solid nodule > 4mm, a groundglass nodule > 5mm, or a chest lymph node > 1 cm not stable for more than twoyears. Clinically significant incidental findings including findings suspicious for pulmonary infection wererecorded.

RESULTS

458 Group 2 and 1302 Group 1 individuals underwent prevalence CT lung screening exams during the studyinterval. Group 2 qualifying risk factors: 44% personal history of smoking related cancer, 28% chronic lungdisease, 24% carcinogen exposure, < 5% primary relative w/lung cancer. Male/female ratio, average age, andaverage pack-years was 50/50, 61, and 40 for Group 2 and 53/47, 63, and 50 for Group 1. 36% of Group 2and 50% of Group 1 were active smokers. Average duration of smoking cessation was 18.5y in Group 2, 6.7y inGroup 1. 25% in Group 2 and 28% in Group 1 had positive exams. 6.1 % in Group 2 and Group 1 had at leastone clinically significant incidental finding. 6.1% in Group 2 and 6.6 % in Group 1 had findings suspicious forpulmonary infection. 23 cases of lung cancer were diagnosed in 1328/1760 (75%) with clinical followup afterscreening: 6 in Group 2 and 17 in Group 1 with an annualized rate of malignancy of 1.6% for Group 1 and1.8% for Group 2.

CONCLUSION

Screening results for NCCN Group 2 are similar to NCCN Group 1 and those reported in the National LungScreening Trial. The prevalence rate of lung cancer in NCCN Group 2 suggests thousand of additional lives couldbe saved each year if screening eligibility is expanded to include this high-risk group.


Expanding CT lung screening eligibility to include NCCN high-risk Group 2 could increase the number of qualifiedAmericans by two to three million and offers the potential to save thousands of additional lives each year.

Trends in CT Screening for Lung Cancer at Leading Academic Medical Centers

Phillip M. Boiselle MD (Presenter): Nothing to Disclose , Caroline Chiles MD : Nothing to Disclose , James G. Ravenel MD : Nothing to Disclose , Charles S. White MD : Nothing to Disclose

PURPOSE

To determine trends in CT lung cancer screening at leading academic medical centers.


An electronic survey was emailed in March 2014 to thoracic radiologists at 21 leading academic medical centers,identified from the 2012-2013 US News and World Report listings of top hospitals, cancer centers, andpulmonary medicine centers. Radiologists who reported that they currently offer lung cancer screening wereasked additional questions which ranged from patient selection policies to the likelihood of implementingforthcoming LUNG-RADS in their practice. March 2014 survey results were compared to March 2013 surveyresults for select questions that overlapped between the 2 surveys.

RESULTS

Of the 20 survey respondents (95% response rate), 19 (95%) currently have an active CT screening program,an increase from 79% in 2013. Five or fewer patients are scanned per week at most sites (14 of 19, 74%), andonly 1 site (5%) reported >20 patients per week. Regarding charges, all exams were self-pay at 9 of 19 (47%)screening sites and a majority was self-pay at the remaining sites. Similar to 2013, most programs (12 of 19,63%) require physician referral for screening. NLST entry criteria remained the most common patient selectioncriteria in 2014, but 5 sites (26%) recently expanded their age criteria in response to new USPSTFrecommendations. Regarding solid nodule size thresholds for defining a positive screen, 13 of 19 (68%) sitesuse ≥4 mm, 3 sites (16%) use ≥ 5mm, 2 sites (11%) use ≥6 mm, and 1 site (5%) does not use a sizecriterion. Less than half of the screening sites (9 of 19, 47%) definitely plan to incorporate LUNG-RADS. Almostall programs (18 of 19, 95%) routinely report coronary artery calcifications and most report this qualitatively(89%) rather than quantitatively (11%).

CONCLUSION

Most leading academic medical centers have CT screening programs, but relatively few patients are beingscreened. Only a minority of sites has modified its selection criteria in response to new USPSTF guidelines andfewer than half definitely plan to incorporate forthcoming LUNG-RADS in their practice.


Screening programs should be encouraged to standardize their lung cancer screening practices. ForthcomingACR-STR practice guidelines and LUNG-RADS can facilitate this process.

Unenhanced Chest CT at 100kV with Spectral Shaping: A Potential New Sub-millisievert Lung CancerScreening Protocol

Holger Haubenreisser (Presenter): Nothing to Disclose , Mathias Meyer : Nothing to Disclose , Sonja Sudarski MD : Nothing to Disclose , Stefan Oswald Schoenberg MD, PhD : Institutional research agreement,Siemens AG , Thomas Henzler MD : Nothing to Disclose

PURPOSE

To prospectively investigate image quality and radiation dose of 100 kV spectral shaping chest CT using adedicated tin filter on a 3rd generation DSCT in comparison to standard 100 kV chest CT.


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Sixty patients that were referred for a non-contrast chest CT were prospectively included in this study andexamined at 100kV with a dedicated tin filter behind the x-ray tube for spectral shaping. These patients wereretrospectively matched with patients that were examined on a 2nd generation DSCT at 100kV without tin filter.All images were reconstructed using iterative reconstruction techniques (ADMIRE, SAFIRE; Siemens). Objectiveand subjective image quality was assessed in various anatomic regions and radiation dose was comparedbetween the two groups.

RESULTS

Radiation dose was decreased by 90% using the 100 kV tin protocol when compared to 100 kV without tinfiltration (mean dose 3.0±1.2 vs. 0.32±0.12 mSv). Soft tissue attenuation and soft tissue image noise was notstatistically different for both examination techniques (p>0.05). Attenuation of air was lower for examinationsperformed with spectral shaping, while image noise was higher (p0.05).

CONCLUSION

100 kV spectral shaping chest CT by means of a tube based tin filter allows 90% dose reduction when comparedto 100 kV chest CT without spectral shaping. Thus, this CT protocol may be ideal for lung cancer screening.


Our study demonstrates the feasibility and dose reduction of spectral shaping at a tube voltage of 100kV fornon-contrast enhanced chest CT,allowing this protocol to be used for lung cancer screening.

Feasibility of Rapid Reading of CT Lung Cancer Screening with Computer-aided Detection Support

Bram Van Ginneken PhD (Presenter): Stockholder, Thirona BV Co-founder, Thirona BV Research Grant,MeVis Medical Solutions AG Research Grant, Canon Inc Research Grant, Toshiba Corporation Research Grant,Riverain Technologies, LLC , Colin Jacobs MSc : Research Grant, MeVis Medical Solutions AG , Ernst T. Scholten MD : Nothing to Disclose , Mathias Prokop MD, PhD : Speakers Bureau, Bayer AG SpeakersBureau, Bracco Group Speakers Bureau, Toshiba Corporation Speakers Bureau, Koninklijke Philips NV ResearchGrant, Toshiba Corporation , Pim A. De Jong MD, PhD : Nothing to Disclose

PURPOSE

The reading effort associated with CT lung cancer screening programs is substantial. We investigated theperformance of rapid reading of chest CT scans with integrated CAD support, with the goal of quickly assigning asubject to either regular one-year follow-up, short-term follow-up or immediate work-up.


From the baseline round of a large randomized controlled low-dose CT lung cancer screening trial, randomly 23cases were selected from each of the three categories used in the trial: 1) no significant nodules, 1 yearfollow-up CT; 2) nodule 50-500 mm3, 3 month follow-up CT; 3) nodule >500 mm3, referral to pulmonologist.All 69 cases were pre-processed with three different CAD systems aimed at detecting both solid and subsolidlesions and set to operate at high sensitivity. CAD marks were merged and presented in a prototype softwareenvironment optimized for rapid reading that includes one-click immediate volumetric segmentation and studypreloading to navigate to the next case in the worklist without delay. Seven blinded readers read all cases inrandom order in a single session as follows. First, CAD marks were inspected and accepted or rejected. Next,readers quickly inspected the scan and added relevant nodules if CAD had not identified these. Finally, readersassigned the scan to one of the three categories of the screening protocol.

RESULTS

Cases had 5.1 CAD marks on average. 73±7% of cases (range 58-80%) were assigned to the correct category.94% of discordances were between category 1 versus 2, or category 2 versus 3. In most cases the reason wasthat the volume of the most suspicious nodule was very close to the cutpoints used in the screening protocol. Ofthe 23 cases in category 3, 14 contained lung cancer. None of these were put in category 1 by any reader; onlytwo of these were placed in category 2, each by only 1/7 readers. 2/9 of the benign category 3 cases were putin category 1: one case by 4/7 readers (a relatively large pleural lesion missed by CAD), and one by 1/7readers. Total median reading time per case was 67±17 seconds.

CONCLUSION

With the support of highly effective CAD systems, nodule volumetry, and an optimized reading environment, itis possible to accurately read lung cancer CT scans in around one minute per case.


An optimized reading environment is presented that can be used for large scale implementation of lung CTscreening.

Nodule Risk Calculator: A New Tool to Reduce Low Dose CT Scans in Lung Cancer Screening

Collette Louise English BMBS, FRCR (Presenter): Nothing to Disclose , Mark Teh MBBS : Nothing to Disclose, Rebecca E. Hall MBChB : Nothing to Disclose , Ana-Maria Bilawich MD : Nothing to Disclose , Stephen Lam : Nothing to Disclose , John R. Mayo MD : Speaker, Siemens AG

PURPOSE

We studied the utility of a nodule follow up algorithm based on malignancy risk assessed using a publishedNodule risk calculator applied to lung cancer screening low dose CT (LDCT) scans. Using this approach, we

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hypothesized more appropriate CT follow up could be performed, reducing cost and radiation dose.


We performed a retrospective study of a cross sectional sample of 200 consecutive LDCT scans (February toMay 2003) obtained in a lung cancer screening program. Entry criteria for screening included; 30 pack yearcurrent or former smoker, 50-74, no previous lung cancer. Baseline CT was assessed and dominant nodulemalignant risk assessed using the nodule calculator based on; nodule diameter, nodule density (solid, partsolid, ground glass), age, spiculation, lobar location, gender, family history of lung cancer, emphysema andtotal nodule count. Up to 12 year follow up (FU) was evaluated for; number of follow up LDCT, diagnosis of lungcancer, total radiation dose and fatality from lung cancer. Comparison was made to proposed follow up basedon nodule calculator; <1.5% 2 year FU (minimal risk), 1.5-6% 1 year FU (low risk), >6% FU as clinicallyindicated (high risk).

RESULTS

Percentage of subjects stratified by dominant nodule risk: 82%with minimal risk; 12% low risk; 6% high risk .Lung cancer developed in 5 participants (3%) in the minimal and low risk group, only one of which arose fromthe dominant nodule on baseline LDCT. The total number of follow up LDCTs performed in the minimal and lowrisk group using conventional FU was 932. Using the risk calculator FU protocol 608 (65%) fewer LDCT scans(average 3 per subject) would have been performed with potential saving of ~$150,000. Using this FU protocolall cancers in the minimal and low risk group would have been detected at T1A size (<20 mm diameter).

CONCLUSION

The Nodule Calculator accurately identified minimal and low risk subjects in a lung cancer screening cohort withup to 12 year FU. A modified FU protocol based on the nodule calculator risk would have detected all cancers atT1A stage, saving 65% of LDCT scans, reducing program costs and subject radiation dose.


Utilization of the nodule risk calculator can greatly reduce the number of follow up CTs in a lung cancer screeingprogram.

Nodule Detection in Lung Cancer Screening: When, Where, and Why are Non-calcified Lung NodulesMissed?

Roberto Lo Gullo MD (Presenter): Nothing to Disclose , Marie-Helene Levesque MD : Nothing to Disclose , Karl Sayegh MD : Nothing to Disclose , Sishir Rao MD : Nothing to Disclose , Scott Bruce Raymond MD,PhD : Nothing to Disclose , Subba Rao Digumarthy MD : Nothing to Disclose , Jo-Anne O. Shepard MD : Consultant, Agfa-Gevaert Group , Mannudeep K. S. Kalra MD : Nothing to Disclose , Atul Padole MD : Nothing to Disclose , Sarabjeet Singh MD : Research Grant, Siemens AG Research Grant, ToshibaCorporation Research Grant, General Electric Company Research Grant, Koninklijke Philips NV , Mark T. Madsen PhD : Nothing to Disclose , Alexi Otrakji MD : Nothing to Disclose

PURPOSE

To assess the variation in lung nodule detection in low dose chest CT based on location, attenuationcharacteristics and reader experience.


In an IRB approved study, we selected and extracted 18 non-calcified lung nodules with solid (n=7 nodules),ground glass (7) and mixed (4) attenuation from 12 chest examinations from patients with known malignantlung disease. All nodules had similar size and shape (mean size 7mm, size range, 6-8 mm). These noduleswere randomly inserted in to 34 normal low dose chest CT examinations belonging to 34 patients (mean age57.5 years, 15M;19F) using a dedicated software (IDL virtual machine) at the following lung sites, apices,bases, peripheral 2 cm, close to heart and major vascular structures, branching points of bronchi and vesselsand in the common regions of image artifacts such as behind the 1st rib. A total of 47 lung nodules (somenodules were inserted multiple times in each scan) were inserted. Two residents (Resident 1 with 2 weeks of CTtraining and resident 2 with at least one complete chest CT rotation) and two radiologists at the end of one yearthoracic fellowship training, all blinded to the details of the study, interpreted the CT examinations in a routinefashion. Variation of nodule detection was assessed based on location, attenuation characteristics and readerexperience; statistical significance was assessed by chi-square test.

RESULTS

Resident 2 and the two fellows identified significantly more nodules in all categories (p=0.01). There issignificantly decreased detection of nodules at branching points, adjacent to heart and major vessels comparedto those at apices, bases and at periphery of the lungs (p=0.004). Identification of mixed density nodules wassignificantly higher for fellows (p=0.008).

CONCLUSION

Dedicated chest CT training improves detection of lung nodules, particularly that of mixed attenuation nodules(which are more likely to be malignant). The detection of nodules adjacent to heart and major vessels and atbranching points is difficult even for fellowship-trained radiologists.


Dedicated training is required for improved lung nodule detection. Nodules in certain locations may be difficultto detect, which may be improved with our dedicated training program. Review of MIP images and use of CAD

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to detect, which may be improved with our dedicated training program. Review of MIP images and use of CADprogram for lung nodule detection may also help.

Agreement of Diameter- and Volume-based Pulmonary Nodule Management in Lung CancerScreening

Marjolein Anne Heuvelmans BSc (Presenter): Nothing to Disclose , Rozemarijn Vliegenthart MD, PhD : Nothing to Disclose , Pim A. De Jong MD, PhD : Nothing to Disclose , Willem P. Mali MD, PhD : Nothing toDisclose , Gonda Jasmijn de Jonge MD, PhD : Nothing to Disclose , Geertruida H. De Bock : Nothing toDisclose , Matthijs Oudkerk MD, PhD : Nothing to Disclose

PURPOSE

To determine the agreement of diameter and volume measurements for different types of nodules found inlow-dose computed tomography lung cancer screening, using data of the NELSON trial.


The study was institutional review board approved. Data of 2,240 solid nodules with volume of 50-500mm3(intermediate-sized) detected at baseline in 1,498 participants were used. Volume based on semi-automatically(SA) derived maximal transversal (MT) diameter and mean of MT and perpendicular diameter were compared toSA-derived volumes by Bland-Altman plots; both for the total group of nodules, per margin (smooth, lobulated,spiculated and irregular) and per shape (spherical or non-spherical). Diameters in a random sample of 100nodules were measured manually by two independent radiologists, and compared to the SA-derived diametersin a prospective validation study. Moreover, the implications for referral rates were evaluated for the use of adiameter-based or a volume-based protocol.

RESULTS

Median participant age was 59 years (interquartile range:8), and 212/1,498 (14.2%) were women. UsingSA-derived mean or MT diameter to assess nodule volume lead to a mean volume overestimation of 47.2%(95%-confidence interval (CI):44.7-49.7%) and 85.1% (95%-CI:81.2-89.0%), respectively, compared toSA-derived volume. For irregular and non-spherical nodules, the mean overestimation was even 161.7%(95%-CI:131.7%-191.8%) and 168.9% (95%-CI:155.2%-182.5%), respectively. Manual diametermeasurement overestimated SA-derived MT diameter by ≥10% in 44% (44/100) and underestimated in 18%(18/100) of the nodules. Compared to a 10-mm criterion for referral, using SA-derived MT diameter, 7.9%(177/2240) of the volume-based indeterminate nodules would have led to direct referral. Manual measurementswould even have led to 31% (31/100) referrals.

CONCLUSION

The agreement between manual and SA-derived diameter, as well as between SA-derived diameter-basedvolume and SA-derived volume is poor. Applying manual and SA-derived diameter measurement in CT lungcancer screening leads to a substantial shift in nodule classification compared to SA volume measurements.


Applying manual and SA-derived diameter measurement in CT lung cancer screening leads to a substantial shiftin nodule classification compared to SA volume measurements.

CT Screening for Lung Cancer: The Frequency of Nonsolid Nodules, Rate of Malignancy, andLong-term Survival in a Large, Long-term Database

Claudia I. Henschke MD, PhD (Presenter): Nothing to Disclose , Rowena Yip MPH : Nothing to Disclose , James Smith MD : Nothing to Disclose , Mingzhu Liang MD : Nothing to Disclose , Dongming Xu MD, PhD: Nothing to Disclose , David F. Yankelevitz MD : Research Grant, AstraZeneca PLC Royalties, General ElectricCompany

PURPOSE

The diagnostic workup of nonsolid pulmonary nodules remains controversial. We address the frequency ofidentifying such nodules, the frequency of resolution or growth, the frequency and stage of lung cancerdiagnoses, and long-term survival of those diagnosed with lung cancer.


Using the screenings in the database, we identified participants with one or more nonsolid nodules identified inthe first, baseline round to determine whether the nodule resolved, decreased in size, remained unchanged, orincreased in size or CT attenuation. Nodule size was based on the average nodule diameter. Follow-up time forthe diagnosed cases of lung cancer was from the date of diagnosis to April 1, 2014 or death, whichever camefirst.

RESULTS

Among the 58,062 participants who underwent baseline CT screening, the prevalence of at least one nonsolidnodule was 4% (2,383). The frequency was: 1060 (45%) for those largest nodule < 5 mm in diameter, 956(40%) for 5-9 mm, 231 (8%) for 10-14 mm, and 136 (7%) for 15+ mm. The nonsolid nodule resolved in 20%(N = 466), decreased in size in 7% (N = 174), was unchanged in 54% (N = 1,281), or increased in size or HUattenuation in 19% (N =462) on annual repeat scans. A diagnosis of lung cancer was made in 65 (3%) of the2,383 participants,3 (0.3%) for those < 5 mm, 26 (2.7%) for those 5-9 mm, 22 (9.5%) for those 10-14 mm,and 14 (10%) for those 15+ mm. Median time to diagnosis was 34 months (range: 1-125). No malignancy wasdiagnosed in those whose nodule resolved or decreased, 2% (N = 27) in those whose nodule did not change

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and 8% (N = 20) among the 462 whose nodule increased in size. All were adenocarcinoma, clinical andpathologic Stage I. There were no lung cancer deaths in the 62 who underwent resection, regardless of whetherresection was lobar (N = 37) or sublobar (N = 25). None of the 3 unresected patients with a cytologic diganosisof malignancy died of lung cancer. Median follow-up time from diagnosis was 80 months (range: 4-161months).

CONCLUSION

Nonsolid nodules, regardless of size, can be followed annually as survival is 100% even when resected yearslater.


Nonsolid nodules of any size can be followed by annual scans to assess growth.

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ISP: Radiation Oncology & Radiobiology (Lung Cancer) Scientific PapersRO CH AMA PRA Category 1 Credits ™: 1.50


Sun, Nov 30 10:45 AM - 12:15 PM Location: S104A

ParticipantsModeratorJing Zeng MD : Nothing to Disclose ModeratorMatthew M. Harkenrider MD : Nothing to Disclose

Sub-Events Radiation Oncology & Radiobiology Keynote Speaker: New Developments in PersonalizedRadiotherapy for Primary Lung Cancer

Jaap Doeke Zindler MD (Presenter): Nothing to Disclose

ABSTRACT

Outcome of treatment in locally advanced non-small lung cancer (NSCLC) needs improvement. Surprisingly, theRTOG 0617 did not show benefit from dose escalation. Potential causes are now under investigation. In the lastyears further technologic improvements in radiotherapy equipment have made advanced dose painting possibleand achievable. Several new strategies are under investigation from which these patients may do benefit. Onesuch strategy is targeted isotoxic dose escalation only on the high FDG uptake region of the primary tumourprior to treatment with relatively sparing of mediastinal structures, such as the heart: the PET boost trial. Otherstrategies are the application of new radiosentizers, hypoxia modulators, and proton therapy. Furthermore, inearly stage NSCLC with stereotactic ablative radiotherapy (SABR) high rates of local control are achievedcomparable to surgery. Favorable results with SABR are also achieved in oligometastatic NSCLC in spinalmetastases, lung metastases, brain metastases, and adrenal gland metastases. Randomized trials in NSCLC areneeded to determine which patients do benefit from these new strategies. With the availability of advancedradiotherapy techniques, treatment in NSCLC will be more personalized in which the patient makes a moreconscious choice between tumour control and toxicity with radiotherapy, systemic therapy, or surgery, or acombination of these treatments.

Stereotactic Body Radiotherapy with Volumetric-Modulated Arc Therapy for Lung Metastases

Maria Antonia Gomez (Presenter): Nothing to Disclose

ABSTRACT

Stereotactic Body Radiotherapy With Volumetric Modulated Arc Therapy For Lung MetastasesPURPOSE:To evaluate efficacy and tolerability of Stereotactic Body Radiotherapy (SBRT) with Volumetric Modulated ArcTherapy (VMAT) in pulmonary metastases in a cohort of patients treated between 2011-2013 in our institution.METHODS:A total of 64 patients with lung metastases were included in our study.Thirty-three patients received 66Gy in 8 fractions, 29 a dose of 55Gy in 5 fractions and 2 a dose of 54Gy in 3fractions.Primary tumor was lung cancer in 65% of patients, colorectal in 21% and others in 14%.Four-dimensional CT was used for each patient to determine internal gross tumor volume (IGTV) to account torespiratory motion.VMAT treatment was delivered with two or four coplanar arcs.Daily Cone-Beam images were used for patient positioning verification.Primary end-point was local control (LC). Secondary end-points were acute toxicity, quality of life (QOL) andsurvival.Acute toxicity was scored following CTC criteria and QOL with EORTC-QLQ-LC13.RESULTS:After a mean follow up interval time of 13 months, LC was 98,44% (1 of 64) and survival 93,75%.Acute toxicity was insignificant with only one case of grade 2 esophageal toxicity. Other types were grade 1.EORTC-QLQ-LC 13 showed improvement in: dyspnea, pain and dysphagia.

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No changes in cough and hemoptysis were observed.CONCLUSION:Our early results in terms of local control and toxicity for patients treated with SBRT-VMAT demonstrated theefficacy of this technique.Further follow-up is required to assess overall survival and late toxicity.

Stereotactic Body Radiation Therapy For Single Post-pulmonary Lobectomy Lung Metastasis OfThoracic Tumor: Survival And Side-effects

Weijie Xiong (Presenter): Nothing to Disclose

ABSTRACT

Purpose/Objective(s):Stereotacticbody radiotherapy (SBRT) has emerged as an alternative treatment forpatients with early stage or medically inoperable non-small cell lung cancer (NSCLC). However, for singlepost-pulmonary lobectomy lung metastasis (PPLLM) of thoracic tumor, the outcomes of SBRT have not beenreported.Materials/Methods:A retrospective search in thoracic SBRT database was conducted in three hospitals.The objects analyzed were local control, progression-free survival(PFS), overall survival (OS) and thetreatment-related side-effects.Results:Totally, 23 patients with single PPLLM treated with SBRT were identifiedand the median follow-up time was 14 months (range: 6.0-47.0 months). The local recurrences were observedin 2 patients during follow-up and the 1-year local control rate was 91.3%. Median PFS and OS for the studiedcohort were10.0 months (95% CI 5.1-14.9months) and 21.0months (95% CI 11.4-30.6 months),respectively.Grade 2 and higher acute radiation-induced pneumonitis (RIP) were observed in 21.7% (5/23) and13.0% (3/23) patients, respectively. Other treatment-related toxicities included chest wall pain (4.3%, 1/23)and acute esophagitis (8.7%, 2/23). By Pearson correlation analysis, the PTV volume and the V5 of ipsilaterallung(IpV5) were significantly related to the acute grade 2 or higher RIP in present study (p<0.05).The optimalthresholds of the PTV volumeand IpV5 to predict acute grade 2 or higher RIP were 59 cm3and 51% , with theirsensitivity/specificity of 75.0%/80.0% and 62.5%/80.0%, respectively.Conclusions:In present study, SBRT forsingle PPLLM was effective and well tolerated. The major reason of disease progression was metastasis to othersites but not local recurrence. The PTV volume and IpV5 might be the predictors of acute grade >=2 RIP andshould be considered in treatment planning among suchpatients.table_{A875DD0B-F1D8-453E-B485-130243368088}$$

Irradiation dose delivered

12 Gy x 4 fractions daily 11 (47.8%)



PTV volume (cm3) Median/range 48.4 (26.0-110.2)

Total lung volume (cm3) Median/range 2301.4 (1983.4-2950.5)

Systematic treatment

Chemotherapy 15 (65.2%)

Tyrosine kinase inhibitora 3 (13.0%)

None 5 (21.7%)

Treatment inpresent study (n=23)

Clinical Outcomes of NSCLC Oligometastatic Patients Treated with Stereotactic Ablative BodyRadiotherapy (SABR) with Flattening Filter Free (FFF) Mode

Pierina Navarria (Presenter): Nothing to Disclose

ABSTRACT

Purpose/Objective(s): Literature data suggest the existence of oligometastatic disease, a state in whichmetastases are limited in number and site. Different kinds of local therapies have been used for the treatmentof limited metastases and in the recent years reports on the use of Stereotactic Ablative radiotherapy (SABR)are emerging and the early results on local control are promising.The aim of this study is the evaluation of localcontrol, toxicity and overall survival in NSCLC oligometastatic patients underwent SABR Materials/Methods: between October 2010 and May 2013, 36 NSCLC patients for 58 lung lesions were treated at our Institution.SABR was performed in case of controlled primary tumor, long interval time from the first diagnoses (greaterthan 6-12 months), exclusion of surgery, and number of metastatic sites Results: Radiological response wasobtained in the vast majority of patients. The local control at 1, 2 and 3 years was 100%, 95% and 95%respectively. No pulmonary toxicity G3-G4, chest pain or rib fracture occurred. The median follow up was 38months (range 6-57 months). Overall Survival (OS) at 1, 2 and 3 years was 90%,84% and 82%respectively.Conclusions: SABR is feasible with limited morbidity. We believe that the discussion within amultidisciplinary team is of pivotal importance to select patients with better prognosis.

Technical Success and Safety of Transbronchial versus Percutaneous Fiducial Placement forCyberKnife Radiotherapy of Lung Tumors

Deirdre E. Moran MBBCh (Presenter): Nothing to Disclose , Robert G. Sheiman MD : Nothing to Disclose , Olga Rachel Brook MD : Research Grant, Guerbet SA , Maryellen Ruth Morris Sun MD : Investigator, Bracco

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Group Investigator, Glaxo SmithKline plc , Anand Mahadevan MD : Nothing to Disclose , Bettina Siewert MD : Nothing to Disclose

PURPOSE

To evaluate the technical success and safety of transbronchial (bronchoscopic) versus percutaneous (CT-guided)fiducial placement for CyberKnife radiotherapy of lung tumors.


From September 2005 to January 2013, we retrospectively reviewed 272 fiducial marker placements in 248patients with lung tumors who subsequently underwent CyberKnife radiation therapy. The study wasIRB-approved, HIPAA-compliant and was performed at a single tertiary institution. Procedure-relatedcomplications were documented. Technical success was defined as implantation enabling adequate treatmentplanning with computed tomographic simulation. Fisher exact probability test was used to compare proportionsof complications and repeat procedures between two groups.

RESULTS

221/272 (81.2%) fiducial markers were placed percutaneously and 51/272 (18.8%) were placed using atransbronchial technique. 15/51 (29%) fiducial placements with transbronchial approach were unsuccessful, asdiscovered at radiotherapy planning session, and required a repeat procedure. 9/15 of repeat procedures wereperformed percutaneously, 5/15 were placed during repeat bronchoscopy, and 1/15 was placed attransesophageal endoscopic ultrasound. No repeat fiducial placements were required for patients who had thefiducials placed using a percutaneous technique (p<0.001), with a technical success rate of 100%.Pneumothorax was seen in 73/221 (33%) of percutaneously placed fiducials and in 4/51 (7.8%) in thetransbronchial placements (p<0.001). Nevertheless, no significant difference was seen in the rate ofthoracostomy tubes placements: 18/221 (8.1%) of percutaneously placed fiducials and 2/51 (3.9%) oftransbronchially placed fiducials (p=0.39).

CONCLUSION

Transbronchial fiducial marker placement has a significantly higher rate of failed placements requiring repeatprocedures in comparison to percutaneous placement, while the rate of pneumothorax requiring thoracostomyplacement is similar between the two approaches.


Fiducial placements for lung tumors should be preferentially performed using a percutaneous approach, as ithas a higher technical success rate with a similar clinically significant complication rate as compared totransbronchial fiducial placement.

Hybrid VMAT for Patients with Large-size Stage III Non-small Cell Lung Cancer

Nobuki Imano (Presenter): Nothing to Disclose

ABSTRACT

Purpose:To avoid the rapid growth of lung cancer, radiotherapy should be started as soon as possible afterdiagnosis. Three-dimensional conformal radiotherapy (3D-CRT) is commonly used in Japan; however, lungcancer with vertebral invasion or lymph node metastasis to the bilateral mediastinum cannot be completelycured using 3D-CRT considering the dose constraints for the spinal cord. Therefore, we developed hybridvolumetric modulated arc therapy (hVMAT), a combination of 3D-CRT and VMAT, for patients with large-sizestage III non-small cell lung cancer (NSCLC). Here, we assessed its utility.Methods:Eleven patients withlarge-size stage III NSCLC who underwent hVMAT between May 2010 and August 2013 were enrolled in thisstudy. For all patients, to maintain the spinal cord with dose constraint (maximum dose of <50 Gy in 25fractions) used for 3D-CRT was impossible. The median total dose and fractionations were 74 Gy and 37fractions, respectively. A dose of up to 36-40 Gy was used for 3D-CRT, and a dose of up to 30-38 Gy was usedfor VMAT. The dose constraint for the lung, defined as the percentage of the total lung volume irradiated with 5Gy and 20 Gy, was less than 50% and 30%, respectively. Nine patients received concurrent chemotherapy,and two received only radiotherapy. We evaluated the following:1)Adverse effects in patients who underwenthVMAT2)Simulated comparison of 3D-CRT and VMAT with hVMAT for PTV D95, lung V5, V20, and mean lungdose (MLD)Results:Only one patient had grade III radiation pneumonitis (RP) during the median 7-monthfollow-up period, whereas grade I and II RP were observed in 4 and 6 patients, respectively. The mean totalvalues for lung V5, V20, and MLD in patients with grade II or III RP were significantly higher compared withthose in patients with grade I RP (48.9% vs. 28.0%, p = 0.027 for V5; 27.0% vs. 14.4%, p = 0.035 for V20;16.4 Gy vs. 9.0 Gy , p = 0.024 for MLD). No other non-hematological toxicities of more than grade III wereobserved.PTV D95 for hVMAT was equal to that for VMAT (89.7% vs. 90.8%, p = 0.736) and superior to thatfor 3D-CRT (89.7% vs. 69.5%, p < 0.001).The total lung dose for hVMAT and VMAT was also equivalent(41.3% vs. 40.2%, p = 0.104 for V5; 22.4% vs. 22.3%, p = 0.856 for V20; 13.7 Gy vs. 14.1 Gy, p = 0.284 forMLD). 3D-CRT exhibited lower V5, but no difference for V20 and MLD in comparison with hVMAT (31.7% vs.41.3%, p < 0.001 for V5; 21.9% vs. 22.4%, p = 0.386 for V20; 13.2 Gy vs. 13.7 Gy, p = 0.152 forMLD).Conclusion:In addition to VMAT, hVMAT could be another treatment option for large-size stage III NSCLC.

Thymic Tumors: A Retrospective Review of the 10-Year Experience @ a NCI-Designated CancerCenter

Charles R. Thomas MD (Presenter): Nothing to Disclose

ABSTRACT

Purpose/Objective(s):TT are rare and poorly understood tumors. TT are often asymptomatic until advanced stage, causing significantmorbidity and treatment-related complications. Outcomes vary depending on the clinical stage and histologicsubtype of TT. The specific aim was to describe the clinical outcomes of patients (pts) with thymic tumors (TT)evaluated at a NCI-Designated Cancer Center over a ten-year period.

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Materials/Methods:The study design as a retrospective case-series of thymic malignancies treated at a NCI-Designated CancerCenter treated at our institution over a 10 year period, including disease presentation and treatment responseto inform potential future research in TT. All pts, eighteen years old or older, with TT seen at OHSU betweenJanuary 1, 2001 and June 30, 2011 were used in this analysis. Subjects were eligible for inclusion if they wereseen during this period and diagnosed with any malignancy arising from the thymus gland, irrespective ofhistologic subtype. Using a case series design, data were collected in a retrospective manner. The medicalrecord was systematically reviewed for pre-specified variables, including demographic data, tumor histology andstage, treatment history, and survival data.Results:Twenty-eight pts were identified with a TT treated at during the defined decade. The mean age at diagnosis was55 yrs. 17 pts had thymoma (61%), 8 had thymic carcinoma (29%), and the remainder had other TT. Of thetotal cohort, the majority were male (61%), lifetime never smokers (61%), and Caucasian (96%). Nine pts hadmyasthenia gravis symptoms (32%). Symptoms at presentation were varied but many experienced chestdiscomfort/pain, dyspnea, cough, and/or fatigue. The majority were treated with surgery (93%) and radiationtherapy (68%) with a mean dose of 54.2 Gy, while 54% received at least one type of chemotherapy (range0-5). The median DFS was 110 months for thymoma, 30 months for thymic carcinoma, and 52.5 months forthe other thymic tumors. The median OS has not been reached for the group of pts.Conclusions:Using a retrospective design, we were able to capture the clinical course of pts with TT treated at our tertiarycare institution over a ten-year period. Pts were treated with standard therapies, and survival (bothdisease-free and overall) is similar to historical reports. In addition to longer follow-up, these data suggestadditional research should be undertaken to better characterize associated causes of TT. Future research shouldevaluate for tumor genetic abnormalities potentially amenable to targeted interventions which may improveDFS and OS, especially for aggressive variants of TT.

Is 18F-FDG PET/CT a Valid Non-invasive Predictor for Regression Grade after NeoadjuvantTreatment in Patients with NSCLC Stage III?

Elvira Fritz : Nothing to Disclose , N. D. Klass : Nothing to Disclose , Michael Schmuecking MD(Presenter): Nothing to Disclose , Richard P. Baum MD, PhD : Stockholder, OctreoPharm Sciences GmbHPrincipal Investigator, AAA Research Consultant, Novartis AG Research Consultant, Ipsen SA Research Grant,ITG-Medical, Inc , R. Bonnet : Nothing to Disclose , Bernd Klaeser MD : Nothing to Disclose , T. G. Wendt: Nothing to Disclose , S. C. Schaefer : Nothing to Disclose , B. Hoksch : Nothing to Disclose , A. Schmid : Nothing to Disclose , Norbert Presselt : Nothing to Disclose , K. M. Mueller : Nothing to Disclose , Barbara E Denker : Nothing to Disclose , Urs R Meier : Nothing to Disclose

PURPOSE

To evaluate the role of molecular remission as detected by 18F-FDG/CT and regression grade according toJunker et al. after neoadjuvant treatment of patients with NSCLC stage III, findings in 58 patients wereanalyzed retrospectively.


For 58 patients with NSCLC stage IIIA (44%) / IIIB (56%) received neoadjuvant treatment consisting ofchemotherapy and radiation therapy. Documentation of involved lymph node stations as detected by PET andlymph node sampling during surgery according to the IASLC lymph node mapping (2009). Evaluation ofhistological regression grade (RG) according to Junker et al. (2001) and correlation with PET for primary tumorand each lymph node station. Calculation of disease free survival using Kaplan-Meier estimates and log ranktests.

RESULTS

Actuarial tumor specific survival for the 32 patients with concomitant chemoradiation: complete vs. incompletemetabolic remission after 60 months: 40% vs. 24% (p = .018), RG III/IIb (no/less than 10% of vital tumorcells) vs. RG IIa/I (more than 10% vital tumor cells) after 60 months: 46% vs. 15% (p < .006). 18/32 (56%)patients with RG III/IIb, 8/32 (25%) patients with regression grade III. 1/8 pts. with RG III were in the18F-FDG PET/CT false positive, 10 pts. with RG IIb (i.e. all pts. with RG IIb) were in the 18F-FDG PET/CT falsenegative, 1 pts. with RG IIa was in the 18F-FDG PET/CT false negative: Hence, the cut-off level in detectingvital tumor cells by 18F-FDG PET/CT after neoadjuvant chemoradiation for NSCLC is about 10%. Actuarialtumor specific survival for the 26 patients with sequential chemoradiation or chemotherapy as a soleneoadjuvant treatment: RG III vs. RG IIb/IIa/I after 60 months: 50% vs. 16%. 05/26 (19%) patients with RGIII.

CONCLUSION

Molecular remission in mediastinal lymph nodes as detected by 18F-FDG PET correlates well with regressiongrade as proposed by Junker et al. and both may predict (long-term) therapeutic outcome in patients withstage III NSCLC. The cut-off level in detecting vital tumor cells by 18F-FDG PET after neoadjuvantchemoradiation for NSCLC is about 10%. Our preliminary data of 58 patients suggest that intensification ofneoadjuvant treatment may lead to an higher amount of complete remission resulting in an increased survival.However this hypothesis has to be tested in prospective trials.


18F-FDG PET/CT is a non-invasive tool for treatment stratification

Longitudinal Computed Tomography Monitoring of Carbon-Ion Radiation Induced PulmonaryFibrosis in Mice in Correlation to the Radiation Therapy Oncology Group (RTOG) Classification

Sebastian Bickelhaupt (Presenter): Nothing to Disclose , Peter Peschke PhD : Nothing to Disclose , Juergen Debus MD, PhD : Nothing to Disclose , Peter Ernst Huber MD, PhD : Nothing to Disclose

PURPOSE

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PURPOSE

Particle radiotherapy including Carbon ion irradiation is of increasing interest for tumor treatments yet its sideeffects are barely investigated, especially for radiosensitive organs such as the lung. We investigated thepulmonary toxicity of carbon ion irradiation in mice lungs and the correlation of computed tomography imagingin correlation to the Radiation Therapy Oncology Group (RTOG) scores and histopathology.


All animal procedures were IRB/GRB approved. Thoraces of female C57BL/6 mice were irradiated with a singledose of 11Gy Carbon ions (C12) , non-irradiated animals served as controls. Computed tomography monitoringusing a SOMATOM multi-slice CT scanner(Siemens) (120kV,100mAS,whole thoracic,0.5-mm slice-thickness,acquisition time 0.5 s) was performed every 2/4 weeks in a longitudinal manner until week 24. Hounsfield Units(HU) with 3D-intrapulmonal homogeneity analyses and pulmonary changes according to the radiological RTOG(Radiation Therapy Oncology Group) scores were measured and correlated. Further lung histology andmorphometric analyses were performed and integrated into the analysis. Statistics were calculated usingStudent�s-t-test, Spearmans correlation coefficient and log-rank tests.

RESULTS

Lung density in mice progressively increased after 12 weeks until 22 weeks after irradiation from about -480HU (SEM+-4.25) to -300 HU (SEM+-26.0) in a homogenous pattern with no significant (p>0.05) differencebetween the intrapulmonal lung regions. Similarly RTOG scores increased from mean 0 to 2.96 (SEM+-0.25) inweek 22, both measurement tools indicated significant (p<0.05) pulmonary changes to controls 16 weeks afterirradiation. A high correlation was found between the RTOG Scores and the HU measurements (p=0.0046,r=-0.89). All findings showed a high correlation to the histopathological examinations presenting lungremodeling indicative of fibrosis that was lethal in all irradiated animals at week 24.

CONCLUSION

Carbon ion irradiation induced lethal pulmonary toxicity in a homogenous pattern with computed tomographymonitoring showing a high correlation between the Hounsfield Units increase and the RTOG scores. Bothmethods seem appropriate for monitoring carbon ion radiotherapy induced pulmonary toxicity.


Hounsfield values and the RTOG scores are a valuable tool for preclinical studies as a translational approach inmonitoring pulmonary toxicity after irradiation.

CHS-SUA

Chest Sunday Poster Discussions Scientific PostersCH AMA PRA Category 1 Credits ™: .50

Sun, Nov 30 12:30 PM - 1:00 PM Location: CH Community, Learning Center

ParticipantsModeratorKatherine Rachel Birchard MD : Nothing to Disclose

Sub-Events Small Invasive Lung Adenocarcinoma: Periostin Expression and Ground-glass Percentage ScalePredict Tumor Recurrence (Station #1)

Ryoji Iwamoto (Presenter): Nothing to Disclose , Kiminori Fujimoto MD, PhD : Nothing to Disclose , Junko Sadohara MD : Nothing to Disclose , Tatsuyuki Tonan MD : Nothing to Disclose , Shuji Nagata MD : Nothing to Disclose , Toshi Abe MD : Nothing to Disclose , Kenji Izuhara : Nothing to Disclose

PURPOSE

Periostin, a matrix protein, was originally identified in osteoblasts. Periostin is believed to promote various typesof tumor growth, in addition to migration and epithelial-mesenchymal transition of the malignant cells. Thisstudy aimed to compare the thin-section CT features with histological assessment of small lung invasiveadenocarcinoma based on the immunohistochemistry stain using periostin to determine the CT features usefulfor the prediction of patient outcomes.


Seventy-seven consecutive patients with small lung invasive adenocarcinoma (< 3 cm in diameter) whounderwent surgical resection from 2000 to 2009 were enrolled. The thin-section CT features were evaluated for7 categories (size, contour, percentage of ground-glass attenuation scale [%GGA score], presence ofair-bronchogram and/or bubble-like appearance, number of involved vessels, shape of pleural indentation, andnumber of pleural indentation). Two independent expert chest radiologists assessed these findings. Periostinexpression was evaluated on the basis of strength and the range of staining. A univariate and multivariableanalyses were performed using the Cox proportional hazards model.

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RESULTS

There was substantial to perfect agreement between the observers for classification of each thin-section CTfinding (kappa value = 0.73- 1.0). Histological WHO typing, pathologic lymphatic invasion, pathologic nodalmetastasis, periostin expression, and %GGA score were statistically significant for recurrence (P = 0.001,0.032, 0.003, < 0.0001, and 0.011, respectively) on univariate analysis. Multivariable analysis revealed thatboth the periostin high expression and the lower %GGA score were relative risk factors for recurrence (P =0.026 and 0.012, respectively).

CONCLUSION

The results of this study suggested that periostin high-expression might be a significant predictor ofpostoperative recurrence. Moreover, preoperative thin-section CT findings (%GGA score) could also predict thelikelihood of postoperative recurrence.


Evaluation of %GGA score before surgical resection and assessment of pathological periostin expression may bepredictors for future tumor recurrence in patients with small invasive adenocarcinoma.

Predicting the Metabolic Activity of Nonsolid Nodules with Low Histologic Grade Lung Cancer Basedon Corrected SUV (Station #2)

Ying Liu MD (Presenter): Nothing to Disclose , Lale Kostakoglu MD, MPH : Nothing to Disclose , Lewen Stempler : Nothing to Disclose , Yu Htwe MD : Nothing to Disclose , Mary Margaret Salvatore MD : Nothing to Disclose , David F. Yankelevitz MD : Research Grant, AstraZeneca PLC Royalties, General ElectricCompany , Claudia I. Henschke MD, PhD : Nothing to Disclose

PURPOSE

To correct the SUV value based on CT attenuation of the nonsolid nodule


We retrospectively evaluated 36 patients (24 female, 12 male, median age 71 year-old) with 40 nonsolidnodules who underwent both FDG-PET scanning and thin-section helical CT scanning before undergoing surgicalresection. All the nonsolid nodules were adenocarcinoma, they were classified by histologic grade according tothe IASLC/ATS/ERS classification (low, moderate, high). The SUVmax value was corrected based on anestimate of the proportion of soft tissue within the nodule by dividing the SUVmax by the proportion of softtissue. The proportion of soft tissue was determined by placing an ROI within the nodule on the CT image todetermine its attenuation. Based on partial voxel effects and using a 2 component model for air and soft tissue,the proportion could be calculated.

RESULTS

The average nodule diameter was 15.2 mm, 33(82.5%) were larger than 10 mm. Of the 40 nonsolid nodules,18 had a low histologic grade and 22 had moderate or high histologic grade. The average SUVmax of the 18nodules with low histologic grade was 1.1 and for the 22 with moderate or high histologic grade it was 1.6. Thecorrected SUVmax was 2.6 and 2.8, respectively. The increase from the SUVmax to the corrected SUVmax wasstatistically significant for both groups (P < 0.0001). Using the traditional SUV cutoff for malignancy of 2.5 forthese cases, the corrected SUVmax was higher for 8 (44%) of the 18 cases with low grade histology and 13(59%) of the 22 cases with moderate or high grade histology.

CONCLUSION

These results demonstrate that the actual cancer within the nonsolid nodule has an SUV similar to traditionalcancer manifesting as a solid nodule and the corrected SUV also correlates with the degree of histologicaggressiveness.


Corrected SUV values provide a means to evaluate nonsolid nodules according to standard PET/CT criteria.

Clinical Significance of Solitary Lung Nodules in Patients with Breast Cancer (Station #3)

Feng Li MD, PhD (Presenter): License agreement, Hologic, Inc License agreement, General Electric CompanyLicense agreement, Toshiba Corporation License agreement, Deus Technologies, LLC License agreement,Riverain Technologies, LLC License agreement, MEDIAN Technologies License agreement, Mitsubishi Corporation, Samuel George Armato PhD : Nothing to Disclose , Heber MacMahon MD : Shareholder, Hologic, Inc

Consultant, Riverain Technologies, LLC Royalties, UCTech

PURPOSE

To evaluate the clinical significance of solitary non-calcified nodules on chest computed tomography (CT) scansin patients with breast cancer.


Of 3313 patients with breast cancer, 1377 patients had at least one chest CT scan between 2002 and 2011 at

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our medical center. Considering the first CT scans of these 1377 patients, 630 (46%) patients had no lungnodules, 529 (38%) patients had multiple nodules, and 218 (16%) patients had one non-calcified nodule. Ofthe 218 CT scans with a solitary pulmonary nodule, the CT section thickness was 1 mm in 138 (63%) scans, 2-3mm in 12 (6%) scans, and 3-7 mm in 68 (31%) scans. The size and pattern of these 218 solitary nodules on CTwere analyzed and compared with the final diagnosis.

RESULTS

The mean dimensions of the 218 solitary nodules on CT was 3-5 mm in 160 (73%) patients, 6-10mm in 34(16%) patients, 11-20 mm in 16 (7%) patients, and 21-40 mm in 8 (4%) patients. There were 185 (85%) solidnodules, 26 (12%) nodules with mixed ground-glass opacity (GGO), and 7 nodules with pure GGO. Finaldiagnosis included 100 (46%) definitely benign lesions (resolved or stable solid nodule after more than 2 yearsor biopsy proven), 72 (33%) benign lesions based on image features alone, 21 (10%) indeterminate orsuspicious lesions, 11 (5%) primary lung cancers, and 14 (6%) nodular metastases (all solid nodules). 201(92%) lesions were diagnosed by imaging findings alone, and only 17 (8%) lesions were confirmed by biopsy(11 lung cancers, 3 benign nodules, and 3 metastatic breast cancers). Among 160 nodules at 3-5 mm, 141(88%) were benign lesions, 12 (8%) were indeterminate or suspicious lesions, 7 (4%) were metastatic nodules,and no primary lung cancers were found. All 7 pure GGO nodules were indeterminate or suspicious by follow-upCT scans.

CONCLUSION

90% of 3-5 mm and 67% of 6-10 mm solitary solid non-calcified nodules in patients with breast cancer werebenign, whereas 5% of 3-5 mm and 17% of 6-10 mm of such nodules were metastases.


The detection of small solitary solid nodules on the initial CT scans of patients with breast cancer should not bea cause for alarm as the large majority are benign, and follow-up CT scans are usually appropriate to confirmbenignity in such cases.

Effect of Reader Adjustments on Lung Nodule Classification in CT Lung Cancer Screening (Station#4)

Marjolein Anne Heuvelmans BSc (Presenter): Nothing to Disclose , Rozemarijn Vliegenthart MD, PhD : Nothing to Disclose , Pim A. De Jong MD, PhD : Nothing to Disclose , Willem P. Mali MD, PhD : Nothing toDisclose , Matthijs Oudkerk MD, PhD : Nothing to Disclose

PURPOSE

To evaluate the impact of radiologists' expertise on test result decisions made in a CT lung cancer screeningtrial.


In the NELSON randomized lung cancer screening trial, the baseline CT screen result was based on the lungnodule with largest volume. According to the protocol, nodule volume<50mm3, 50-500mm3 and >500mm3 ledto a negative, indeterminate and positive screen result, respectively. However, the NELSON protocol allowedradiologists to manually adjust the screen result in case of high suspicion on benign or malignant nature. In thisstudy, all participants whose baseline screen result was based on a solid nodule were included. The screenresult that should have been made accordingly to the nodule management protocol and the final baseline CTscreen result were compared, to see whether the screen result was manually adjusted. Histology was thereference for diagnosis, or, to confirm benignity, stability of the nodule volume on subsequent CT scans for atleast two years after baseline.

RESULTS

In 3268 participants (2759 male, median age 58.0 years), the baseline result was based on a solid nodule. In189 participants (5.8%) the initial baseline screen result for the largest nodule was adjusted by the radiologist.The screen result was adjusted downwards from positive or indeterminate to negative in two and 118participants, respectively, and from positive to indeterminate in 64 participants. None of these nodules turnedout to be malignant, two years after baseline. The result was adjusted upwards from negative to indeterminatein one participants. No lung cancer was diagnosed in this nodule. In four participants the screen result wasadjusted upwards from indeterminate to positive; two nodules were malignant (50%).

CONCLUSION

In baseline lung cancer screening, readers adjusted screen results in about one in twenty cases (97.4%downwards), leading to reduction of false-positive and false-negative test results.


In lung cancer screening, radiologists' expertise can improve nodule classification in addition to a generalnodule management protocol.

CHS-SUB

Chest Sunday Poster Discussions Scientific PostersCH AMA PRA Category 1 Credits ™: .50

Sun, Nov 30 1:00 PM - 1:30 PM Location: CH Community, Learning Center

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Sub-Events Pulmonary Nodule Volume in Ultra-low-dose CT with Sinogram-affirmed Iterative Reconstruction(Station #1)

Wei Song MD : Nothing to Disclose , Xin Sui MD (Presenter): Nothing to Disclose , Zhengyu Jin : Nothing to Disclose , Huadan Xue MD : Nothing to Disclose

PURPOSE

The objective was to compare the nodule volumes measured in low-dose CT (LDCT)with filtered back projection(FBP) versus ultra-low-dose CT (ULDCT) with sinogram-affirmed iterative reconstruction (SAFIRE).


Forty-two patients (mean [SD] age, 53.1[8.9] years) were erolled in this study. Clinical indications for chest CTincluded a follow-up study of primary or metastatic lung malignancy, a solitary pulmonary nodule on theradiograph. Clinical diagnoses were lung cancer (n=18), breast cancer (n=15), thyroid carcinoma (n=9). All thepatients underwent LDCT (reference parameters 120 kV, 50 mAs) and ULDCT(reference parameters 80 kV, 5mAs) with dual-source flash 128-slice CT system (SOMATOM Definition Flash, Siemens Healthcare,Germany).The average body mass index (BMI) of patients was 24.1(±2.6)kg/m2.Radiation dose was recorded.All the CT images were reconstructed with filtered back projection (FBP) for LDCT data and with SAFIRE forULDCT data. 101 solid nodules were identified by 2 different radiologists by a consensus panel. Automatednodule volume measurements were performed by using computer-assisted volume measurement software(Syngovia, Siemens Healthcare).

RESULTS

The mean effective doses were 0.13±0.02 mSv and 2.01±0.31 mSv for ULDCT and LDCT, respectively. Thereare 25 nodules (smaller than 4mm by RECIST), 68 nodules (between 4mm and 8mm by RECIST) and 8 nodules(size greater than 8mm RECIST). The volume of the indentified nodules were compared between the 2 groupsby use of the Wilcoxon's rank test, and no significant differences were observed (Z=-1.375, P=0.175).

CONCLUSION

In comparison with LDCT, SAFIRE of ULDCT enables significant reduction in radiation dose for lung screening,while no affecting solid nodule measurement. It is safe to convert LDCT FBP protocols to ULDCT SAFIRE forvolume of solid lung nodule follow up.


ULDCT for lung cancer screening retains potential for the lung nodule volume follow-up.

A Phantom Study for Ground Glass Nodule Detection by Chest Digital Tomosynthesis with IterativeReconstruction Algorithm: Influence of Radiation Dose and Nodular Characteristics (Station #2)

Katsunori Miyata RT (Presenter): Nothing to Disclose , Yukihiro Nagatani MD : Nothing to Disclose , Masashi Takahashi MD : Nothing to Disclose , Satoru Matsuo : Nothing to Disclose , Mitsuru Ikeda MD : Nothing to Disclose , Norihisa Nitta MD : Nothing to Disclose , Hideji Otani MD : Nothing to Disclose , Shinichi Ota MD : Nothing to Disclose , Masatake Imai : Nothing to Disclose , Kiyoshi Murata MD : Nothing to Disclose

PURPOSE

To compare detectability of simulated ground glass nodules (GGND) on chest ditigal tomosynthesis (CDT)among 12 images obtained at 6 radiation exposure levels using 2 different reconstruction algorithms andanalyze the influence of nodular size and its computed tomography attenuation value (CTAV) on GGND


Seventy-four simulated GGNs (5, 8 and 10 mm in a diameter/ -630 and -800 Hounsfield of Unit (HU) in CTAV)were placed in the chest phantom with reproduced peripheral pulmonary structures in 14 different patterns ofnodular distribution. In each of the 14 distribution patterns, 12 sets of reconstructed coronal images wereobtained using CDT (SONIALVISION Safire, Shimadzu, Kyoto, Japan) with 6 different radiation level:120kV-10mA/20mA/80mA/160mA, 100kV-80mA and 80kV-320mA (effective dose : 0.08/0.16/0.65/1.30, 0.39and 0.77mSv in standard body habitus, respectively) with and without iterative dose reduction algorithm (IRA).Ten radiologists independently recorded GGN presence and their locations by continuously-distributed rating intotal 168 sets of images. Receiver-operating characteristic (ROC) analysis was used to compare GGND of the 12images in total and detection sensitivities (DS) of GGN were compared among the 12 images in subgroupsclassified by their nodular diameters and CTAV.

RESULTS

In total, GGND in images at 120kV-80mA with IRA was similar to that at 120kV-160mA with IRA, as area underROC curve was 0.79±0.03 and 0.80±0.03, respectively, and higher than the other 6 images obtained at 120kV.(p<0.05) DS of GGN with the diameter of 8mm and -630 HU in CTAV was 73.5±6.0 % in images at120kV-10mA without IRA and similar to those in the other 11 images. (p=0.157) DS of GGN with the diameterof 10mm and -800 HU in CTAV was 56.3±11.9 % in images at both 120kV-80mA and 120kV-160mA with IRAand higher than the other 4 images obtained at 120kV without IRA. (p<0.05)

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CONCLUSION

CDT demonstrated sufficient GGND for less attenuated nodules with the diameter of 8mm or more even in thelowest radiation level (0.08mSv) and improved DS of GGN for more attenuated nodules with the diameter of10mm at submilli-Sv with IRA.


CDT has a sufficient potential to be used for detection of pure GGN and IRA synergistically boosts its ability.

Detection of "Missed" Lung Cancers using Computer-aided Detection Systems (CAD) in CT Screeningfor Lung Cancer (Station #4)

Mingzhu Liang MD (Presenter): Nothing to Disclose , Wei Tang MD : Nothing to Disclose , Dongming Xu MD, PhD : Nothing to Disclose , Rowena Yip MPH : Nothing to Disclose , Artit C. Jirapatnakul PhD : Nothing to Disclose , Yu Htwe MD : Nothing to Disclose , David F. Yankelevitz MD : Research Grant,AstraZeneca PLC Royalties, General Electric Company , Claudia I. Henschke MD, PhD : Nothing to Disclose

PURPOSE

To evaluate the usefulness of CAD in detecting lung cancer in low-dose CT scans that was missed by theradiologist in earlier rounds.


Lung cancers manifesting as a solid nodule and diagnosed in annual rounds of screening were reviewed todetermine whether the cancer could be identified in the prior round of screening. All CT images were obtainedat 1.25 mm slice thickness or less. Three software packages (Lung VCAR (GE healthcare), Image Checker CT(LN-1000, R2 Technology) and Syngovia(Siemens Medical Solutions)) were used to evaluate the scan when thecancer was first identified by the radiologists and the frequency with which the CAD identified the cancer wascalculated. The CAD was also used to determine whether it could identify the cancer on the earlier CT scans,when it was missed by the radiologist. The false positive rate of any nodule detection by the CAD wascalculated using the consensus of two radiologists.

RESULTS

50 cases of lung cancer were identified (median age of 63 years), where in retrospect the cancer could be seenbut was not reported. The average diameter was 11.4 mm (SD of 10.1 mm) when the cancer was identified bythe radiologist for workup. The detection rates for GE, R2, and Siemens system were 74%, 82%, and 82%,respectively. On the earlier CT scans (when missed by the radiologist), the average diameter was 4.8 mm (SDof 1.6 mm). The detection rates for each CAD were 56%, 70% and 68%, respectively. The false positive ratefor any nodule was 7.4, 1.7 and 0.6 per study.

CONCLUSION

The CAD detected 56% to 70% of cancers on the earlier CT scans, all of which had been missed by theradiologists. However, the CAD missed 18% to 26% of cancers when it was identified by the radiologist. Thissuggests that the current CADs may be useful as a second reader in CT screening programs as the lung cancersmay be identified one year earlier although the false positive rate was highly variable.


CAD has the potential to detect the majority of cancers missed by the radiologists in earlier round of screeningwhen the cancer is smaller and more curable.

RC101

Pulmonary Thromboembolism: Concepts and Controversies 2014 Refresher/Informatics

CT CH



Sun, Nov 30 2:00 PM - 3:30 PM Location: S406B

ParticipantsModeratorMark L. Schiebler MD : Shareholder, Cellectar Biosciences, Inc

Sub-Events The Problem of Subsegmental Pulmonary Emboli

Lacey Washington MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) Review evidence from the literature on the prevalence of subsegmental pulmonary emboli. 2) discuss direct

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RC101A

1) Review evidence from the literature on the prevalence of subsegmental pulmonary emboli. 2) discuss directand indirect evidence concerning the significance of subsegmental emboli and reasons for continued controversy.

Optimizing Imaging Utilization

Linda Broyde Haramati MD, MS (Presenter): Investor, OrthoSpace Ltd Investor, Kryon Systems Ltd Spouse,Board Member, Bio Protect Ltd Spouse, Board Member, OrthoSpace Ltd Spouse, Board Member, Kryon SystemsLtd

LEARNING OBJECTIVES

1) To become familiar with structured and unstructured risk assessment for patients with suspected pulmonaryembolism. 2) To review the impact of disease prevalence on the performance characteristics of diagnostic tests.3) To understand the strengths and weakness of various strategies for imaging patients with suspectedpulmonary embolism.

ABSTRACT

Patient suspected of having a pulmonary embolism initially present for clinical evaluation and may be referredfor imaging. There is a great deal of geographic and institutional variability in the disease prevalce for patientswho undergo imaging. As in other areas of medicine, the performance characteristics of imaging tests varieswith the disease prevalence. This session will discuss different methods used to determine whether imaging isperformed including structured vs unstructured risk assessment and D-dimer. The various imaging modalitiesthat are employed with an emphasis on CTA and V/Q scanning and a brief discussion of leg ultrasound andechocardiography. Practical imaging strategies vary with intistitutional resourses. V/Q scanning should maintainan active role in the imaging armamentarium .

Active handout

http://media.rsna.org/media/abstract/2014/14000779/RC101B Sec.pdf

Optimizing CTPA: Contrast Dynamics and Administration

Kristopher W. Cummings MD (Presenter): Research Consultant, Biomedical Systems Research Consultant,Medtronic, Inc

LEARNING OBJECTIVES

1) Describe the two most common methods for contrast timing to the pulmonary arterial system. 2) List twoimportant factors affecting the degree of contrast enhancement during CTPA.

ABSTRACT

CT pulmonary angiography has largely replaced catheter based angiography for evaluation for acute pulmonaryembolism. In order to detect acute or chronic emboli, adequate opacification of the pulmonary arterial systemmust be achieved. With advanced MDCT allowing rapid imaging of the entire chest, modifications to contrastadministration protocols are required to assure diagnostic scans. A brief review of current techniques andapproaches to contrast administration for fast multidetector CTPA will be given.

Optimizing CTPA: Radiation Dose Reduction

Diana Litmanovich MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) Review range of radiation exposure with common CTPA studies. 2) Become familiar with principles ofradiation dose assessment in CTPA 3) Become familiar with tools for dose reduction, recording the dose andauditing.

ABSTRACT

CT radiation exposure has received much attention lately in the medical literature and media, given itsrelatively high radiation dose per examination. There is a variety of possible strategies to reduce radiationexposure from CT in an individual patient. Optimal scan acquisition requires understanding by the radiologist ofnew scanner technology and implementation of the most effective methods available for dose reduction whilemaintaining image quality. Cardiothoracic imaging should be performed according to As Low As ReasonablyAchievable (ALARA) principle. CT radiation dose metrics including CT dose index, Dose-length product, effectivediameter and size-specific dose estimate are discussed. CT scanner parameters directly and indirectlyinfluencing radiation dose, such as scan length, x-ray tube output, tube current modulation, pitch, imagereconstruction technique (including iterative reconstructions), and noise reduction are also discussed in relationto the major MDCT scanners available. The goal of radiation dose reduction is to decrease the radiation dosedelivered to the patient. For CT pulmonary angiography, restricted length of scanning, increased pitch,decreased kVp to 100 in the vast majority of patients, and application of automatic exposure control wouldprovide the best combination. Noise reduction techniques afford additional radiation dose reduction. All theparameters are presented according to their respective importance to image quality and the implications ofparameter changes on image quality and diagnostic content.

Optimizing Pulmonary MRA

RC101B

RC101C

RC101D

Optimizing Pulmonary MRA

Mark L. Schiebler MD (Presenter): Shareholder, Cellectar Biosciences, Inc

LEARNING OBJECTIVES

1) Technique is critical. 2) Understand the promise of MRA in the pulmonary vasculature. 3) Beware of thelimitations. 4) Who can benefit from MRA-PE exams.

ABSTRACT

Abstract There has recently been the development of some uncertainty with regards to the need for the nearperfect sensitivity for the detection of pulmonary embolism in the subsegmental size range that is provided byCTA-PE exams. There are two major groups fighting for clinical dominance of the treatment paradigm. There isone camp that stresses the need for long term anti-coagulation for any documented venous thromboembolicevent (VTE). The second camp is less stringent in its dogmatic approach to mandatory treatment for alldocumented VTE, and suggests not treating those subsegmental PE in patients that have no other risk factorsfor thromboembolic disease. Outcomes data from our group support the second group's framework for thetreatment of this disease. With careful attention to the injection rate, contrast concentration, breathinginstructions, and the use of parallel imaging, single breath-hold near isotropic whole lung MRA-PE exams can beroutinely obtained of very high quality. The important artifacts of Gibbs ringing, cardiac and respiratory motion,Maki, need to be understood. While MRA-PE does not have the efficacy (lower sensitivity) of CTA for thedetection of all PE, it has been shown to be an effective (high NPV) alternative for the diagnosis of this conditionwithout the use of medical radiation.

PE: Pitfalls in Diagnosis

Danielle Seaman MD (Presenter): Research Grant, Bracco Group

LEARNING OBJECTIVES

1) Recognize potential causes for a nondiagnostic CT angiogram for pulmonary embolism. 2) Be able to correctthe problem in a nondiagnostic study to obtain a diagnostic examination. 3) Recognize potential mimicks ofpulmonary embolism and be able to distinguish those from true pulmonary emboli.

RC104

Sports Injuries in the Chest and Abdominal Wall: A Core Curriculum of the Body's Core Refresher/Informatics

MK GU GI CH MK GU GI CH



Sun, Nov 30 2:00 PM - 3:30 PM Location: N227AB

ParticipantsDavid Alan Rubin MD (Presenter): Nothing to Disclose Jonathan Craig Baker MD (Presenter): Research Consultant, Biomedical Systems William E. Palmer MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES1) Understand the relative strengths and weaknesses of radiographs, ultrasound, CT and MR in the evaluation of suspectedinjuries to the anterior chest wall structures, and use this information to logically direct an imaging evaluation. 2) Understand theanatomy of the anterior chest wall musculature and its relevance to the imaging patterns of injuries, together with how thatinformation assists treatment planning. 3) Recognize and characterize the common and less common injuries in the abdominaland pelvic wall musculature and supporting pelvic ligaments.

ABSTRACTThe imaging of sports injuries to the extremities, joints, groin, spine, and head receive much attention. Nevertheless athleticinjuries to the trunk also occur with some frequency. The thoracic, abdominal, and pelvic walls form the body's central core. Thethoracic wall includes the ossified and cartilaginous parts of the ribs together with the clavicles and sternum, which provide aprotective cage for the vital chest organs, as well as a site of origin for the chest wall muscles. In turn, these powerful musclesare responsible for the large movements of the upper extremities and for stabilizing the upper body during twisting motions.Similarly, the abdominal and pelvic wall muscles and supporting ligaments anchor the trunk and lower extremities to the spineand pelvis, while stabilizing the body during locomotion and limb movements. Each of these bone and soft tissue structures aresusceptible to direct blunt force trauma in contact and collision sports and to indirect stretching injuries during running, cutting,throwing, kicking, and related activities. There is growing understanding of the role of the thoracoabdominal musculoskeletalstructures in sports, with training regimens now incorporating 'core strengthening' as an important pillar. The recognition,staging, therapy, and rehabilitation of these injuries are likewise becoming more sophisticated. This refresher course will reviewthe role imaging plays for these injuries, emphasizing the added value of advanced imaging modalities for diagnosis, treatmentplanning, and prognostication.

PS12

Sunday Afternoon Plenary Session

RC101E

RC101F

Plenary Sessions

RO NR MK GI CH BR



Sun, Nov 30 4:00 PM - 5:45 PM Location: Arie Crown Theater

ParticipantsPresidingN. Reed Dunnick MD Nothing to Disclose President, Radiological Society of North America

Sub-Events Report of the RSNA Research and Education Foundation

James P. Borgstede MD (Presenter): Nothing to Disclose Chairman, Board of Trustees, RSNA Research andEducation Foundation

Abstract

The RandE Foundation - A Transformative Force in Radiology The theme of the 2014 RSNA Scientific Assemblyand Annual Meeting is "A Century of Transforming Medicine." For 30 years of that century, the RandEFoundation has played a significant role in advancing the RSNA mission to promote excellence in patient careand health care delivery through education, research and technologic innovation. In celebration of 100 years,the Foundation is launching Inspire-Innovate-Invest, The Campaign for Funding Radiology's Future. This boldcampaign seeks to raise $17.5 million to fund grants in radiologic research and education, bridging the gaps infunding for promising investigators and educators. The need is great and the time is now, if the Foundationreaches its campaign goal of $17.5 million, it will keep pace with the growing demand and help ensure thatcritical discoveries by radiologic investigators come to fruition. This year, the Foundation will fund 95 grantstotaling $3.7 million. This means the RandE is funding 25% of our ever increasing number of excellent grantapplications. While pleased with these achievements, imagine what the R and E Foundation could fund withadditional support from all of us as radiology colleagues? And please recall that we are all the beneficiaries ofthis research. Of these individuals, who will start their academic research career with an RandE grant, and whatwill grow from this initial funding? What advances will emanate from their research? And, how can radiologistssupport these investigators and educators as they pursue their chosen career paths in an effort to make thespecialty even stronger? During the meeting week, please take time to visit the RandE Foundation Booth,located on Level 3 of Lakeside Center to learn more about how you can be a part of the campaign and supportthe RandE Foundation and the future of our specialty.

Image Interpretation Session

Moderator Jeffrey C. Weinreb MD : Nothing to Disclose , Donald P. Frush MD Nothing to Disclose , Carol H. Lee MD Nothing to Disclose , Theodore T. Miller MD (Presenter): Nothing to Disclose , Reginald F. Munden MD, DMD (Presenter): Nothing to Disclose , Anwar Roshanali Padhani MD (Presenter): Advisory Board,Acuitas Medical Ltd Advisory Board, Siemens AG Speakers Bureau, Siemens AG Researcher, Siemens AGSpeakers Bureau, Johnson & Johnson , Howard A. Rowley MD (Presenter): Research Consultant, BraccoGroup Research Consultant, Guerbet SA Research Consultant, General Electric Company Consultant, F.Hoffmann-La Roche Ltd Consultant, W.L. Gore & Associates, Inc Consultant, H. Lundbeck A/S

LEARNING OBJECTIVES

1) Identify key abnormal findings on radiologic studies that are critical to making a specific diagnosis. 2)Construct a logical list of differential diagnoses based on the radiologic findings, focusing on the most probabledifferential diagnoses. 3) Determine which, if any, additional radiologic studies or procedures are needed inorder to make a specific final diagnosis. 4) Choose the most likely diagnosis based on the clinical and theradiologic information.

MSRO21

BOOST: Lung—Oncology and Anatomy (An Interactive Session) Multisession Courses

RO OI CH RO OI CH



Mon, Dec 1 8:30 AM - 10:00 AM Location: S103AB

ParticipantsModeratorSimon Shek-Man Lo MD : Research support, Elekta AB Speaker, Varian Medical Systems, Inc Travel support, Varian MedicalSystems, Inc Michelle Segall Ginsberg MD (Presenter): Nothing to Disclose Gregory Videtic MD, FRCPC (Presenter): Nothing to Disclose

LEARNING OBJECTIVES1) 'Patterns of spread of lung cancer. 2) Contouring of organs-at-risk e.g. esophagus, brachial plexus, heart, airway; etc. 3)Contouring of gross tumor volume (GTV), clinical target volume (CTV), and planning target volume (PTV) for stereotactic body

PS12A

PS12B

Contouring of gross tumor volume (GTV), clinical target volume (CTV), and planning target volume (PTV) for stereotactic bodyradiotherapy for medically inoperable non-small cell lung cancer. 4) Contouring of gross tumor volume (GTV), clinical targetvolume (CTV), and planning target volume (PTV) for conventional external beam radiotherapy for non-metastatic non-small celllung cancer and small cell lung cancer. Review thoracic anatomy that impacts treatment decision making: 1) Proximity to greatvessels/heart. 2) Involvement of airway/esophagus. 3) Involvement of diaphragm, phrenic nerve. 4) Involvement of vertebralcolumn. 5) Medistinal and hilar nodes'

RC201

Lung Cancer Screening: Structured Reporting, Management and Practice Metrics (LUNGRADS)

Refresher/InformaticsCT CH CT CH AMA PRA Category 1 Credits ™: 1.50


Mon, Dec 1 8:30 AM - 10:00 AM Location: E451A

ParticipantsModeratorElla A. Kazerooni MD : Nothing to Disclose

LEARNING OBJECTIVES

1) To learn why structured reporting is important in the practice of lung cancer screening with CT. 2) To learn what theLUNGRADS structured reporting categories are and what management is associated with each category. 3) To understand howto evaluate lung nodules for reporting in the LUNGRADS coding scheme. 4) To learn basic practice audit variables to collect andfollow to evaluate a a lung cancer screening CT program.

ABSTRACTLung cancer is the leading cause of cancer death in the US for both men and women, exceeding the number of deaths fromcancers of the breast, colon, and prostate combined. For each of these cancers, there are well established screening tests.Screening for current and former smokers with LDCT is the only method ever proven to reduce lung cancer mortality in this highrisk population and it has also been shown to be cost effective. In December 2013 the USPSTF gave lung cancer screening withCT a grade ;B; recommendation for high risk older current and former smokers. To prepare radiologists to practice lung cancerscreening with CT, the ACR Committee on Lung Cancer Screening formed a working group to develop LUNGRADS, which madeit#39;s version 1.0;debut in 2014. Similar to BIRADS which is in ;, LUNGRADS provides practicing radiologists with a tool touse for categorizing abnormalities found on lung cancer screening CT exams, with management recommendations for eachcategory. In this course we will review why structured reporting and management is important in lung cancer screening CT. Asa public health screening tool, performing the exams with high quality, using standardized reporting and following standardmanagement algorithms is important to minimize overdiagnosis, overutilization of diagnostic testing and interventionalprocedures ranging from percutaneous biopsy to bronchoscopy and surgery. The LUNGRADS categories try to follow BIRADSapproach to coding when possible, recognizing that there are differences in screening for lung cancer and breast cancer. Examsare coded as incomplete (category 0), negative; for clinically active cancer (category 1), benign (category 2), probably benign(category 3) and suspicious (category 4). Additional modifers such as ;S; can be used for clinicially significant or potentiallyclinically signifiant findings (non lung cancer). Details of using this coding system and metrics to evaluate a screening practicewill be discussed.

Sub-Events Development

Ella A. Kazerooni MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES


ABSTRACT

See course abstract

Benign and Prob Benign

Ann N. C. Leung MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) To review the CT findings and types of abnormalities that are classified under the 'Benign' and 'ProbablyBenign' categories.

Suspicious/Malignant

Reginald F. Munden MD, DMD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) To recognize the CT findings and types of abnormalities that are classified under the 'suspicious' and'malignant' categories.

Significant Other Findings

RC201A

RC201B

RC201C

RC201D

Caroline Chiles MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) Recognize and report significant incidental findings on LDCT lung cancer screening examinations.

Practice Metrics and Audit

William C. Black MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES


MSRO22

BOOST: Lung Cancer—Integrated Science and Practice (ISP) Session Multisession Courses

RO OI CH



Mon, Dec 1 10:30 AM - 12:00 PM Location: S103AB

ParticipantsModeratorSimon Shek-Man Lo MD : Research support, Elekta AB Speaker, Varian Medical Systems, Inc Travel support, Varian MedicalSystems, Inc ModeratorFeng-Ming Kong MD, PhD : Nothing to Disclose

Sub-Events Invited Speaker:

David Palma MD, FRCPC (Presenter): Nothing to Disclose

Long Time Prognosis on 474 Patients of Locally Advanced Non-small Cell Lung Cancer afterThree-dimensional Conformal Radiotherapy (3d-crt)--Single Centre Data

Yu-Xiang Wang MD (Presenter): Nothing to Disclose

ABSTRACT

Purpose/Objective(s)To retrospective evaluate long time prognosis and its related prognosticfactors for locally advanced non-small cell lung cancer (NSCLC) after involved fieldthree-dimensional conformal radiotherapy(3D-CRT).: Materials/Methods:From August 2000 toDecember 2010, 474 patients who suffered with locally advanced NSCLC was diagnosied andtreated with involved field 3D-CRT. Among them, 211 cases with stage IIIA, 263 cases with stageIIIB; males in 382 and female in 92 cases; median ages was 63 years old. 55 cases receivedconventional radiotherapy(CRT) add late-course 3D-CRT, 340 cases with 3D-CRT, and 79 cases withintensity modulated radiation therapy(IMRT).The median equivalent dose was 60Gy(range44-77Gy). There were 165 cases treated with radiotherapy alone, 175 cases with concurrentchemoradiotherapy, and 134 cases with sequential chemoradiotherapy. 270 of 474 cases had intactradiation treatment planning and ralated parameter was analysis with Dose VolumeHistogram(DVH). Statistics analysis was used with SPSS13.0 software.Results:The deadline offollow-up was 30 August 2013, and the follow-up rate was 96.6%. After radiotherapy, CR in 41cases, PR in 392 cases, SD in 31 cases, PD in 10 cases, and the total efficiency(CR+PR) is 91.4%.Rates of CR+PR was higher in T1-2 than in T3-4(p<0.05). Rate of acute radiation-relatedpneumonitis was 53.8% (255/474), grade 1 in 62 cases,grade 2 in 74 cases, 114 cases in grade 3,grade 4 in 5 cases, respectively; rate of acute radiation esophagitis rate was 41.1% (195/474 ), 95cases in grade 1, 93 cases in grade 2 , 7 cases in grade 3. 1-, 3- and 5-years overall survival andmedian was 63.0%, 24.9%, 17.8% and 18 months. With univariate analysis, the prognostic facterwas gender, age, style of radiotherapy, chemotherapy, primary tumor volmle, short-time response,radiation-related pneumonitis, and GTV, GTVD100, GTVD95, GTVV60, CTV, CTVD100, CTVD90,CTVV60, CTVV55, PTV in DVH(p0.05). Conclusions:In patients with local advanced NSCLC, theindependent prognostic factor were gender, age, short-time response, and GTV after 3D-CRT.3D-CRT comparied with chemotherapy could increased survival comparied with radiotherapy aloneand boost dose did not increase survival.

FLT-PET/CT Differentiates Post-radiation Therapy Changes from Local Recurrence in ThoracicMalignancies

Susan Mary Hiniker MD (Presenter): Nothing to Disclose , Andrew Quon MD : Nothing to Disclose , Maximilian Diehn MD, PhD : Research Consultant, Varian Medical Systems, Inc Research Grant, VarianMedical Systems, Inc , Billy Wiseman Loo MD, PhD : Research support, Varian Medical Systems, Inc Research

RC201D

RC201E

MSRO22-01

MSRO22-02

MSRO22-03

support, RaySearch Laboratories AB

PURPOSE

Radiation therapy (RT) is increasingly used in the treatment of thoracic malignancies. Post-RT changes areoften difficult to distinguish from local recurrence by FDG-PET or CT. This is a pilot study of3-deoxy-3-[18F]fluorothymidine (FLT)-PET/CT in patients with equivocal post-RT FDG-PET/CT, to assess theutility of FLT-PET/CT in identifying tumor recurrence.


We prospectively enrolled 10 patients who had a FDG-PET/CT scan that was indeterminate for local diseaserecurrence after thoracic RT and performed FLT-PET/CT for further characterization. Interpretation criteria forFLT-PET included a semi-quantitative assessment of SUVmax of the lesion and background activity in lung andmediastinum and a qualitative assessment of the focality of the suspicious lesion. The FDG-PET/CT occurringimmediately prior to FLT-PET was also evaluated for maximum SUV of the suspicious lesion. Biopsy or clinicalfollow-up including serial diagnostic contrast CT and FDG-PET/CT imaging served as the reference andoutcomes measurement.

RESULTS

10 patients with a median age of 70 years (51-81) underwent FLT-PET/CT. 9 patients received stereotacticablative RT (SABR), and 1 patient received conventionally fractionated RT. To date, 5 patients have undergonebiopsy and 2 patients had serial imaging that resulted in either unequivocal disease progression or resolution ofthe suspicious lesion. 5/7 were found to have disease recurrence. In 4/5 patients with disease recurrence, theratio of FLT SUV in the suspicious lesion to FLT SUV in the mediastinal blood pool was > 2.0, while this was truein 0/2 patients without disease recurrence. Focality of the lesion on FLT was a specific marker for diseaserecurrence, as 3/3 patients with focal lesions were found to have recurrent disease on biopsy or unequivocalprogression on subsequent FDG-PET scans.

CONCLUSION

Adjunctive FLT-PET/CT can complement FDG-PET/CT in distinguishing post-RT changes from disease recurrencein thoracic malignancies. A ratio >2.0 between the SUVmax of the lesion of interest and the mediastinal bloodpool may be a useful criteria for diagnosing recurrence in patients treated with thoracic RT.


FLT-PET/CT imaging may differentiate local recurrence from post-treatment changes in patients treated withthoracic RT and with equivocal findings on follow-up FDG-PET/CT imaging.

Comparison of Internal Gross Target Volumes Delineated on 4DCT Maximum Intensity Projection(MIP) and FDG-PET/CT Images of Non-Small Cell Lung Cancer

Yili Duan (Presenter): Nothing to Disclose

ABSTRACT

Objective To compare the positional and volumetric differences of internal gross target volumes(IGTV) basedon the maximum intensity projection(MIP) of four-dimensional CT(4D-CT) images and different standardizeduptake values of 18F-fluorodeoxyglucose positron emission tomography CT(PET-CT) for the primary tumor ofnon-small cell lung cancer(NSCLC). Methods Ten NSCLC patients underwent enhanced three-dimensional CTscan followed by enhanced 4D-CT scan of the thorax under normal free breathing and then 18F-FDG PET-CTscan was performed in the same position based on the same positioning parameters. IGTV of the primary tumorwere contoured by the same radiotherapist on the MIP images of 4D-CT to generate IGTVMIP. IGTVPET weredetermined with nine different threshold methods using the auto-contouring function and manual contouring.The differences in the position, volume, matching index (MI) and degree of inclusion(DI)of the targets betweenIGTVPET and IGTVMIP were compared. Results There were statistically significant differences between thecentric coordinate positions of IGTVPET and IGTVMIP only in z axes (P=0.014~0.044). In volume terms,IGTVPET2.0 and IGTVPET20% approximated closely to IGTVMIP with mean volume ratios of 1.02±0.35 and1.06±0.43, respectively, but there was no significant difference between them(P=0.806). The highest MI werebetween IGTVMIP and IGTVPET2.0 or between IGTVMIP and IGTVPET20% (0.46±0.24 and 0.45±0.23), andthere was no significant difference between them (P=0.603). The best DI were IGTVPET20% in IGTVMIP or IGTVPET2.0 in IGTVMIP (0.61±0.26 and 0.61±0.25), and there was no significant difference betweenthem(P=0.963). Conclusion The IGTVPET contoured by SUV2.0 or 20% of SUVmax approximate closely to theIGTVMIP in target size and the extent of spatial missing is relatively lower between them, but neither of themcould replace each other in spatial position.[Key words] Non-small cell lung cancer; Fluorodeoxyglucosepositron emission tomography; Four-dimensional computed tomography; Maximum intensity projection;Standardized uptake value

Real-time Profile Based 3D Tumor Volume Generation in Image Guided Cancer Radiation Treatment

Songan Mao (Presenter): Nothing to Disclose , Huanmei Wu PhD : PerkinElmer Inc Varain Inc , George Sandison : Nothing to Disclose , Shiaofen Fang : Nothing to Disclose

PURPOSE

Generating 3D volume of the tumor and critical organs in real-time during image guided radiation treatment willbe of great importance for precise dose delivery and accurate dose calculation. This project will develop analgorithm to generate 3D volume of the tumor and critical organs in real-time for image guided cancer radiationtreatment.

MSRO22-04

MSRO22-05


The markers had been implanted before the 4DCT images were acquired. For any interested time instance, onlythe 3D positions of the markers were acquired (target phase). The 3D volume were reconstructed based on thefollowing procedure. First, based on the motion sequence similarity using the combined amplitude and phaseinformation, the most appropriate phase of the 4DCT is chosen as the source phase. The correspondingdisplacements of markers between the source and target phases are calculated. For each marker, the distancebased weight coefficient displacement vectors are computed based on the marker displacement. The smallerEuclidean distance, the larger weight coefficient will be. For each voxel, the weighted marker displacementvector is applied to predict its new positions in the target phase. Iteratively predicting all the voxels willgenerate the 3DCT at the target phase.

RESULTS

The simulation framework prototype have been implemented. For the validation, a 4DCT phase is randomlychosen as the source image. A non-linear artificial deformation function, which has considered the effect oftarget movement, rotation, and volume deformation, has been applied to the source 3DCT to generate theground truth at the target phase. The marker positions at the target phase can also be computed from thedeformation function. With the target and source marker positions and the source 3DCT, the iterative morphingapproach will predict the 3DCT at the target phase. The voxel level difference between the ground truth andpredicted 3DCT is used to assess the simulation accuracy. In one simulation, the average voxel coordinatedifferences averaged over 5443 voxels on the directions of the x, y, z-axis are 0.31, 1.10 and 0.19 pixels,respectively. The average Euclidean distance between the corresponding voxels is 1.3 pixels.

CONCLUSION

The proposed algorithm can simulate and accurately predict 3D volume information in real-time situation, whichis potentially useful for image guided cancer radiation treatment.


NA

Stage I Lung Cancers Treated with Stereotactic Body Radiation Therapy (SBRT): Comparable Resultsin a South-east Asian Population

Seng Hup Chia MBChB (Presenter): Nothing to Disclose , Su Woon Kim : Nothing to Disclose , Kam Weng Fong : Nothing to Disclose , Whee Sze Ong : Nothing to Disclose , Swee Peng Yap : Nothing to Disclose , Tian Rui Siow : Nothing to Disclose , Anuradha Thiagarajan : Nothing to Disclose , Yoke Lim Soong : Nothing to Disclose

ABSTRACT

ObjectivesStereotactic body radiation therapy (SBRT) is a well established treatment option for medically inoperable stageI lung cancer patients. Several studies have shown its benefits in local control and survival. We report the firstoutcomes of lung cancer patients treated with SBRT at our institution and the factors that influence the outcome.Materials and methodsAll stage 1 lung cancer patients treated with SBRT since the technique was introduced in our hospital wasretrospectively reviewed. Patients were identified using radiotherapy department electronic records and thedetails of patient characteristics, diagnosis and treatments were collected. Survival distributions were estimatedusing Kaplan-Meier method and univariate Cox regression analyses were performed. Toxicities were gradedusing common terminology criteria for adverse events (CTCAE) version 4.ResultsA total of thirty five stage I lung cancer patients were treated with SBRT between May 2009 and November2012. Median follow-up was 20.3 months. Thirty four patients (97%) had biopsy proven primary lung cancer.Twenty one patients (60%) were treated with 48 Gy in 4 fractions and the remaining patients were treated with60 Gy in 5 fractions. At the time of analysis three patients developed local relapse and seventeen developedregional and/or distant relapse. Thirteen deaths were observed of which ten were due to lung cancer. Localrelapse free survival, overall survival (OS) and cancer specific survival (CSS) at 2 years was 85 %, 65.4 % and70 % respectively. Univariate analysis showed significantly higher rates of OS in patients who underwentpre-treatment PET-CT scan (HR 0.23, 95% CI: 0.07 - 0.72; p=0.006). Higher numbers of regional and distantrelapses were seen in stage IA patients where only 68% of the patients underwent PET scan compared to 100% in stage IB (HR 0.21, 95% CI: 0.05-0.98; p=0.033) The presence of an active synchronous cancer wasassociated with lower rates of OS (HR 10.78, 95% CI: 1.95 - 59.69; p=0.001). Clinically significant grade 2 andabove toxicities were seen in rib fracture (11%), dyspnoea (12%), cough (9%), pleural effusion (9%), chestwall pain (6%) and fatigue (3%).ConclusionsSBRT remains an important treatment option for medically inoperable stage I lung cancer patients.Pre-treatment PET-CT scan has a significant association with survival. This could be accounted for by theimproved staging accuracy and is thus recommended for all patients planned for SBRT.

Stereotactic Ablative Body Radiation Therapy (SABR) Using Volumetric Modulated Arc Therapy toEarly Stage Non-small Cell Lung Cancer (NSCLC) And Lung Oligometastases. Brazilian SingleInstitution Early Experience and Clinical Outcomes

Lisa Morikawa : Nothing to Disclose , Ernani Anderson MD (Presenter): Nothing to Disclose

ABSTRACT

Purpose/Objectives: Although radiotherapy technology is advancing rapidly, the availability of some new

MSRO22-06

MSRO22-07

techniques such as Volumetric Modulated Arc Therapy (VMAT) remains low in Brazil due to their highimplementation costs. Others such as SABR are still not covered by any health insurers in the country. The aimof this study is to report the preliminary clinical outcomes and toxicity of SABR delivered to early stage NSCLCand lung oligometastases using VMAT without a rigid imobilization system.Materials/Methods: Between March2012 and November 2013, a total of 20 lung lesions were treated with SABR in 18 patients (16 by VMAT and 2by 3D conformal technique). Among these lesions, 13 (65%) were peripheral and 7 (35%) were centrallylocated. Histology was proven in 17 patients (12 adenocarcinoma, 4 squamous cell carcinoma, 4 others).Median age was 75 years old (53 - 88). Serial PET scans and/or CT scans confirmed local control (LC). No 4DCTwas used, instead ins-expiration technique or slow imaging acquisition using a conventional CT scan wereemployed. The dose/fractionation regimes most used were: 50-60 Gy in 5 fractions (BED 100-132 Gy10) and60Gy in 8 fractions (BED 105 Gy10). Median ITV-PTV margin was 5 mm. Dose was prescribed to the median97% isodose. Cone-beam CT was used for lesion localization and no fiducials were utilized. All patients weretreated using a low-cost and simple setup: thin mattress, wing board and knee support.Results: The medianfollow-up was 12 months (1 - 19). Two patients died, giving a crude overall survival rate of 89%. The cause ofdeath was progression of disease in 1 patient. There was evidence of in-field disease progression in only 1lesion giving a crude local control rate of 95%. This local progression occurred in the lesion located close to thediaphragm on a patient with 2 primary lung lesions. Treatment was well tolerated and there were nointerruptions because of acute toxicity. Pulmonary late complication of NCI-CTC grade >=3 was noted in 1patient who had a single lung.Conclusions: SABR using VMAT is a feasible and well-tolerated treatment in earlystage NSCLC and for selected patients with lung oligometastatic disease. Due to the inexpensive setup and fastdelivery provided by VMAT, which maximized the number of patients treated per machine, individual costs weresignificantly reduced thus making it feasible for patients to privately afford SABR in our reality. Although no4DCT was used, LC rates were excellent in this series. Nonetheless, a longer follow up is needed to confirm ourfindings.

The Effects of Abdominal Compression on the Motion and Volume of the GTV, Lungs and Heart inLung Cancer Patients Using 4DCT

Abdullah Rasheed (Presenter): Nothing to Disclose

ABSTRACT

Purpose/Objective(s): Lung cancer tumors exhibit motion during respiration, complicating the delivery ofradiation therapy (RT). The abdominal compression plate (ACP) is thought to mitigate this clinical problem bycontrolling respiratory motion. This study intends to quantify the effect of ACP on respiratory-induced motionby evaluating volume and displacement changes of the heart, lungs, and tumor with and without ACP asdemonstrated by 4DCT.Materials/Methods: Lung cancer patients (n=17) received 4DCT simulation scans (10CTs from 0%-90% breathing phases) with and without ACP. Maximally tolerated diaphragmatic pressure wasapplied and tumor motion was visualized by fluoroscopy. The gross tumor volume (GTV), heart and lungs werecontoured in treatment planning software for each of the 10 phases. Structures were exported for externalalgorithmic analysis. For each phase of the 4DCT with and without ACP, tumor and organ absolute centroidrange of motion, 3D centroid displacement from the average, and volume were calculated. Parametric Student'st-test comparing the motion and volume with and without ACP were conducted with significance set atp<0.05.Results: 9 patients (53%) had upper lobe tumors, 4 (24%) had middle lobe tumors and 4 (24%) hadlower lobe tumors. Averaged across all patients, centroid range of motion for GTV, heart, and lungs withoutcompression was 4.77 ± 4.75 mm, 5.92 ± 2.13 mm and 6.99 ± 2.79 mm, respectively and 4.80 ± 3.85 mm,5.65 ± 1.99 mm and 5.99 ± 3.19 mm, with compression, respectively. With ACP use, GTV centroiddisplacement was reduced in 3 patients (17.6%; 3 upper lobe tumors) by a mean of 1.13 mm (p<0.01),increased in 5 patients (29.4%; 3 upper lobe tumors, 1 middle lobe, 1 lower lobe) by a mean of 0.87 mm(p<0.01), and not significantly changed in 9. Of the 8 patients with a significant change in GTV centroiddisplacement, on average, all exhibited increased mean GTV volume and decreased centroiddisplacement/mean volume of the heart and lungs.Conclusions: ACP efficacy is patient specific, with variationpossibly attributable to preexisting factors such as COPD severity, chest wall elasticity, lung tumor location, orpatient comfort. Tumor lobe location does not pre-determine compression efficacy. Patients should be simulatedwith and without ACP, regardless of tumor location, to grossly assess feasibility of ACP use. It appears that GTVmotion is most important in determining whether a patient is suitable for compression. Of the 8 patients with asignificant change in GTV motion (increased or decreased), on average, all experienced improved motion andvolume control of the heart and lungs. Alternative motion control should be considered in patients who do notbenefit from compression. In patients who clearly benefited, ACP may enhance tumor coverage whileminimizing toxicity to surrounding organs. Larger scale studies are necessary to make definitive treatmentrecommendations.

Documentation of Clinical Radiotherapy Lung Target Motion Beyond the Treatment Planning InternalTarget Volume

Joseph Charles Barbiere MS (Presenter): Nothing to Disclose

ABSTRACT

Purpose: Recent studies have questioned whether the traditional internal target volume (ITV)defined by a four-dimensional computed tomography (4DCT) accurately represents all the motionactually present during radiotherapy. Unpredictable variations in breathing pattern combined withpoor sampling during a single 4DCT are often cited as the leading causes for underestimating theITV. Numerous phantom studies have correlated variation of motion parameters with computed ITV.However, clinical studies based on a limited data set may not represent a complete motion history.The purpose of our work is to present a methodology using routine daily imaging that can be usedretrospectively to document if the target motion ever exceeded the treatment planning ITV. Byperforming a large series of such studies an institution can realistically asses the selection ofappropriate margins. Our hypothesis is that a large series of free breathing CTs are a betterrepresentation of all possible target motion than a limited series of 4DCTs.Method: A T1 NSCLC patient had a Philips Bellows 4DCT (0.071 pitch, 0.5 sec per rotation), a freebreathing CT, and contoured using Philips Pinnacle. Target contours on the left side were drawn on asingle representative phase using automated density thresholding to avoid user bias. The targetcontours were converted to a mesh and propagated automatically to all other phases. The center ofmass for each phase target was computed. The ITV4D was constructed as the sum of all ten phasetargets and associated with the free breathing CT.The patient was treated using TomoTherapy with daily imaging. Thirty-two daily MVCTs (10 sec per

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rotation, 0.6 mm/sec couch speed) were transferred to Pinnacle. Each MVCT was registered to thefree breathing planning CT concentrating mainly on the spine and lungs. It was not possible toautomatically propagate the ITV4D to each of the MVCT due to differences in quality but anexperienced user manually placed the reference mesh in each study so that all visible target wasincluded. The treatment internal target (ITVRT) was constructed as the sum of all MVCT targets andalso associated with the free breathing CT.Results: The center of mass motion in the 4DCT target was as expected, approximately 10.0 mmSup-Inf, 4mm Ant-Post, and 1.5 mm Rt-Lt.The ITV4D volume was 5.93cm3 and ITVRT was 10.24 cm3, an increase of 72.7%. This dramaticdifference may be accentuated by motion due to the targets proximity to the heart.The ITVRT expansion from the ITV4D was approximately 2.8 mm Sup-Inf, 5.8mm Ant-Post, and 8.9mm Rt-Lt.Conclusions: The methodology presented in this work can be used with any daily CT imagingtechnique. Careful analysis of an entire course may reveal that some proposed ITV4D tight marginsunder 10 mm may be inappropriate.

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Chest (Lung Nodule) Scientific PapersNM CT CH AMA PRA Category 1 Credits ™: 1.50


Mon, Dec 1 10:30 AM - 12:00 PM Location: S404AB

ParticipantsModeratorCornelia Maria Schaefer-Prokop MD : Advisory Board, Riverain Technologies, LLC ModeratorDavid F. Yankelevitz MD : Research Grant, AstraZeneca PLC Royalties, General Electric Company

Sub-Events Dual Time-point and Respiratory-gated 18FDG PET/CT in the Characterization of IndeterminatePulmonary Nodules

Jonathan Hero Chung MD (Presenter): Research Grant, Siemens AG Royalties, Amirsys, Inc , Demitry Kazlouski : Nothing to Disclose , Hope McGee : Nothing to Disclose , Ramya Rajaram : Employee, SiemensAG , David Augustine Lynch MBBCh : Research support, Siemens AG Scientific Advisor, PAREXEL InternationalCorporation Consultant, Boehringer Ingelheim GmbH Consultant, InterMune, Inc Consultant, Gilead Sciences,Inc Consultant, F. Hoffmann-La Roche Ltd Consultant, Veracyte, Inc Research support, Johnson & JohnsonResearch support, AstraZeneca PLC

PURPOSE

Previous studies have shown mixed results in the setting of dual time-point 18FDG PET in characterizingindeterminate pulmonary nodules as benign or malignant. The purpose of this study was to determine ifrespiratory gating would increase the accuracy of the dual time-point PET technique in characterizingindeterminate pulmonary nodules.


Subjects with pulmonary nodules ranging in size from 6-20 mm, being evaluated with 18FDG PET/CT wereprospectively recruited for our study. Subjects were imaged with 18FDG PET/CT one and two hours afterinjection of approximately 15 mCi 18FDG using static and phase-based respiratory-gated techniques. Themaximum SUVs of pulmonary nodules were measured on static PET images as well as for every gate ofrespiratory-gated PET images. Malignancy or benignity was determined by tissue biopsy or follow-up imaging.

RESULTS

There were 29 malignant and 78 benign nodules. The maximum SUV of malignant nodules was statisticallyhigher than that of benign nodules at the first (8.35+/- 7.29 vs. 2.34 +/-2.13) and second (10.39 +/- 8.91 vs.2.55 +/-2.42) hour time points (p-values <0.0001). The percentage change in the maximum SUV values forrespiratory-gated data (19.3% +/- 30.2% vs 7.5% +/- 20.1%, p-value 0.0210) and static data (23.3% +/-60.0% vs 3.8% +/- 23.0%, p-value 0.0161) from 1st to 2nd time points was significantly higher in malignantthan benign nodules. This relationship persisted even when considering nodules with a maximum SUV ofgreater than 3.0 (with gating: 29.0% +/-23.7% vs 9.9% +/- 29.0%, p-value 0.0107; without gating: 32.3%+/-53.3% vs 2.0% +/- 26.9%, p-value 0.0217).

CONCLUSION

There is a statistical difference in percentage change of maximum SUV values from 1st to 2nd time pointsbetween malignant and benign pulmonary nodules for both respiratory-gated and static PET images. Thisrelationship persists even when considering pulmonary nodules with substantial 18FDG uptake (maximum SUVgreater than 3.0). There was less dispersion of percentage change of maximum SUV across time points withthan without respiratory gating (standard deviation of 30% compared to 60%).


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A dual-time point technique may be helpful in characterizing indeterminate pulmonary nodules as malignant orbenign even in nodules with substantial 18FDG uptake.

Accuracy and Potential of Maximum Standard Uptake Value in the Diagnosis of Solitary Lung Nodules

Alberto Bazzocchi MD : Nothing to Disclose , Stefano Brocchi MD (Presenter): Nothing to Disclose , Valentina Ambrosini : Nothing to Disclose , Giancarlo Facchini : Nothing to Disclose , Salvatore Ascanio : Nothing to Disclose , Giuseppe Battista : Nothing to Disclose , Stefano Fanti MD : Research Consultant,Siemens AG Advisory Board, Bayer AG

PURPOSE

Criticisms and limitations of standard uptake value (SUV) in positron emission tomography (PET) imaging arewell known. Our aim was to investigate the role of SUVmax in the detection of malignancy of solitary lungnodules and to study its potential prognostic value.


We retrospectively analyzed the clinical history of 1010 patients (657 males, 353 females, 72.6±11.8 year-old)who were submitted to PET/CT for solitary lung nodules, between January 2002 and May 2012 in a singlecentre. The analysis included the evaluation of images and physicians' reports of PET/CT exams, anamnesis ofpatients and subsequent diagnostic examinations in their follow-up (imaging, biopsy specimen and/orpathological analysis after surgical resection). Follow-up of all patients ended with survival control at the time ofthe present study. Receiver operating characteristic (ROC) curves and Kaplan-Meier method were used forstatistical analysis.

RESULTS

In 457/1010 (45.2%) subjects a non-small cell lung cancer (NSCLC) was diagnosed; in all other patients553/1010 (54.8%) lesions were classified as non-oncologic diseases or benign. Area under the ROC curve was0.956, with SUVmax cut-off value of 2.3, resulting in 93.6% and 90.4%, sensitivity and specificity respectively.The survival analysis was possible in 459 patients (217/459 NSCLC), with a mean follow-up of 70.2±30.34months. Nodules with higher SUVmax value (>2.3) were associated with lower survival rate (p<0.0001): forSUVmax >2.3 and <2.3 the survival rates 1 year after PET imaging were respectively 75% and 94%, at 2years after PET 59% and 90%, while survival expectancies at 3 years were 51% and 85%. The outcome wasindependent from the dimension of the lesion or from surgical/non-surgical treatment approach.

CONCLUSION

In conclusion, our single-centre experience showed that a cut-off value of 2.3 SUVmax is a very accuratemarker for prognosis stratification in patients with solitary lung nodules.


The detection of a solitary lung nodule is common and its management critical. A PET/CT scan is often requiredto guide the clinicians in the management of such patients. The use of SUVmax from PET/CT imaging in a locallarge population showed to be very accurate in differentiating malignant from benign lesions and it deservesconsideration in predicting patients prognosis.

Pulmonary Nodule Detection in Patients with a Primary Malignancy Using Hybrid PET/MRI: Is thereValue in Adding Gadolinium-enhanced MR Imaging?

Kyunghee Lee MD (Presenter): Nothing to Disclose , Chang Min Park MD, PhD : Nothing to Disclose , JinMo Goo MD, PhD : Research Grant, Guerbet SA , Sang Min Lee : Nothing to Disclose , Gi Jeong Cheon : Nothing to Disclose , Jeong Min Lee MD : Research Grant, Guerbet SA Equipment support, Siemens AGResearch Grant, Bayer AG , Jeong Yeon Cho MD : Nothing to Disclose

PURPOSE

To investigate the added value of a gadolinium-enhanced VIBE (radial volumetric interpolated breath-holdexamination) sequence to hybrid PET/MR imaging for the detection of pulmonary nodules in patients with aprimary malignancy.


This retrospective HIPAA-compliant institutional review board-approved study included 51 consecutive patientswho underwent 18F-fluorodeoxyglucose (FDG) PET/MR imaging followed by PET/CT for staging work-up. In allpatients, the thorax station was examined with pre-and post-contrast VIBE MR imaging and PET data weresimultaneously acquired. Two readers blinded to the patient data independently recorded their levels ofsuspicion for the presence of a pulmonary nodule on a five-point scale based on PET, pre-contrast VIBE, andPET/MR images (1st session), and reassessed them 4 weeks later after addition of the post-contrast VIBEsequence (2nd session). Jackknife alternative free-response receiver-operating characteristic (JAFROC) analysiswas performed to evaluate detection accuracy. PET/CT served as the reference standard for the presence andsize of nodules.

RESULTS

On PET/CT, a total of 151 pulmonary nodules were detected including 43 FDG-avid nodules and 61 nodules>0.5 cm in diameter. In the first session, the average nodule detection rate was 53.3% for all nodules, 100%for FDG-avid nodules, and 87.7% for nodules >0.5 cm in diameter. In the second session withgadolinium-enhancement, the average nodule detection rate was 53.3% for all nodules, 100% for FDG-avid

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nodules, and 85.2% for nodules >0.5 cm in diameter. The average JAFROC figure of merit was 0.837 in thefirst session and 0.848 in the second session. There were no significant differences in detection accuracybetween the first and second sessions (P = 0.48).

CONCLUSION

The addition of gadolinium-enhanced MR imaging to hybrid PET/MR imaging provided no additional value in thedetection of pulmonary nodules.


For the simple purpose of lung nodules detection, T1-weighted gradient-echo MR sequence (VIBE) may notnecessitate additional contrast media injection for thoracic imaging in hybrid PET/MR.

Staging Workup for Patients with Pure Ground Glass Nodular Adenocarcinomas: Are PET/CT andBrain MRI Mandatory?

Hyoun Cho MD (Presenter): Nothing to Disclose , Ho Yun Lee MD : Nothing to Disclose , Kyung Soo Lee MD, PhD : Nothing to Disclose , Byung-Tae Kim MD : Nothing to Disclose , O. Jung Kwon : Nothing toDisclose , Joungho Han : Nothing to Disclose , Jhingook Kim : Nothing to Disclose

PURPOSE

As a staging workup for pure ground glass opacity (GGO) nodular adenocarcinoma, the role of 18F-FDG PET/CTscanning or brain MRI has been questioned. The purpose of this study was to determine the value of 18F-FDGPET/CT and brain MRI for the preoperative staging of lung adenocarcinoma manifesting as pure GGO.


164 patients (M:F=73:91; mean age=62) with lung adenocarcinoma manifesting as pure GGO who underwent18F-FDG PET/CT or brain MRI before surgery were included. Pathologic findings for nodal staging and pathologicor follow-up imaging findings for M staging were reference standards.

RESULTS

Among all 175 tumors, 34 were adenocarcinoma in situ (19 %), 54 were minimally invasive adenocarcinoma(31 %) and 87 were invasive adenocarcinoma (50 %). The most frequently observed histologic subtypes, indecreasing order, were lepidic (69%), acinar (26%), and papillary (5%). On PET/CT scan, abnormalFDG-uptake of lymph node was found in two of all 136 patients (1.5%), which were negative on final pathology.Abnormal FDG-uptake of liver was detected in one patient, which was also negative confirmed by dedicatedabdomen CT. No brain metastasis was found in brain MRI of all 109 patients. The median follow-up time was36.7 months, and only one patient (0.9%) developed brain metastasis after surgical resection.

CONCLUSION

18F-FDG PET/CT and brain MRI add little values in the staging of lung adenocarcinoma manifesting as pure GGO.


Lung adenocarcinoma manifesting as pure GGO do not require 18F-FDG PET/CT scan nor brain MRI for staging.

Textural Analysis and Imaging Features to Differentiate Benign from Malignant Pulmonary Nodules

Jean SZ Lee MRCP, MBBChir (Presenter): Nothing to Disclose , Lyndsey Clare Pickup MEng, DPhil : Employee, Mirada Medical Ltd , Eugene Jueren Teoh MRCP, FRCR : Nothing to Disclose , James Franklin MA, MBBS : Nothing to Disclose , Aymeric Larrue PhD : Employee, Mirada Medical Ltd , Mark John Gooding MENG, DPhil : Employee, Mirada Medical Ltd , Timor Kadir : Employee, Mirada Medical Ltd , Fergus Vincent Gleeson MBBS : Alliance Medical Ltd Consultant

PURPOSE

Differentiating benign from malignant pulmonary nodules is critical in the management of patients withpulmonary nodules. The purpose of this study was to investigate the use of textural and imaging features todifferentiate pulmonary nodules using machine learning methods.


33 patients with histology-proven pulmonary nodules were included. All patients underwent a volumetric chestCT (VCT) scan, with first dynamic contrast-enhanced chest CT (dceCT) and PET-CT scans. 23 (71.9%) weremalignant. Nodules were manually contoured on the VCT and baseline dceCT scans, and propagated to theremaining scans using deformable image registration (Mirada XD, Mirada Medical, Oxford, UK). Imagingmeasures, such as maximum and mean intensity, and textural features, such as kurtosis or fractal dimension,were calculated considering both the full-nodule volumes and sub-volumes inside and outside the drawncontours. Volume doubling time (VDT) and SUV/TLG statistics for PET were also included to create large featurevectors with several hundred entries per nodule. Gaussian distributions were fitted to subsets of 2-3 features forthe malignant and benign training populations separately. A leave-one-out paradigm was adopted (train onall-but-one datapoints; test on the withheld one). Each test nodule was classified as belonging to whichever

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all-but-one datapoints; test on the withheld one). Each test nodule was classified as belonging to whicheverpopulation gave a higher likelihood score given its feature vector.

RESULTS

32/33 (97%) nodules were correctly classified as cancer/benign under the leave-one-out paradigm. The 3optimal features were a "fractalness" measure on the nodule at 2 minutes post-contrast, the minimum intensitywithin the nodule at 4 minutes post-contrast, and a skewness measure on the core of the nodule (defined asareas not within a small distance of the contour boundary) also at 2 minutes post-contrast. These featuresremained optimally discriminative when the nodule dataset was entirely re-contoured by an independentresearcher.

CONCLUSION

Textural analysis and imaging features using machine learning methods can help differentiate benign frommalignant pulmonary nodules and help guide management.


Differentiation of benign and malignant pulmonary nodules is a common clinical problem that may be helpedusing textural analysis and imaging features.

Computer Extracted Texture Features on CT Predict Level of Invasion in Ground Glass Non-SmallCell Lung Nodules

Mahdi Orooji PhD (Presenter): Nothing to Disclose , Mirabela Rusu DPhil, MENG : Nothing to Disclose , Prabhakar Rajiah MD, FRCR : Institutional Research Grant, Koninklijke Philips NV , Michael Yang : Nothingto Disclose , Frank Jacono : Nothing to Disclose , Robert C. Gilkeson MD : Research Consultant, RiverainTechnologies, LLC Research support, Koninklijke Philips NV Research support, Siemens AG , Philip Aaron Linden: Nothing to Disclose , Anant Madabhushi MS : Research partner, Siemens AG Research partner, GeneralElectric Company Research partner, F. Hoffmann-La Roche Ltd Founder and President, IbRiS, Inc

PURPOSE

Radiographic characteristics to reliably define the degree of invasion of early Non-Small Cell Lung nodules withground glass opacity (GGO) components on CT have yet to be reliably defined. Our goal is to identifyquantitative computer extracted image texture features to distinguish GGO nodules with no/minimal invasionfrom those with frank invasion on pre-operative CT. Computer-extracted texture features quantitativelydescribe the spatial arrangement of intensities in an image and have been shown to distinguish benign frommalignant nodules. In this study we evaluate the utility of computer extracted texture features in distinguishingGGO with no/minimal and frank invasion.


We used a retrospective cohort of 33 slices (15 no/minimal and 18 frank) of in vivo lung CT from patients whohad surgical resection. All nodules measured less than 16 mm in diameter. The size of the invasive componentwas utilized to stratify the nodules in the no/minimal (<5mm) or invasive category (>5mm invasion). A total of63 of computer extracted texture features including gray-level statistical, steerable Gabor, Haralick, and Lawswere obtained on CT from the manually delineated nodule. Following feature extraction, the total number offeatures was reduced from 63 to 3 via principal component analysis.

RESULTS

Three texture features, Inertia, Correlation and Difference Entropy, were selected by the classifier, providing anarea under the receiver operating characteristic curve (AUC) of 0.92 for distinguishing on CT the no/minimalinvasion nodules from the frank invasion tumors. By comparison, Laws features provided an AUC of 0.61 andGabor features yielded an AUC of 0.68.

CONCLUSION

Texture analysis of CT scan showed reasonable discrimination of level of invasion in the context of GGOcancerous lung nodules.


Computerized image analysis of in vivo CT may allow for identification of computer extracted CT featuresassociated with no/minimal and frank invasion in GGO lung nodules. It has the potential to impact clinical,economic, and societal burden of lung cancer by increasing average 5-year survival rate from early detection ofinvasive nodules, significant economic benefits to the health care system by reduction in unnecessaryinterventions, better image analytics can potentially reduce dependence on repeat or higher resolution CTexams, and noninvasive means of assessing response to targeted therapies.

Ground Glass Nodule Detectability on Ultra-Low dose Computed Tomography (CT) with AdaptiveIterative Dose Reduction Using 3D Processing: Comparison with Low-dose CT by Receiver-OperatingAnalysis Based on Nodular Characteristics and Location

Yukihiro Nagatani MD (Presenter): Nothing to Disclose , Masashi Takahashi MD : Nothing to Disclose , Mitsuru Ikeda MD : Nothing to Disclose , Tsuneo Yamashiro MD : Nothing to Disclose , Hisanobu Koyama MD, PhD : Nothing to Disclose , Mitsuhiro Koyama MD : Nothing to Disclose , Hiroshi Moriya MD : Nothing to Disclose , Kiyoshi Murata MD : Nothing to Disclose , Sadayuki Murayama MD, PhD : Nothing toDisclose

PURPOSE

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PURPOSE

To compare ground glass nodule detectability (GGND) on computed tomography (CT) with adaptive iterativedose reduction using three dimensional processing (AIDR3D) between ultra-low dose scanning (ULDS) and lowdose scanning (LDS) and analyze association of GGND with nodular characteristics and location.


This was part of the Area-detector Computed Tomography for the Investigation of Thoracic Diseases (ACTIVe)Study, a multicenter research project being conducted in Japan. The Institutional Review Board of eachinstitution approved this study and written informed consent was obtained. In a single visit each, 68 subjectsunderwent multi-detector chest CT (64-row helical mode) at a gantry rotation speed of 0.35-sec with 3 differenttube currents: 240,120 and 20 mA (2.51, 1.26 and 0.21mSv, respectively). Axial CT images with 2-mmthickness and increment were reconstructed using AIDR3D. Standard of reference (SOR) as to GGN presencewith the longest diameter (LD) of 3mm or more was determined based on CT images at 240mA by consensusreading of 2 radiologists. Another 4 radiologists independently recorded GGN presence and their characteristicsby continuously-distributed rating on CT images at 20mA (ULDS) and 120mA (LDS). Receiver-operatingcharacteristic (ROC) analysis was used to evaluate GGND of both methods in total and subgroups classified bynodular LD (>5mm), characteristics (pure and mixed) and locations (ventral/intermediate/dorsal,central/peripheral and upper/middle/lower).

RESULTS

For SOR, 22 mixed and 86 pure GGN were identified. No significant difference in GGND with LD of 5mm or morewas shown between both methods, as area under ROC curve was 0.96±0.02 in ULDS and 0.97±0.01 in LDS.For the entire mixed GGN, GGND was almost the same, as area under ROC curve was 0.97±0.02 in bothmethods. Inter-observer variance of GGND with LD of 5mm or more was not demonstrated among 4 radiologistsin 5 locations except for lower, peripheral and intermediate locations.

CONCLUSION

It was demonstrated that ULDS with AIDR3D had comparable GGND to LDS with AIDR3D except for pure GGNwith LD of less than 5mm.


ULDS with AIDR3D has a sufficient potential to be used for GGN screening except for smaller ones without solidpart.

Automatic Classification of Perifissural Pulmonary Nodules in Thoracic CT Images

Francesco Ciompi PhD (Presenter): Nothing to Disclose , Bartjan De Hoop MD : Nothing to Disclose , Colin Jacobs MSc : Research Grant, MeVis Medical Solutions AG , Mathias Prokop MD, PhD : SpeakersBureau, Bayer AG Speakers Bureau, Bracco Group Speakers Bureau, Toshiba Corporation Speakers Bureau,Koninklijke Philips NV Research Grant, Toshiba Corporation , Pim A. De Jong MD, PhD : Nothing to Disclose , Bram Van Ginneken PhD : Stockholder, Thirona BV Co-founder, Thirona BV Research Grant, MeVis MedicalSolutions AG Research Grant, Canon Inc Research Grant, Toshiba Corporation Research Grant, RiverainTechnologies, LLC

PURPOSE

Up to one third of pulmonary nodules detected in heavy smokers are perifissural nodules (PFNs) that do notrequire follow-up. An automatic method is presented to distinguish PFNs from solid nodules.


We used all baseline scans with a pulmonary nodule from one of the sites of the NELSON trial. All participantswere either current or former heavy smokers (age between 50 and 75 years), and underwent low-dose CT(Mx8000 IDT 16; Philips Medical Systems, Cleveland, Ohio). Experts annotated non-calcified solid nodules in1,729 scans, and classified these as PFN (788) and non-PFN (3,038). We formulated PFN classification as amachine learning problem where a classifier is trained to automatically label nodules as PFN or non-PFN. Giventhe characteristic triangular-like shape of PFNs, a novel descriptor encoding information on nodule morphologywas designed. The descriptor is based on frequency analysis of intensity profiles sampled in the CT image.Given a detected nodule, spherical surfaces up to a maximum radius R are considered, centered on the centerof mass of the nodule. For each sphere, the image intensity is sampled along C circular profiles on the surfaceof each sphere at constant angular distance. The profiles are interpreted as a periodic signal, and their spectrumis obtained using a Fast Fourier Transform. Each spectrum encodes information on nodule morphology throughcharacteristic frequencies. A set of K spectral signatures is computed applying K-means on the collection ofspectra. A compact nodule descriptor is obtained as the histogram of spectral signatures along the spheres. ARandom Forests classifier with 100 trees was used for supervised learning. A 10-folds cross-validation schemewas applied to evaluate the method on the 3,826 nodules, using C=128, K=100. Since the range of PFNsdiameters is 2.8-10.6 mm, we used R = 7.5 mm.

RESULTS

We obtained a value of area under the ROC curve of 0.85, with an optimal operating point of 77% sensitivityand 79% specificity. Misclassified PFNs were often close to the pleura or to other vascular structures.

CONCLUSION

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Classification of pulmonary nodules as PFN is feasible and has the potential to be used as an automatic tool inCAD.


PFNs rarely turn out to be malignant, even though their growth rate is similar to that of malignant nodules.Automatic recognition of PFNs could reduce the number of unnecessary follow-up CT exams.

CT Nodule Enhancement Pattern in Patients after SABR

William Henry Moore MD (Presenter): Research Grant, EDDA Technology, Inc Medical Board, EDDATechnology, Inc Research Grant, Galil Medical Ltd Research Grant, Endo Health Solutions Inc , Ammar Ahmed Chaudhry MD : Nothing to Disclose , Yair Chaya MD : Nothing to Disclose , Thomas Bilfinger MD : Nothing to Disclose , Samantha D. Glass MD : Nothing to Disclose , Sarel Gaur MD : Nothing to Disclose , George Mikhail MD : Nothing to Disclose , Kevin S. Baker MD : Nothing to Disclose , Bong S. Kim MD : Nothing to Disclose

PURPOSE

To evaluate whether the pattern of nodule enhancement on delayed contrast-enhanced CT performed afterStereotactic ablative Radiotherapy (SABR) for early-stage lung cancer can differentiate individuals withrecurrence from non-recurrence.


A retrospective study was performed evaluating a total of 81 patients who underwent SABR for primary stage Ior II lung cancer with follow-up contrast chest CT at 1, 3, 6, 12, 18, and 24 months. The size of the ablationzone was measure in addition CT density of the nodules were obtained pre-contrast and at 30 seconds and 1, 2,3, and 4 minutes post contrast injection at each follow-up. Each ablation zone was measured five times using auniform region of interest pre-contrast and at each time point after contrast. The mean attenuation of these fivepoints was recorded. The CT bed position was used to ensure that the same area was interrogated with eachsubsequent time point.

RESULTS

60 patients were included in this study. 49 patient without evidence of recurrence and 11 patients later provento have recurrent lung cancer in the ablation zone. In the recurrence group there was a peak of enhancementseen with rapid washout. Specifically ,at 1 month the mean attenuation of the ablation zone in the recurrencegroup was 10 HU pre-contrast with a peak in attenuation of 35 HU at 1 minute with an attenuation of 18 HU at4 minutes. The non-recurrence group showed a mean attenuation of -13HU pre-contrast and a peak attenuationof 47 HU at 4 minutes the mean peak attenuation. Similar findings were seen at each 3, 6 and 12 mothfollow-up CT scans. Using a paired-samples student t-test, there was no statically significant difference in thechange in attenuation .

CONCLUSION

The absolute change in attenuation is a poor discriminator of recurrence from non-recurrence. However, thereis a difference in the pattern of enhancement. The patients with evidence of recurrence showed an early peak inenhancement and then a washout of contrast. While patients without recurrence showed continued increase inattenuation over time. This is similar to the patterns seen in other malignancies comparing malignancy toinflammatory masses.


Enhancement pattern changes associated with treatment of lung cancer with SABR may assist in evaluatingpotential early recurrence where a change in treatment can most affect prognosis.

CHS-MOA

Chest Monday Poster Discussions Scientific PostersCH AMA PRA Category 1 Credits ™: .50

Mon, Dec 1 12:15 PM - 12:45 PM Location: CH Community, Learning Center

ParticipantsModeratorPrachi P. Agarwal MD : Nothing to Disclose

Sub-Events Lung Volume and Heterogeneity: CT Quantification of Lobar Contribution (Station #1)

Mario Silva MD : Nothing to Disclose , Stefan Franz Nemec MD : Nothing to Disclose , Benedikt H Heidinger MD (Presenter): Nothing to Disclose , Mariaelena Occhipinti MD : Nothing to Disclose , Valerie Dufresne : Nothing to Disclose , Francesco Molinari MD : Nothing to Disclose , Alexander A. Bankier MD,PhD : Author with royalties, Reed Elsevier Consultant, Olympus Corporation

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CHS242

PURPOSE

To quantify the contributions of individual lobes to lung volume and to characterize quantitative morphologicalmetrics associated with these volumes.


17 healthy volunteers underwent spirometrically monitored volumetric chest CT at total lung capacity (TLC),functional residual capacity (FRC), and mean inspiratory capacity (MIC), measured half-way between TLC andFRC. Dedicated software (Pulmo3D, MeVis, Germany) was used to measure lobar volume, lobar mean lungdensity (MLD) and the standard deviation of lobar MLD (MLD-SD), as a surrogate parameter for parenchymalheterogeneity. Differences between groups were tested by t-test and analyses of variance.

RESULTS

The biggest contributors to lung volume at TLC were RLL (27%) and LLL (27%), at MIC RLL (26%) and LLL(26%), and at FRC LUL (25%) and RLL (24%). The smallest contributor in all three respiratory capacities wasthe RML (TLC 8%, MIC 9%, FRC 11%). Relative volumes of lower lobes decreased from TLC to FRC (RLL 27 to24%; LLL 27 to 23%), whereas relative volumes of middle (RML 8 to 11%) and upper lobes (RUL 17 to 18%;LUL 21 to 25%) increased. All CT lung volume changes between TLC, MIC, and TRC were statistically significant(p<0.001). Lobar MLD density was higher in lower lobes, at any lung volume (p<0.001). MLD-SD increasedfrom TLC to FRC, in all lobes (p<0.001), again with different pattern of variation between upper and lowerlobes. Lower lobes showed substantial increase in MLD-SD from TLC to MIC and to FRC. Otherwise, MLD-SD ofupper lobes and right middle lobe were near-identical at any lung volume.

CONCLUSION

Our study provides normative data on absolute and relative lobar contribution to lung volume and lungheterogeneity in normals. The findings confirm the major contribution of the lower lobes to lung volumechanges and reveal that substantial physiological heterogeneity throughout all lobe is a normal finding inhealthy lungs.


Our data provide normative reference values for lobar contribution to lung volume and lung heterogeneity, andcan be used as quantitative benchmark for the evaluation of these parameters.

Impact of Endobronchial Coiling for Lung Volume Reduction on Pulmonary Volume and Attenuation:Pre- and Post-interventional CT-quantification using Separate Lobe Measurements (Station #2)

Ulrich Grosse MD : Nothing to Disclose , Juergen Hetzel : Nothing to Disclose , Lutz Guendel : Employee,Siemens AG , Sergios Gatidis MD : Nothing to Disclose , roland syha : Nothing to Disclose , Christoph Schabel MD : Speaker, Siemens AG , Fabian Springer MD : Nothing to Disclose , Claus Detlef Claussen MD : Nothing to Disclose , Konstantin Nikolaou MD : Speakers Bureau, Siemens AG Speakers Bureau,Bracco Group Speakers Bureau, Bayer AG , Marius Horger MD (Presenter): Nothing to Disclose

PURPOSE

To objectify changes in volume and density of treated and untreated pulmonary lobes following endobronchialcoiling for lung volume reduction (LVR) by comparison with clinical (6 meter walk test [6MWT]) and pulmonaryfunction tests (PFT).


22 lobes in 17 patients (8 men, 9 female; mean age 66.2 ± 5.9 years) with severe heterogeneous emphysemawere treated by endobronchial coils and underwent pre-and post-interventional CT-examinations (inspiratoryand expiratory phase). Clinical response was defined as an increase in the walking distance (6MWT) afterLVR-therapy. PFT measurements with forced expiratory volume in 1 second (FEV1), ratio of residual volumeover total lung capacity (RV/TLC) and single-breath diffusion capacity for carbon monoxide (DLCOSB) wereused for correlation.

RESULTS

Responders (N=14) presented a significant increase (70 ± 11 m) in the walking distance (6MWT) andFEV1-values (61 ± 21 ml). In non-responders, walking distance significantly decreased (70 ± 15 m) and theresults of PFT did not improve. Inspiratory volume (VolIn) of the target lobe significantly decreased (10.0 ±16.4 %; p-value = 0.0245) compared to pre-interventional lobe volume in responders, while no marked volumechange could be detected in non-responders. VolIn of the non-treated ipsilateral lobe significantly increased inresponders (5.5 ± 9.1 %; p-value = 0.0209) while the increase of VolIn of the contralateral lung did not reachstatistical significance.

CONCLUSION

Our results objectify volume reduction of the treated lobe coupled by a significant volume expansion of theipsilateral lobe as a sole correlate for clinical improvement in responders.


CHS243

The results of this preliminary study demonstrate the interplay between treated and untreated lung lobes withrespect to volume and density changes in patients treated with LVR-coils.

Visual Assessment of Calcification of Solitary Pulmonary Nodule (SPN) on Chest Radiography (CXR)According to the Nodule Size: Correlation with MDCT Volumetric Measurement of Calcification(Station #4)

Joo Sung Sun MD : Nothing to Disclose , Eun Young Kim MD (Presenter): Nothing to Disclose , SeonYoung Park MD : Nothing to Disclose , Young Keun Sur MD : Nothing to Disclose , Jin Wook Choi MD : Nothing to Disclose , Eun Ju Ha : Nothing to Disclose , Sung Hoon Park MD : Nothing to Disclose , SungJung Kim : Nothing to Disclose , Tae Sun Han : Nothing to Disclose , Boram Yi MD : Nothing to Disclose , Jae Yong Cho MD : Nothing to Disclose , Hun Cho MD : Nothing to Disclose , Kyung Joo Park MD : Nothing to Disclose

PURPOSE

To correlate MDCT volumetric information of calcification of SPN and visual assessment of calcification of SPN onCXR


Retrospective review of consecutive 221 SPNs that were identified by both CXR and thin-section chest CT.Eleven observers who blinded to the results of CT assessment about calcification reviewed all CXR. They scoredeach nodules with 5 confidence scale in terms of nodule calcification. Reference standard for calcification of SPNwas made by 2 radiologist consensus reading and they were not involved review of CXR. Volumetric informationof calcification was acquired by using commercial software. ROC analysis was done and AUC was obtained toanalyse overall diagnostic performance. For ROC analysis, 2431 nodules (221*11) were used as target nodules.Intraclass correlation coefficient (ICC) for inter-rater reliability was calculated. ROC analysis and ICC werecalculated according to the nodule size. Group1 ( < 10mm),Group2(10~20mm),group3(greater than 20mm).

RESULTS

Among 221 SPNs (mean diameter 13.9mm), a total of 76 SPNs were calcified (34.4%). Average percentage ofcalcification (>=160 HU) in all each 76 calcified nodules was 41.5%. Average percentage of calcification of 17focal calcified nodules and 59 definite benign calcified one was 4.16% (Figure 1) and 49.72% respectively.There was significant correlation between confidence and nodule calcification. Correlation coefficient (r) was0.625 (p < .001). The positive predictive value of a "confidence 5" assessment was 0.95, and the negativepredictive value of a "confidence 1" assessment was 0.952 in case of nodule < 10mm. AUC for group 1, 2, 3 ,and all nodules was 0.835, 0.639, 0.6 ,and 0.71 respectively. AUC for group 1 ( < 10mm) was significantlyhigher than those of group 2 and 3 (p < 0.0001). ICC for group 1, 2, 3, and all nodules, was 0.65, 0.48, 0.33,and 0.51 respectively.

CONCLUSION

Overall diagnostic performance of perception of nodule calcification was best in nodules less than 10mmdiameter. SPNs depicting benign calcification would contain about 50% of calcification in their volume.


Misdiagnosis of non calcified nodule as calcified one on CXR reading could lead bad choice for management ofSPN. Diagnostic performance for identifying calcification is low in case of nodules >= 10mm in diameter, sothat we should carefully evaluate calcification when nodule size is greater than 10 mm.

Ultra-low-dose Chest CT: Should we Acquire it at 80 or 135 kV? A Qualitative and QuantitativeProspective Study on 30 Patients (Station #5)

Claire Lucchetta MD (Presenter): Nothing to Disclose , Aissam Labani MD : Nothing to Disclose , Mi-Young Jeung MD : Nothing to Disclose , Marysa Schaal MD : Nothing to Disclose , Karim Haioun : Employe,Toshiba Corporation , Catherine Roy MD : Nothing to Disclose , Mickael Ohana MD, MSc : Nothing toDisclose

PURPOSE

To qualitatively and quantitatively compare ultra-low-dose (ULD) chest CT acquired at 80 and 135kV.


30 patients (68% men, 55yo ±14) referred for a clinically indicated unenhanced chest CT were prospectivelyincluded. Participants underwent a triple acquisition on a second-generation 320-row scanner: a standard 'fulldose' acquisition (120kV, automated tube current modulation) and two ULD acquisition (80kV with 40mA and135kV with 10mA), all reconstructed with mediastinal and lung kernels using an iterative algorithm (AIDR 3D).ULD acquisition parameters were chosen to achieve the same level of radiation dose between 80 and 135kV.Image quality of both ULD acquisitions was independently and blindly assessed by two chest radiologists, eachreader having to designate for every patient which kV provided the best diagnostic and image quality. Imagenoise was measured within the trachea and compared between both ULD acquisitions with a paired Student ttest. A p<0.05 was considered significant.

RESULTS

Radiation dose was similar between 135kV and 80kV ULD acquisitions, with a mean DLP of 17.2mGy.cm ±1.6and 16.2mGy.cm ±1.5 respectively. DLP of the standard 120kV acquisition was 210mGy.cm ±87. The 135kVULD acquisition was found to be better in 100% of patients for reader 1 and in 97% of patients for reader 2.The agreement between the two readers was almost perfect with a Cohen's κ of 0.98. The noise wassignificantly lower at 135kV than at 80kV (61.5 ±5.7 vs 81.4 ±11.8, p<0.01). Reference noise for standard120kV acquisition was 44.7 ±6.5.

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CONCLUSION

For ULD chest CT, acquisitions made at 135kV are qualitatively and quantitatively better than those made at80kV.


Ultra-low-dose unenhanced chest CT must be acquired with a high kV/low mA technique.

CHS-MOB

Chest Monday Poster Discussions Scientific PostersCH AMA PRA Category 1 Credits ™: .50

Mon, Dec 1 12:45 PM - 1:15 PM Location: CH Community, Learning Center

Sub-Events Prediction of Post-operative Pulmonary Function after Lobectomy for Primary Lung Cancer:Sub-segment Counting Method vs. Lobar Volumetry using Inspiratory/expiratory MDCT Data(Station #1)

Hidetake Yabuuchi MD (Presenter): Nothing to Disclose , Satoshi Kawanami MD : Research Grant, ModestResearch Grant, Bayer AG Research Grant, Koninklijke Philips NV , Takeshi Kamitani MD : Nothing toDisclose , Masato Yonezawa : Nothing to Disclose , Michinobu Nagao MD : Research Grant, Bayer AGResearch Grant, Koninklijke Philips NV , Hiroshi Honda MD : Nothing to Disclose , Yuzo Yamasaki MD : Nothing to Disclose , Yoko Fujita : Nothing to Disclose

PURPOSE

Surgical indication of primary lung cancer based on pulmonary function could be uncertain when the candidatehas underlying conditions such as emphysema or interstitial pneumonia, and conventional segment countingmethod might misjudge the indication. Purpose of this study was to compare the predictive abilities of thesub-segment counting method and lobar volumetry using inspiratory/expiratory MDCT data to assesspost-operative pulmonary function after lobectomy for primary lung cancer.


Twenty-eight patients who underwent lobectomy for primary lung cancer (13 males, 15 females; age range,53-81 years; mean age, 68 years) were enrolled. Inspiratory/expiratory MDCT and pulmonary function testswithin 2 weeks before surgery and post-operative pulmonary function tests within 6-7 months after surgerywere performed in all patients. Actual pulmonary function losses (ΔFEV1.0 and ΔVC) were calculated from preand post-operative pulmonary function test data. Predictive pulmonary function losses (Pred.ΔFEV1.0 andPred.ΔVC) were calculated from sub-segment counting method and lobar volumetry of inspiratory/expiratoryMDCT data using two methods (effective volume at inspiratory phase and volume change between inspiratoryand expiratory phases). Correlations between ΔFEV1.0 and Pred.ΔFEV1.0 and those between ΔVC and Pred.ΔVCwere tested among three methods; sub-segment counting method, effective volume at inspiratory phase, andvolume change between inspiratory/expiratory phases, using Pearson's correlation coefficient. P < 0.05 wasconsidered a significant difference.

RESULTS

ΔFEV1.0 and Pred.ΔFEV1.0insp-exp were strongly correlated (r = 0.72), whereas ΔFEV1.0 andPred.ΔFEV1.0count (r=0.586) and ΔFEV1.0 and Pred.ΔFEV1.0eff.vol. (r = 0.599) were moderately correlated,respectively. ΔVC and Pred.ΔVC eff.vol. (r = 0.698) were strongly correlated, whereas ΔVC and Pred.ΔVCcount(r = 0.575), and ΔVC and Pred.ΔVC insp-exp (r=0.576) were moderately correlated, respectively.

CONCLUSION

Volumetry from inspiratory/expiratory MDCT data could be useful to predict post-operative pulmonary functionafter lobectomy for primary lung cancer.


Accurate prediction of postoperative pulmonary function using lobar volumetric measurement might be useful inpatients with borderline preoperative pulmonary function for primary lung cancer.

Getting it in the Neck: Predicting Whether Supraclavicular Lymph Nodes Suitable for FNA Will BeFound on Ultrasound in Patients with Lung Cancer (Station #3)

David Swienton MBBCHIR, MA (Presenter): Nothing to Disclose , Amrita Bajaj MD, FRCR : Nothing toDisclose , Joseph Harry Mullineux BMBCh, BSC : Nothing to Disclose , Jonathan Bennett : Nothing toDisclose

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CHS249

PURPOSE

Standard practice at our institution includes ultrasound of the neck in all patients with multistation N2 or N3lung cancer. We examined whether supraclavicular lymphadenopathy on staging CT could be used to reliablypredict whether lymph nodes suitable for sampling with fine needle aspiration (FNA) would be found onultrasound of the neck.


Analysis of 361 ultrasound reports and the preceding CT scans was performed. The primary outcomes werewhether CT scans with multistation N2 or N3 lung cancer demonstrated supraclavicular lymphadenopathy and ifsubsequent ultrasound demonstrated lymph nodes amenable to FNA. Subgroup analysis was used to determinepredictors for the presence or absence of nodes suitable for tissue sampling.

RESULTS

Results were grouped accordingly: Supraclavicular lymph noded (LN) present on CT with: LN present onultrasound (Group 1) or LN absent on ultrasound (Group 2); Supraclavicular LN absent on CT with: LN presenton ultrasound (Group 3) or LN absent on ultrasound (Group 4). For both N2 and N3 stage lung cancer: Group1, n = 84; Group 2, n = 12; Group 3, n = 17; Group 4, n = 179. Specificity 93.7%, Sensitivity 83.2%, NPV91.3% and PPV 87.5%. Diagnostic odds ratio = 74 (95% CI 34 -161). For N3 disease: Group 1, n = 69; Group2, n = 9; Group 3, n = 9; Group 4, n = 81. Specificity 90.0%, Sensitivity 88.5%, NPV 90.0% and PPV 88.5%.For N3 disease and those initially staged as N2 with supraclavicular LN on review of CT:Group 1, n = 84; Group2, n = 12; Group 3, n = 9; Group 4, n = 81. Specificity 87.1%, Sensitivity 90.3%, NPV 90.0% and PPV 87.5%.For N2 disease including those with supraclavicular LN on review of CT (although these should have beenclassified as N3 originally):Group 1, n = 12; Group 2, n = 2; Group 3, n = 7; Group 4, n = 93. Specificity97.9%, Sensitivity 63.2%, NPV 93.0% and PPV 85.7%

CONCLUSION

Overall CT of the chest is highly specific (94%) in ruling out whether lymph nodes suitable for tissue samplingwill be found on neck ultrasound in the context of lung cancer with multistation N2 or N3 disease. Specificity of98% can be achieved in N2 disease and sensitivity increased to 90% by selecting only N3 disease.


Selecting those patients most likely to have supraclavicular lymphadenopathy suitable for tissue samplingavoids exposing patients to unnecessary procedures and makes more efficient use of radiology services.

Lung Cancers Showing Growth in Only the Short-axis Dimension (width): The Advantage of using theAverage Diameter (Station #4)

Rowena Yip MPH (Presenter): Nothing to Disclose , David F. Yankelevitz MD : Research Grant, AstraZenecaPLC Royalties, General Electric Company , Claudia I. Henschke MD, PhD : Nothing to Disclose

PURPOSE

To determine the frequency of lung cancers with growth observed only in the short-axis dimension (width) andto examine their cell-type and nodule consistency distribution.


We reviewed 364 diagnosed cases of lung cancer in which the cancer was recommended for biopsy afterdemonstration of growth on low-dose screening CT scans. Lung nodule diameter was calculated using themaximum length and width measured on the same CT image just before diagnosis (L Time2, WTime2) andwhen it was first identified (LTime1, WTime1). Percentage change in both length and width was computed usingthe measurement at time 1 and 2: ΔL = (LTime2 -LTime1) / LTime1 x100%, ΔW = (WTime2 -WTime1) /WTime1 x100% Among these 364 cases, we determined how many had less than 10% growth in length (ΔL <10% ) while there was more than a 10% increase in width (ΔW ≥ 10%). Cell-type and nodule consistency werealso recorded.

RESULTS

Among the 364 lung cancers, 40 (11%) only demonstrated an increase in the width. The cell-type of these 40was: 29 (73%) adenocarcinoma, 5 (13%) squamous cell, 2 (5%) small cell and 4 (10%) other cell-types.Among the 40 cancers, 6(15%) manifested as a nonsolid nodule, 7 (18%) part-solid and 27 (68%) solid.

CONCLUSION

Average diameter (a bi-dimensional measurement) is useful in measuring nodule growth as it better reflects theactual volume growth of the nodule and is also an average of two measures rather than the singleone-dimensional measure, length.


Use of average diameter, a bi-dimensional measure, as opposed to a uni-dimensional measure of length allowsfor growth to be ascertained when it is asymmetric and not increasing in length. Lung cancers do not growuniformly and growth may manifest only as a change in width. The use of bi-dimensional measure can capturesuch asymmetric growth.

CHS250

“Virtual” High-dose CT: Converting Ultra-low-dose (ULD) to Higher-dose (HD) CT by Means ofSupervised Pixel-based Machine-learning Technique (Station #5)

Kenji Suzuki PhD (Presenter): Royalties, General Electric Company Royalties, Hologic, Inc Royalties,AlgoMedica Royalties, MEDIAN Technologies Royalties, Riverain Technologies, LLC Royalties, ToshibaCorporation Royalties, Mitsubishi Corporation , Toru Higaki PhD : Nothing to Disclose , Wataru Fukumoto : Nothing to Disclose , Kazuo Awai MD : Research Grant, Toshiba Corporation Research Grant, Hitachi LtdResearch Grant, Bayer AG Research Consultant, DAIICHI SANKYO Group Research Grant, Eisai Co, Ltd

PURPOSE

Although CT has been shown to be effective for screening lung cancer, current radiation dose in CT is still highfor screening population. Our purpose was to develop a "virtual" high-dose CT technology to convert ULDCT toHDCT images with less noise or artifact.


We developed a supervised pixel-based machine-learning technique to convert ULDCT into HDCT images. Wetrained our technique with ULDCT (4mAs, 120kVp, 5mm slice thickness) and corresponding "teaching" HDCT(120mAs, 120kVp) of an anthropomorphic chest phantom (Kyoto Kagaku, Kyoto, Japan). Once trained, ourtechnique does not require HDCT any more, and it provides "virtual" HDCT where noise and artifact aresubstantially reduced. To test our technique, we collected ULDCT (6.0±3.5mAs, 120kVp, 0.14±0.08mSv, 5mmslice thickness) of 12 patients on multiple vendor CT scanners (GE LightSpeed VCT; Toshiba Aquilion ONE). Todetermine a dose reduction rate of our technology, we acquired 6 CT scans of the anthropomorphic chestphantom at 6 different radiation doses (4, 10, 20, 40, 60 and 120mAs; 120kVp). Contrast-to-noise ratio (CNR)was used to evaluate the image quality of CT.

RESULTS

Our "virtual" HDCT technology reduced noise and streak artifacts in ULDCT (0.1mSv) substantially, whilemaintaining anatomic structures and pathologies such as vessels and nodules. With our technology, theaverage CNR of ULDCT images was improved by 14.3±1.9dB (from -16.1±4.3 to -1.8±3.7dB) (two-tailedt-test; P<.05). This 14.3 dB CNR improvement was equivalent to a radiation dose reduction rate of 0.1 in ourphantom study. The processing time for each case was 48 sec on a PC (AMD Athlon, 3.0GHz).

CONCLUSION

Our technology converted ULDCT to virtual HDCT where noise and streak artifacts were reduced substantially,and it can potentially reduce radiation dose by 90% in CT.


Substantial reduction of radiation dose in CT with our technology would be beneficial to screening population.Very short processing time is an advantage of our technology over iterative reconstruction.

MSCT21

Case-based Review of Thoracic Radiology (An Interactive Session) Multisession Courses

CH



Mon, Dec 1 1:30 PM - 3:00 PM Location: S100AB

Sub-Events Pleural Disorders

Gautham P. Reddy MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) To describe the imaging evaluation of pleural diseases. 2) To identify imaging findings in a variety of pleuraldiseases. 3) To discuss the differential diagnosis of pleural diseases.

Community and Hospital Acquired Pulmonary Infections

Tomas C. Franquet MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) To understand the role of imaging in the diagnosis of pulmonary infections. 2) To illustrate the spectrum ofCT findings of lung infections according to clinical and immune status of the patients. 3) To become familiar withtypical patterns of specific pulmonary infections.

CHS251

MSCT21A

MSCT21B

ABSTRACT

Respiratory infections (RI) including community acquired pneumonia (CAP) and nosocomial pneumonia (NP)represent a major health care problem because of their high morbidity and mortality rate. The spectrum ofcausative organisms of CAP includes gram-positive bacteria such as Streptoccocus pneumoniae (thepneumoccocus), Haemophilus influenzae and Staphyloccocus aureus, as well as atypical organisms such as Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella pneumophilia and viral agents such as RSV andinfluenza. Pulmonary infections may affect both immunocompetent individuals and patients with impairedimmune function. Moreover, mildly impaired host immunity as it occurs in chronic debilitating illness, diabetesmellitus, malnutrition, alcoholism, advanced age, prolonged corticosteroid administration and COPD have alsobeen regarded as predisposing factors of pulmonary infections. Although accurate clinical information isessential to narrow the differential diagnosis, it is often very difficult to determine the cause of parenchymalabnormalities in this group of patients. Combination of pattern recognition with knowledge of the clinical settingis the best approach to pulmonary infectious processes. A specific pattern of involvement can help suggest alikely diagnosis in many instances. CT can be helpful in the detection, differential diagnosis, and management ofpatients with pulmonary infection. Thus, a systematic approach to the radiological evaluation of patients withpulmonary infection is essential and includes not only chest imaging pattern recognition, but integration ofavailable demographic, clinical and laboratory information.

Pulmonary Nodules and Masses

Jane P. Ko MD (Presenter): Editor, Reed Elsevier

LEARNING OBJECTIVES

1) to understand the radiologic significance of the subsolid nodule. 2) to learn of the pitfalls that can occur whenevaluating the pulmonary nodule. 3) to improve knowledge in management of pulmonary nodules.

MSRO23

BOOST: Lung—Case-based Review (An Interactive Session) Multisession Courses

RO OI CH RO OI CH




ParticipantsModeratorSimon Shek-Man Lo MD : Research support, Elekta AB Speaker, Varian Medical Systems, Inc Travel support, Varian MedicalSystems, Inc Jing Zeng MD (Presenter): Nothing to Disclose Jyoti D. Patel MD (Presenter): Nothing to Disclose George Rodrigues MD,PhD, FRCPC (Presenter): Nothing to Disclose Marcelo C. Dasilva MD (Presenter): Nothing to Disclose Gregory Kicska MD, PhD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) Stage I non-small cell lung cancer not suitable for lobectomy based on co-morbidities. 2) Locoregionally advanced non-smallcell lung cancer (T3/4 or N2/3). 3) Limited stage small cell lung cancer. 4) Extensive stage small cell lung cancer. 5)Oligometastasis.

ABSTRACT

No abstract.

SSE05

ISP: Chest (Radiation Dose Reduction) Scientific PapersSQ CT CH AMA PRA Category 1 Credits ™: 1.00

ARRT Category A+ Credit: 1.00

Mon, Dec 1 3:00 PM - 4:00 PM Location: S404CD

ParticipantsModeratorNarinder S. Paul MD : Research funded, Toshiba Corporation ModeratorMannudeep K. S. Kalra MD : Nothing to Disclose

MSCT21C

Sub-Events Chest Keynote Speaker: Approaches to Radiation Dose Reduction and Image Optimization forThoracic CT

Narinder S. Paul MD (Presenter): Research funded, Toshiba Corporation

MicroSievert Chest CT: Detection of Lung Findings Using Three Different Reconstruction Algorithms(IMR, iDose, FBP) in a Prospective Clinical Study

Ranish Deedar Ali Khawaja MD (Presenter): Nothing to Disclose , Rachna Madan MD : Nothing to Disclose , Amita Sharma MBBS : Nothing to Disclose , Subba Rao Digumarthy MD : Nothing to Disclose , Jo-Anne O. Shepard MD : Consultant, Agfa-Gevaert Group , Mannudeep K. S. Kalra MD : Nothing to Disclose , Sarabjeet Singh MD : Research Grant, Siemens AG Research Grant, Toshiba Corporation Research Grant,General Electric Company Research Grant, Koninklijke Philips NV , Atul Padole MD : Nothing to Disclose , Thomas Koehler PhD : Employee, Koninklijke Philips NV

PURPOSE

To assess the detection of lung nodules (solid and ground-glass 'GGO LN') at microSievert (µSv) chest CTexaminations reconstructed with iterative reconstruction techniques (iDose and iterative model reconstruction[IMR]), and non-iterative filtered back projection (FBP) technique.


This IRB-approved prospective study included 116 CT image series for 29 patients (51-87 years, BMI16-32kg/m2) who underwent a routine chest CT on 256 MDCT(iCT,Philips Healthcare). Each patient underwentthree µSv-CT exams at 3 dose levels: 500µSv [120kV,12mA], 250µSv [100kV,10mA], 100µSv [80kV,10mA])immediately after standard-of-care (SD) CT [3mSv, 120kV AEC enabled]. SD-FBP, µSv-FBP, µSv-IMR andµSv-iDose were reconstructed at 2.5 mm thickness. Four radiologists assessed subjective quality independentlyusing a continuous scale. Lesions (true, pseudo and missed) were detected on µSv-images and compared toSD-FBP "reference-standard". Noise spectral density (NSD) curves to assess noise in frequency domain wereobtained. Student's t-test, intraclass correlation coefficient, and Jackknife free-response receiver operatingcharacteristic method were used for data analysis.

RESULTS

Missed lesions (mostly GGO LN <5mm) included 24/503 (at 250µSv FBP), 3/503 (at 250µSv IMR/iDose),32/503 (at 100µSv FBP), and 14/503 (at 100µSv IMR/iDose). FBP images were clinically adequate for all lungfindings at 250µSv (in patients with BMI ≤25kg/m2) and at 500µSv (≤30kg/m2) dose levels. Iterative imagesenabled adequate evaluation for solid LN at 100µSv irrespective of patient BMI ( P >0.05), and GGO LN at100µSv (≤25kg/m2; P 0.02). Irrespective of patient BMI and lesion size, both solid and GG LN were evaluatedas "clinically adequate" at 250µSv and 500µSv dose levels on iterative images. Conspicuity of emphysematousand low-contrast mediastinal lesions was better with IMR images at 500µSv dose level. Compared to SD-FBP,objective noise was significantly lower in IMR images at all dose levels (P <0.001). NSD showed higher noisereduction in lower frequency for IMR compared to SD-FBP method.

CONCLUSION

Iterative reconstruction techniques enable optimal detection and evaluation of lung nodules (both solid- andground-glass) at 250µSv radiation dose or higher.


Clinically adequate lung evaluation in CT is achievable at 500µSv [~0.5 mSv] with filtered back projectiontechnique and at 250µSv [~0.25 mSv] using advanced iterative reconstruction algorithms such as iDose andIMR.

Five Different Iterative Reconstruction Techniques across Three Vendors at the Lowest PossibleRadiation Doses in Chest CT: Prospective Randomized Blinded Study

Ranish Deedar Ali Khawaja MD (Presenter): Nothing to Disclose , Sarabjeet Singh MD : Research Grant,Siemens AG Research Grant, Toshiba Corporation Research Grant, General Electric Company Research Grant,Koninklijke Philips NV , Rachna Madan MD : Nothing to Disclose , Subba Rao Digumarthy MD : Nothing toDisclose , Jo-Anne O. Shepard MD : Consultant, Agfa-Gevaert Group , Mannudeep K. S. Kalra MD : Nothingto Disclose , Roberto Lo Gullo MD : Nothing to Disclose , Atul Padole MD : Nothing to Disclose , Sarvenaz Pourjabbar MD : Nothing to Disclose , Alexi Otrakji MD : Nothing to Disclose

PURPOSE

To assess diagnostic performance of chest CT examinations reconstructed with five different iterativereconstruction techniques (IRT) from major CT vendors at lowest possible radiation doses with a comparison tostandard of care CT.


This multi-phase prospective randomized trial was HIPAA-compliant and IRB-approved. In 3 different phases, 3separate patient cohorts underwent a routine chest CT on 3 different scanners from 3 different vendors (64MDCT and above). In addition to standard-of-care CT (SD; CTDIvol 6 mGy), all patients (n=72; 26-87 years;M:F 39:33) provided written informed consent for acquisition of additional 3 ultra low-dose "LD" series (0.9, 0.4and 0.2mGy) immediately after SD-exam. SD-data were reconstructed with FBP (reference-standard) and LDdata were reconstructed with 5 IR (IRA, IRB, IRC, IRD and IRE) at 2.5mm thickness resulting into 417 totalimage series. Independent blinded evaluation of lesion detection and diagnostic quality was performed.Objective noise (HU ±SD) was measured. Student's t-test, ANOVA and Jackknife free-response receiveroperating characteristic method were used for data analysis.

RESULTS

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SSE05-02

SSE05-03

242 lesions (lung, 178; mediastinal, 64) were detected on standard of care chest CT. Lesion detection for bothlung and mediastinal lesions was optimal across all studied 0.9 mGy IRT images (94-100% detection rate). At0.5 mGy, detection rate for mediastinal lesions was substantially lower for IRC, IRD and IRE (33-41% missedlesions compared to SD CT). Detection for lung lesions was substantially lower for IRA, IRB and IRC (24-36%missed lesions). At 0.2 mGy, IRE missed most abnormalities (pulmonary 58% and mediastinal 60%). IRAmissed the least mediastinal lesions (20%). IRC missed the least lung lesions (15%). Subjective image qualityof lung parenchyma and soft-tissues (table 1) was statistically different across IR techniques (P <0.001).

CONCLUSION

Iterative reconstruction techniques from major CT vendors differ in lesion detection at radiation dose of 0.5mGy and lower. Subjective image quality is also statistically different across IRT at ultra-low dose chest CT.


Low dose CT protocols from one vendor iterative reconstruction technique cannot be applied to other vendorsdue to significant differences in image quality and lesion detection.

Knowledge Based Iterative Reconstruction Technique for Radiation Dose Reduction in Chest CT:Comparison with Hybrid Iterative Reconstruction and Filtered Back Projection Techniques

Qiong Li (Presenter): Nothing to Disclose , Shiyuan Liu PhD : Nothing to Disclose , Hong Yu MD, PhD : Nothing to Disclose , Yan Jiang MD : Employee, Koninklijke Philips NV

PURPOSE

To prospectively evaluate dose reduction and image quality features of chest CT reconstructed by usingknowledge based iterative reconstruction technique(IMR,Philips Healthcare) compared with hybrid iterativereconstruction( iDose4,Philips healthcare) and filtered back projection (FBP) techniques.


Institutional review board approval was obtained for this study. 42 patients (54.3±6.7 years, 28 male)underwent unenhanced chest CT with both ultra-low lose(ULD) and routine low dose (LD) protocols for once. Allimages were reconstructed with a 1mm slice by IMR which included 3 different settings (L1 body routine, L1body sharpPLus and L1 body soft tissue), iDose4 (level 4)and FBP techniques, respectively. Total dose-lengthproduct (DLP) of both ULD and LD protocols were recorded. Image quality assessments for both normal lungand mediastinal structures were performed by 2 radiologists according to the features of structure demarcation,noise and artifacts using a five point scale. Standard deviation(SD) of CT attenuation in the descending aortawas measured as objective image noise.

RESULTS

The radiation dose of ULD-CT was 0.62±0.02mSv compared with 2.54± 0.63 mSv for LD-CT (P<0.001) , therewas a 75.6% decrease in ED. All three settings of IMR reduced image noise significantly than iDose4 and FBP(p<0.01, respectively). Both IR algorithms showed better image quality than FBP, and all IMR settings werebetter than iDose4 (p<0.01, respectively), IMR-sharpPlus images enabled exhibited the lung parenchyma, whileIMR-routine or soft tissue images enabled showed the mediastinal images.

CONCLUSION

Diagnostically acceptable chest CT image acquired with radiation exposure in the range of a posterior to anteriorand lateral chest X-ray can be obtained by using IMR. IMR allows more noise reduction and significant imagequality improvement in ultra-low dose chest CT compared to iDose4 techniques and FBP. Different settings ofIMR can be the complement for each other which may provide more diagnosis information to reach lower doseCT without compromising image quality.


Different settings of IMR can be the complement for each other which may provide more diagnosis informationto reach lower dose CT without compromising image quality.

Iterative and Standard Filtered Back Projection Reconstruction – Comparing Image Quality ofStandard and Low-dose Chest CT

Monika Christine Dadrich MD (Presenter): Speaker, Koninklijke Philips NV , Gregor Pahn DIPLPHYS : Nothing to Disclose , Jessica Hirsch : Nothing to Disclose , Johanna Laura Mayer MD : Nothing to Disclose , Waldemar P. Hosch MD : Nothing to Disclose , Hans-Ulrich Kauczor MD : Research Grant, BoehringerIngelheim GmbH Research Grant, Siemens AG Research Grant, Bayer AG Speakers Bureau, BoehringerIngelheim GmbH Speakers Bureau, Siemens AG Speakers Bureau, Novartis AG , Wolfram Stiller PhD,DIPLPHYS : Nothing to Disclose

PURPOSE

Recently, iterative reconstruction algorithms (IR) have been introduced in CT, offering a new possibility forradiation dose (RD) reduction by reducing image noise resulting from CT examinations. The purpose of thisstudy was to assess different levels of an IR algorithm (iDose, Philips Healthcare, Best, The Netherlands) innon-enhanced low-dose chest CT examinations in comparison with standard dose chest CT reconstructed withfiltered backprojection (FBP).


Non-enhanced low-dose chest CT examinations (LDCT) were acquired with a tube voltage of 100kVp and a tubecurrent-time product of 120mAs with tube-current modulation (TCM) (Group A; 20 patients), or 60mAs withoutTCM (Group B; 24 patients). Images were reconstructed with FBP and different levels of iDose (levels 40 and

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60 with/without MFR, i.e. homogeneous noise texturing) using lung (L) and soft-tissue kernels (B). Each patienthad a prior standard-dose chest CT (SDCT; 120kVp, 120mAs with TCM, FBP). CT numbers and image noise wereobjectively measured in different anatomic structures (lung, aorta, liver). Three independent, blinded readersassessed diagnostic image quality by subjective ranking (best to worst) of the differently reconstructed imagedata sets. Radiation dose parameters (CTDIw and DLP) were recorded.

RESULTS

Radiation exposure could be reduced by 41% (group A), and by 72% (group B), respectively. IR did not affectCT numbers while image noise could be reduced by up to ~40 %. With regard tothe assessment of subjectiveimage quality interreader-agreement was fair to moderate (κ=0.24-0.48). Iteratively reconstructed images withiDose60 were ranked highest independent of low-dose protocol and reconstruction kernel. No differencebetween iDose60 with and without MFR could be observed. FBP-images of all low-dose data sets were rankedlowest.

CONCLUSION

Image noise can be reduced by IR in low-dose chest CT, thereby improving image quality compared to FBP.iDose60 is superior to iDose40, the use of MFR however doesn't affect subjective image quality. Intra-individualcomparisons between SDCT and LDCT suggest that IR enables radiation dose reduction of up to about 70%,while maintaining overall diagnostic acceptability.


IR algorithms have great potential for reducing image noise in chest CT, allowingto lower radiation exposure ofchest CT examinations while preserving overall diagnostic image quality.

Radiation Dose from Single-KV and Dual-KV chest CT for Routine Chest and Pulmonary EmbolismProtocols

Alexi Otrakji MD (Presenter): Nothing to Disclose , Roberto Lo Gullo MD : Nothing to Disclose , Sarabjeet Singh MD : Research Grant, Siemens AG Research Grant, Toshiba Corporation Research Grant, GeneralElectric Company Research Grant, Koninklijke Philips NV , Katherine Stockton : Nothing to Disclose , Jo-Anne O. Shepard MD : Consultant, Agfa-Gevaert Group , Mannudeep K. S. Kalra MD : Nothing toDisclose , Subba Rao Digumarthy MD : Nothing to Disclose , Atul Padole MD : Nothing to Disclose , RanishDeedar Ali Khawaja MD : Nothing to Disclose , Sarvenaz Pourjabbar MD : Nothing to Disclose , Diego Alfonso Lira MD : Nothing to Disclose

PURPOSE

To compare radiation dose associated with single-KV (sK-CT) and dual-kV (dK-CT) chest CT examinations forroutine chest (RC) and pulmonary embolism (PE) protocols across two CT vendors.


Our IRB approved study included 824 adult patients who had contrast enhanced sK-CT using RC (n= 210patients) dual source CT, 128-DSCT (Siemens Definition Flash):100 patients, M:F 56:44,mean age 60±15years,mean weight 78±23 kg; 64-slice single source CT 64-SSCT,GE Discovery 750HD:110 patients,M:F 58:52,mean age 60 ± 17years,mean weight 75±19 kg) and PE protocols(n= 202 patients) (128-DSCT: 92patients,M:F 37:55,mean age 62 ± 16years,mean weight 80±24 kg; 64-SSCT:110 patients,M:F 52:58,meanage 62±16years,mean weight 81±22kg) and dK-CT using RC (n= 210 patients)(128-DSCT: 100 patients,M:F48:52,mean age 59 ±16years,mean weight 77±19kg; 64-SSCT:110 patients M:F 48:62,mean age63±14years,mean weight 73±16kg) and PE protocols (n= 202 patients)(128-DSCT:92 patients,M:F37:55,mean age 55±18years,mean weight 79±25kg; 64-SSCT:110 patients, M:F 53:57,mean age61±16years,mean weight 80±21kg).For each patient,we recorded CTDIvol,DLP and estimated effective dose(EED).Data were analyzed using Student's t test and ANOVA.

RESULTS

There was no significant difference between weights of the patients undergoing sK-CT and dK-CT on the two CTscanners for RC and PE protocols (p=0.4).Following doses were noted for dK-CT: RC(64-SSCT):7.6±0.7mGy,288±37 mGy.cm, 4±0.5mSv; RC (128-DSCT):6.6±2.8mGy,220±99mGy.cm,3.1±1.4mSv;PE (64-SSCT):9.3 ± 2 mGy, 326±70 mGy.cm, 4.6±1mSv; PE (128-DSCT):9±3.2mGy,284±104mGy.cm, 4±1.5mSv.There was significant reduction in CTDIvol with dK-CT as compared to the sK-CT,ranging from 11-43% (p<0.0001).The dK-CT on 128-DSCT resulted in 4-16% lower CTDI vol as compared todK-CT acquisition on 64-SSCT (p<0.01). Patient weight had significant effect on dose reduction with dK-CT ascompared to the sK-CT, with mean dose reduction of 19% for patients < 90 kg (7.2 versus 8.8 mGy) versus30% dose reduction for patients > 90 kg (11.1 versus 16.8 mGy) (p<0.001).

CONCLUSION

Routine chest CT, and pulmonary embolism CT protocols can be performed using dual kV acquisition mode atlower radiation dose levels compared to the single kV acquisition


Dual kV CT can be applied for acquiring routine chest CT and pulmonary embolism CT without any dose penaltycompared to single energy chest CT

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MSCT22

Case-based Review of Thoracic Radiology (An Interactive Session) Multisession Courses

CH




Sub-Events Mediastinal Abnormalities

Laura Elizabeth Heyneman MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) Recognize normal mediastinal lines, stripes, and interfaces on the chest radiograph. 2) Use the mediastinallines, stripes, and interfaces to localize mediastinal abnormalities. 3) Know the differential diagnosis forabnormalities in all mediastinal compartments, and recognize findings that can help distinguish one abnormalityfrom another.

Diffuse Infiltrative Lung Disease

H. Page McAdams MD (Presenter): Research Grant, General Electric Company Consultant, MedQIA Author,Reed Elsevier Author, UpToDate, Inc

LEARNING OBJECTIVES

1) Describe thin-section CT findings that, in and of themselves, suggest a specific cause for diffuse infiltrativelung disease. 2) Describe thin-section CT findings that, when correlated with clinical information, suggest aspecific cause for diffuse infiltrative lung disease.

ABSTRACT

The diffuse infiltrative or interstitial lung diseases (DILD) are relatively common and can lead to significantdisability or even death. Definitive diagnosis usually rests upon a triad of clinical information, thin-section CT(HRCT) findings, and lung biopsy. Thin-section CT is now a mainstay for evaluation of known or suspected DILDand is used as a surrogate for lung biopsy in selected patients. In some cases, CT findings are specific enoughto warrant a single best diagnosis and can sometimes obviate lung biopsy ("classics"). In others, CT findingsmust be correlated with clinical information to yield a specific diagnosis ("near-classics"); lung biopsy cansometimes be avoided these patients as well. However, there are some patients where CT findings and clinicalinformation are just not specific enough for definitive diagnosis; lung biopsy is frequently required in thesepatients for definitive diagnosis. This case-based review will focus on common forms of DILD whose CT findingscan be considered either "classics" or "near-classics" (e.g., sarcoidosis, lymphangitic carcinomatosis, usualinterstitial pneumonia, non-specific interstitial pneumonia, Langerhans cell histiocytosis, hypersensitivitypneumonitis, etc.). The role of clinical correlation and lung biopsy for definitive diagnosis will be emphasizedwhen appropriate.

Aortic and Pulmonary Arterial Disorders

Diana Litmanovich MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) To understand the appropriateness criteria of use of imaging in the diagnosis of aortic and pulmonary arterialdisorders. 2) To illustrate the spectrum of CT and MR findings of aortic and pulmonary arteries disorders and tolearn the pitfalls that might prevent the correct diagnosis. 3) To improve knowledge in management of specificaortic and pulmonary arteries pathology.

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Precision Medicine through Image Phenotyping Refresher/InformaticsIN BQ VA CH CA IN BQ VA CH CA AMA PRA Category 1 Credits ™: 1.50

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Mon, Dec 1 4:30 PM - 6:00 PM Location: S501ABC

ParticipantsModeratorElla A. Kazerooni MD : Nothing to Disclose

LEARNING OBJECTIVES

1) To learn what the term precision medicine means. 2) To understand how informatics intersects with clinical radiology toenable precision medicine in practice. 3) To learn through concrete examples how informatics based radiology precisionmedicine impacts health

ABSTRACTBiomarkers have been emrabced by both the scientific and regulatory communities as surrogates end points for clinical trials,paving the way for their widespread use in medicine. The field of imaging biomarkers has exploded, and the their integrationinto clinical practice relies heaving on and intersects with the field of bioinformatics.. Once specific biomakers are show to havevalue, easily integrating them into the digital environment of the radiologist and communcating them to the health careproviders and or directly to patients effeiciently and seamlessly is important for their value and impact on health to be realized.Culturally, it is taking radiologists from the era of description and largely qualitative reporting, into a quantitative future state,and leveraging informatics to extract information from imaging alone ot together with data available in the electronic medicalrecord is essential for future sucess in this new world. To get there, understanding the impact of this approach as a value of ourservices, and standardization of imaging technques along the lines of what the RSNA QIBA initiative is designing, are essential,so that imaging biomarkers are robust, accurate and reprodicbile. Embraching this approach enables and facilitates newappracohes, relationships of imaging and IT researchers, vendors and consumers, to fully realize the possiblities. This course willdiscuss and describe the overall constructs, and use tangible exams of using this in practice today and for the future.

Sub-Events Imaging Biomarkers Meet Informatics: The Personalized Medicine Construct


LEARNING OBJECTIVES


ABSTRACT

View abstract under main course title.

Lung Nodules: Combining Population and Patient Specific Data to Inform Personalized DecisionMaking

Eliot L. Siegel MD (Presenter): Research Grant, General Electric Company Speakers Bureau, Siemens AGBoard of Directors, Carestream Health, Inc Research Grant, XYBIX Systems, Inc Research Grant, Steelcase, IncResearch Grant, Anthro Corp Research Grant, RedRick Technologies Inc Research Grant, Evolved TechnologiesCorporation Research Grant, Barco nv Research Grant, Intel Corporation Research Grant, Dell Inc ResearchGrant, Herman Miller, Inc Research Grant, Virtual Radiology Research Grant, Anatomical Travelogue, Inc MedicalAdvisory Board, Fovia, Inc Medical Advisory Board, Toshiba Corporation Medical Advisory Board, McKessonCorporation Medical Advisory Board, Carestream Health, Inc Medical Advisory Board, Bayer AG Research,TeraRecon, Inc Medical Advisory Board, Bracco Group Researcher, Bracco Group Medical Advisory Board, MergeHealthcare Incorporated Medical Advisory Board, Microsoft Corporation Researcher, Microsoft Corporation

LEARNING OBJECTIVES

1) Describe how data from a clinical trial can be repurposed as a decision support tool. 2) List some of thepotential techniques that can be utilized to predict likelihood of a malignant nodule from the NLST database. 3)Explain how the Fleischner Guidelines can be personalized utilizing data from NLST and PLCO. 4) Detail theimplications for lung screening trials of having access to NLST and PLCO data. 5) Demonstrate how a healthcareenterprise can create their own local reference database using information from their own patient population.

ABSTRACT

The era of personalized/precision medicine offers the potential to utilize patient and lesion specific data topersonalize screening and diagnostic work-up, diagnosis, and treatment selection to a particular patient tooptimize effectiveness. Although recently, the emphasis has been on utilization of genomic data in personalizedmedicine, there is a 'gold mine' of useful data in previously conducted clinical trials as well as patient medicalelectronic records that has, until now, gone largely untapped. The purpose of this presentation is to describehow the screening, diagnosis, and treatment of lung nodules can be personalized utilizing data from the NLSTand PLCO clinical trials and how the Fleischner Guidelines and screening criteria for lung cancer can be modifiedaccording to the characteristics of an individual patient and individual nodule. The presentation will also includeways in which a facility can collect local data on their own patients to supplement these reference databaseswith experience from their own patient population.

Managing Cardiovascular Care through Image Phenotyping Combined with Patient Level Data

John Jeffrey Carr MD, MS (Presenter): Nothing to Disclose

LEARNING OBJECTIVES


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SPDL21

RSNA Diagnosis Live™: Chest/Abdomen/Neuroradiology Special Courses

NR GI CH


ARRT Category A+ Credit: 0

Mon, Dec 1 4:30 PM - 6:00 PM Location: E451B

ParticipantsPaul J. Chang MD (Presenter): Co-founder, Stentor/Koninklijke Philips Electronics NV Technical Advisory Board, Amirsys, IncResearch Contracts, Koninklijke Philips NV Medical Advisory Board, lifeIMAGE Inc Medical Advisory Board, Merge HealthcareIncorporated Neety Panu MD, FRCPC (Presenter): Nothing to Disclose Gregory Lewis Katzman MD (Presenter): Author, Amirsys, Inc Stockholder, Amirsys, Inc

LEARNING OBJECTIVES1) The participant will be introduced to a series of radiology case studies via an interactive team game approach designed toencourage "active" consumption of educational content. 2) The participant will be able to use their mobile wireless device(tablet, phone, laptop) to electronically respond to various imaging case challenges; participants will be able to monitor theirindividual and team performance in real time. 3) The attendee will receive a personalized self-assessment report via email thatwill review the case material presented during the session, along with individual and team performance. This interactive sessionwill use RSNA Diagnosis Live™. Please bring your charged mobile wireless device (phone, tablet or laptop) to participate.

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Chest Series: Thoracic CT and MR Imaging: State of the Art Series CoursesMR CT BQ CH AMA PRA Category 1 Credits ™: 3.25


Tue, Dec 2 8:30 AM - 12:00 PM Location: S405AB

ParticipantsModeratorJonathan G. Goldin MBChB, PhD : Nothing to Disclose ModeratorHiroto Hatabu MD, PhD : Research Grant, Toshiba Corporation Research Grant, AZE, Ltd Research Grant, Canon Inc

Sub-Events Quantitative CT for Interstitial Lung Disease

Jonathan G. Goldin MBChB, PhD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) Review the approaches for detecting and quantifying lung changes in IPF. 2) Understand the predictive valueof disease quantitation with respect to survival and outcome. 3) Become familiar with the role of change inquantitative measures at follow up both in the setting of clinical trials and practice.

Quantification of Interstitial Lung Disease in Idiopathic Inflammatory Myopathy Patients Using the“Computer-Aided Lung Informatics for Pathology Evaluation and Rating” (CALIPER) SoftwareSystem

Katelynn Maries Wilton BS (Presenter): Nothing to Disclose , Brian Jack Bartholmai MD : Nothing to Disclose, Sanjay Kalra MD : Nothing to Disclose , Cynthia S. Crowson MS : Nothing to Disclose , Sushravya Raghunath : Nothing to Disclose , Srinivasan Rajagopalan PhD : Nothing to Disclose , Floranne Ernste MD: Nothing to Disclose

PURPOSE

In idiopathic inflammatory myopathy (IIM), interstitial lung disease (ILD) is a major cause of morbidity andmortality. ILD in IIM may manifest with a variety of pathological and radiographic abnormalities . Most ILDsubtypes have characteristic clinical and radiographic features; hence, diagnosis is usually aided by expertradiologist assessment. Radiography and pulmonary function tests (PFT) may provide a qualitativemeasurement of severity. However, CT evaluation is subject to inter- and intra-observer variability. PFT resultscan be influenced by patient effort and do not differentiate specific restrictive pulmonary pathologies. Wehypothesize that Computer-Aided Lung Informatics for Pathology Evaluation and Rating (CALIPER) software,which characterizes CT parenchyma, can help predict clinical outcomes, objectively quantify extent of ILD in IIMand help in disease monitoring.

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CALIPER was utilized to quantify ILD features on CT in 172 subjects with IIM. We retrospectively collecteddemographic, PFT and medication data at baseline, years 1, 3 and 5. IIM-related mortality was retrospectivelyassessed.

RESULTS

CALIPER detected diverse parenchymal involvement, with variable quantities of uninvolved parenchyma, groundglass opacities, reticular densities, honeycombing and low attenuation areas. In 95% of patients, CALIPERdetected ≥5% parenchymal abnormalities characteristic of ILD. Compared to treated patients, untreatedpatients had more baseline parenchymal abnormalities. The treated cohort showed improvement in quantity ofreticular densities (year 1, 3) and total interstitial abnormalities (year 1), while our untreated subgroup showedworsening interstitial abnormalities (year 3).

CONCLUSION

CALIPER analysis, including identification and quantification of baseline ILD and detection of change, inparenchymal involvement may prove to be a useful clinical tool in patients with IIM.


Detection and monitoring of ILD progression in patients with IIM can better inform the use ofimmunomodulatory treatments, both in the clinic and in future research trials.

Quantitative CT for COPD

Alexander A. Bankier MD, PhD (Presenter): Author with royalties, Reed Elsevier Consultant, OlympusCorporation

LEARNING OBJECTIVES

1) To review quantitative CT techniques for airway and parenchyma assessment in patients with COPD. 2) Todiscuss the potential and limitations of these techniques. 3) To review how these techniques can impact on theclinical management of patients with COPD.

Quantitative CT Can Define Clinically Different Subgroups of Cigarette Smokers

David Augustine Lynch MBBCh (Presenter): Research support, Siemens AG Scientific Advisor, PAREXELInternational Corporation Consultant, Boehringer Ingelheim GmbH Consultant, InterMune, Inc Consultant,Gilead Sciences, Inc Consultant, F. Hoffmann-La Roche Ltd Consultant, Veracyte, Inc Research support, Johnson& Johnson Research support, AstraZeneca PLC , Douglas C. Everett PhD : Nothing to Disclose , Eric A. Hoffman PhD : Founder, VIDA Diagnostics, Inc Shareholder, VIDA Diagnostics, Inc , John D. Newell MD : Research Consultant, Siemens AG Research Grant, Siemens AG Consultant, WebMD Health Corp Author,Springer Science+Business Media Deutschland GmbH Consultant, VIDA Diagnostics, Inc , Francine Jacobsen MD : Nothing to Disclose , Barry J. Make : Nothing to Disclose

PURPOSE

To determine in a population of cigarette smokers whether distinct subgroups defined by quantitative CTmeasures of emphysema and gas trapping differ in symptoms, quality of life, or exacerbation frequency.


We studied 8144 current or former cigarette smokers enrolled in the COPDGene® study. All underwentinspiratory and expiratory volumetric CT with automated quantification of % low attenuation areas (LAA) forestimation of emphysema and gas trapping, using thresholds of -950 on inspiratory CT (LAA-950 insp) and-856 on expiratory CT (LAA-856 exp). Normal cutoff values for these parameters, based on 92 normalsubjects, were 5.8% for % LAA-950insp, and 24.3% for % LAA-856exp. Cutoff values were adjusted for currentsmokers. Dyspnea was evaluated by MMRC questionnaire, respiratory symptoms by St George RespiratoryQuestionnaire, and quality of life by SF-36 questionnaire. We used binary recursive partitioning (tree function inR) to identify subgroup differences in clinical outcomes.

RESULTS

Of the 8144 subjects, 768 (9%) met criteria for emphysema without gas trapping ("emphysema"), 579 (7%)had gas trapping without emphysema ("gas trapping"), 2413 (30%) had mixed gas trapping and emphysema,and 4384 (54%) did not meet criteria for emphysema or gas trapping. Compared with the emphysema group,the gas trapping group was significantly older, had shorter 6 minute walk distance, higher frequency ofexacerbations, and had higher scores for dyspnea, respiratory symptoms, and physical component of SF-36.When binary recursive partitioning was used, a cutoff value of approximately 40% for gas trapping identifieddichotomous subgroups of severity, assessed by FEV1% predicted, FEV1/FVC ratio, MMRC score, 6 minute walkdistance, exacerbation frequency, and St George Respiratory questionnaire.

CONCLUSION

Quantitative CT assessment of emphysema and gas trapping identifies subgroups of subjects with clinicallysignificant differences in disease severity.


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Quantitative CT may be used to identify important clinically important subtypes of COPD.

CT: Innovations for Dose Reduction

Narinder S. Paul MD (Presenter): Research funded, Toshiba Corporation

LEARNING OBJECTIVES

1) Discuss the latest approaches to low dose and ultralow dose thoracic CT. 2) Understand the prioritization ofX-ray exposure factors for different CT chest protocols. 3) Appreciate the role of Iterative Reconstructionalgorithms in low dose and ultraow dose chest CT. 4) Understand the approach to compressive sensingalgorithms in low dose and ultralow dose chest CT.

ABSTRACT

This refresher course wil provide a comprehensive review of the latest approaches to low dose and ultralowdose chest CT

Assessment of Image Based, Adaptive Statistical, and Model Based Iterative ReconstructionTechniques for Chest CT at Less than 1 mGy CTDIvol

Atul Padole MD (Presenter): Nothing to Disclose , Efren Jesus Flores MD : Nothing to Disclose , Rachna Madan MD : Nothing to Disclose , Shelly Mishra : Nothing to Disclose , Sarabjeet Singh MD : ResearchGrant, Siemens AG Research Grant, Toshiba Corporation Research Grant, General Electric Company ResearchGrant, Koninklijke Philips NV , Sarvenaz Pourjabbar MD : Nothing to Disclose , Mannudeep K. S. Kalra MD : Nothing to Disclose , Ranish Deedar Ali Khawaja MD : Nothing to Disclose , Diego Alfonso Lira MD : Nothing to Disclose , Subba Rao Digumarthy MD : Nothing to Disclose

PURPOSE

To assess image quality of chest CT reconstructed with image based (SafeCT), adaptive statistical (ASIR), andmodel based (MBIR) iterative reconstruction techniques (IRT) at less than 1 mGy CTDIvol.


Our IRB approved prospective study included 23 patients (mean age 63±13 years, 80±18 kg, M:F18:5) whounderwent routine chest CT on a 64 channel MDCT (GE Discovery CT750 HD) and gave written informedconsent for acquisition of ultra low dose (ULD) chest CT series. Standard chest CT (8±3.4 mGy) was followed by3 ULD chest image series (0.2, 0.4, and 0.8 mGy) (total additional dose <1 mSv). Images were used toreconstruct SafeCT (CH0, CH1) and sinogram data were used to reconstructed with ASIR (SS70, SS90) andMBIR and standard CT with ASIR (SS40) (n=23*3*5+23=368 series). Board-certified thoracic radiologistsperformed independent and blinded evaluation for lesion detection, lesion conspicuity, and visibility of smallstructures from lowest to highest dose of ULD series and subsequently for standard dose CT.

RESULTS

Of 182 lesion, 112 non-calcified lung nodules (LN) and 8 ground glass opacities (GGO). There were 34 missedlesions [24 LN, 4GGO, 2 thyroid nodule (TN), 3 pleural effusions (PL)] at 0.2 mGy, 27 [18 LN, 2GGO, 2TN, 2PL] at 0.4 mGy, and 11 [3LN,2GGO, 2TN, 2PL] at 0.8 mGy. The size of missed LN was less than 4mm. Therewere 7 and 4 false positive lesions at 0.2 and 0.4 mGy, respectively but none at 0.8 mGy. The conspicuity of LNwas sufficient fo diagnostic performance for 3/19 at 0.2 mGy, 6/19 at 0.4 mGy and 10/17(SafeCT:10,ASIR:10,MBIR:7) at 0.8 mGy. Visibility of sub-segmental bronchi was suboptimal at 0.2 and 0.4mGy but sufficient for diagnostic performance at 0.8 mGy. Visibility of major fissure was suboptimal at0.2and0.4 mGy but sufficient for 11/23 with IRT. Visibility of mediastinal and axillary lymph nodes wassuboptimal at 0.2and0.4 mGy but sufficient for 9/23 with SafeCT, 8/23 with ASIR, 14/23 with MBIR at 0.8mGy. Visibility of other mediastinal structures was limited at 0.8 mGy and suboptimal at 0.2and0.4 mGy.

CONCLUSION

Most clinically significant lung lesions can be detected at CTDIvol of 0.8 mGy with SafeCT, ASIR, and MBIR.However, mediastinal structures could not be assessed with sufficient diagnostic confidence at 0.2-0.8 mGywith any IRT.


Lung nodules >4mm can be assessed with IRT at CTDIvol as low as 0.2 mGy but those < 4mm can be missedat CTDIvol less than 0.8 mGy regardless of the IRT.

CT: Applications of Spectral Imaging

Martine J. Remy-Jardin MD, PhD (Presenter): Research Grant, Siemens AG

LEARNING OBJECTIVES

1) To make radiologists familiar with a daily use of spectral imaging. 2) To describe the clinical usefulness ofthis imaging modality. 3) To discuss the possibility of applying dual energy for routine chest CT.

MR: State of the Art

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Hiroto Hatabu MD, PhD (Presenter): Research Grant, Toshiba Corporation Research Grant, AZE, Ltd ResearchGrant, Canon Inc

LEARNING OBJECTIVES

1) Understand reasons for the renewed interest in thoracic MR. 2) Be familiar with current and emerging clinicalapplications of MR imaging in the chest. 3) Become acquainted with recently developed MR approaches to chestimaging. 4) Be aware of investigational MR methods for imaging lung function.

ABSTRACT

Thoracic MRI, exclusive of cardiovascular imaging, has evolved through stages of initial enthusiasm followed bylimited clinical utilization for specific applications. Examples of the latter have included differentiation of thymichyperplasia vs lymphoma, characterization of mediastinal duplication cysts, neurogenic/thoracic spinal lesions,cardiac/paracardiac masses, evaluation of superior sulcus tumors and the brachial plexus, stagingmesothelioma, and evaluating primary chest wall lesions. Ongoing advances in CT in combination with therelative complexities of MR and its suboptimal visualization of the pulmonary parenchyma have continued torestrict the use of MR in the chest. However, there has been a recent resurgence of interest in thoracic MRbased upon the development of practical protocols for improved lung imaging with faster proton MR sequences,parallel imaging, non-gadolinium MRA, etc. coupled with increased concern regarding radiation exposure withCT. This presentation will provide an overview of current and emerging clinical applications of nonvascularthoracic MR (including diffusion and whole body MR tumor imaging and the recent introduction of PET-MR),present an update on investigational techniques for imaging lung function including hyperpolarized gas MR, andserve as an introduction to these topics covered in further detail by the refresher course faculty.

MR: Practical Proton and Perfusion Imaging

Scott K. Nagle MD, PhD (Presenter): Stockholder, General Electric Company Research Consultant, VertexPharmaceuticals Incorporated

LEARNING OBJECTIVES

1) Identify the basic MR pulse sequences for clinical evaluation of lung structure. 2) Explain the advantages ofusing 3D radial ultrashort echo time MRI to image the lung. 3) List the critical scan parameters for robustevaluation of lung perfusion using time-resolved contrast-enhanced MRI.

ABSTRACT

Although many small studies have suggested a useful role for MRI in imaging lung structure and perfusion, ithas yet to see widespread use. Because CT is well-established as the primary cross-sectional imaging modalityfor the lungs, most thoracic radiologists are much more comfortable with CT than they are with MRI. This hashindered the translation of lung MRI protocols into clinical practice. However, MRI offers the potential of greatersoft tissue contrast and the ability to assess both lung structure and function without the need for ionizingradiation. The purpose of this presentation is to familiarize the thoracic radiologist with the existing MRImethods for imaging both lung structure and perfusion, to highlight how emerging methods such as 3D radialultrashort echo time MRI may improve the performance of lung MRI, and to suggest clinical scenarios in whichthoracic MRI may be most useful.

Computed Diffusion-weighted Imaging with High b-Value: How to Apply for Improving PulmonaryNodule/Mass Assessment Capability with Acquired Diffusion-weighted Imaging

Hisanobu Koyama MD, PhD (Presenter): Nothing to Disclose , Yoshiharu Ohno MD, PhD : Research Grant,Toshiba Corporation Research Grant, Koninklijke Philips NV Research Grant, Bayer AG Research Grant, DAIICHISANKYO Group Research Grant, Eisai Co, Ltd Research Grant, Terumo Corporation Research Grant, Fuji YakuhinCo, Ltd Research Grant, FUJIFILM Holdings Corporation Research Grant, Guerbet SA , Shinichiro Seki : Nothing to Disclose , Mizuho Nishio MD, PhD : Research Grant, Toshiba Corporation , Takeshi Yoshikawa MD : Research Grant, Toshiba Corporation , Sumiaki Matsumoto MD, PhD : Research Grant, ToshibaCorporation , Masao Yui : Employee, Toshiba Corporation , Hitoshi Yamagata PhD : Employee, ToshibaCorporation , Yu Ueda PhD : Nothing to Disclose , Katsusuke Kyotani RT : Nothing to Disclose , Kazuhiro Kubo RT : Nothing to Disclose , Kazuro Sugimura MD, PhD : Research Grant, Toshiba Corporation ResearchGrant, Koninklijke Philips NV Research Grant, Bayer AG Research Grant, Eisai Co, Ltd Research Grant, DAIICHISANKYO Group

PURPOSE

Computed diffusion-weighted imaging (cDWI) is the newly proposed method to generate DWI with arbitraryb-values from acquired DWIs (aDWIs) with different b values. The purpose of this study is to directly andprospectively compare capabilities for pulmonary nodule/mass detection and differentiation of malignant frombenign lesions among cDWI and aDWIs.


Ninety-seven patients (64 men and 33 women, mean age 69.1 years) with 121 pulmonary nodules/masses(mean diameter; 28.9mm, median; 24mm) underwent DWI with b values at 0, 500 and 1000 s/mm2 by 1.5 TMR system. According to pathological and/or follow up examinations, these pulmonary lesions were divided intomalignancy (n=97) and benign (n=24). Then, cDWI with b value at 1,000 s/mm2 (cDWI1000) werecomputationally generated from aDWIs with b-values at 0 and 500 s/mm2 by our propriety software. Toevaluate detection capability of DWI, aDWIs with b values at 500 s/mm2 (aDWI500) and 1,000 s/mm2(aDWI1000) and cDWI1000 were visually assessed by means of 5-points scoring system. For quantitativediagnosis of pulmonary lesion, lesion to spinal cord ratio (LSR) on each DWI was calculated. To evaluate thedetection capability, detection rate was compared among aDWI500, aDWI1000 and cDWI1000 by McNemar'stest. To determine the feasible threshold value for differentiation, ROC-based positive test was performed, anddifferentiation capability was compared by sensitivities (SE) and accuracies (AC) among aDWI500 with andwithout cDWI1000, aDWI1000, and cDWI1000 by McNemar's test.

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RESULTS

The detection rate of aDWI500 (99.2%) was significantly higher than that of aDWI1000 (92.6%, p<0.05),however no significant difference with that of cDWI1000 (96.7%, p>0.05). There was no significant differenceamong aDWI500 without cDWI1000 (SE; 72.6%, and AC; 70.3%), aDWI1000 (SE; 73.2%, and AC; 71.9%) andcDWI1000 (SE; 78.5%, and AC; 75.2%). However, the SE and AC of aDWI500 with cDWI1000 (SE; 80.4%, andAC; 76.9%) were significantly higher than those of aDWI500 without cDWI1000 and aDWI1000 (p<0.05).

CONCLUSION

Computed DWI was useful technique, and the combination of aDWI500 with cDWI1000 would be better tochoose in clinical practice for the evaluation of pulmonary nodules/masses.


Computed DWI with high b value added to really acquired DWI with a relatively low b value improves thediagnostic capabilities for the evaluation of pulmonary nodule/mass.

MR: Building a Clinical Program

Jeanne B. Ackman MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) Learn why nonvascular thoracic MRI has been underutilized despite proven advantages in tissuecharacterization (e.g. mediastinal masses) and its absence of ionizing radiation. 2) Learn what should be doneto increase its utilization to an appropriate level for good patient care. 3) Learn the various componentsrequired to build and maintain a successful nonvascular thoracic MRI practice.

ABSTRACT

Nonvascular thoracic MRI has been underutilized despite proven advantages in tissue characterization and itsabsence of ionizing radiation because of insufficient nonvascular thoracic MR training during residency andfellowship, a resultant lack of recognition of its value to patient care, and a resultant discomfort inrecommending, protocoling, and interpreting thoracic MR studies. Improved education of trainees,technologists, and radiologists is needed to increase its utilization to an appropriate level for good patient care.Nonvascular thoracic MRI can be cost-effective when considered in the context of the full care cycle of thepatient. The various components required to build a successful nonvascular thoracic MRI practice, include: 1)continuous development and maintenance of updated MR protocols, 2) continuous sharing of these updatedprotocols with one's radiology group, 3) MRI technologist training with regard to thoracic anatomy, cardiacgating, and successful breath-hold imaging, 4) education of referring physicians about the value of nonvascularthoracic MRI to their practice, 5) facilitation of ordering of these MR examinations via computer order entry, 6)creation of structured reporting voice recognition Macros to facilitate reporting by trainees and staff, 7) sharingof interesting and instructive MRI cases at weekly conferences, 8) a quality assurance initiative.

Hyperpolarized 129Xe Gas-Transfer Spectroscopy and Imaging: Initial Experience in Patients withIdiopathic Pulmonary Fibrosis (IPF)

Justus E. Roos MD (Presenter): Nothing to Disclose , Sivaram Kaushik MS : Nothing to Disclose , H. Page McAdams MD : Research Grant, General Electric Company Consultant, MedQIA Author, Reed Elsevier Author,UpToDate, Inc , Bastiaan Driehuys PhD : Research support, General Electric Company Royalties, GeneralElectric Company Stockholer, Polarean, Inc

PURPOSE

Inhaled hyperpolarized 129Xe diffuses across the alveolar-capillary membrane and dissolves into twocompartments: interstitium (barrier) and red blood cells (RBC). This results in an almost 200 ppm frequencyshift in 129Xe resonance. The aim of this study is to quantify global and regional pulmonary gas-transfer usinghyperpolarized (HP) 129Xe gas transfer MR spectroscopy and MRI, in healthy volunteers and subjects with IPF.


This IRB-approved and HIPAA compliant study was performed on a 1.5T GE clinical scanner. Gas transferspectra were acquired in 11 healthy volunteers (HV) and 6 IPF subjects using 200-mL of HP 129Xe. Globalgas-transfer was quantified using the ratio of the areas under the curves of the RBC and barrier resonancespectra. This RBC:Barrier ratio was correlated with DLCO. In two IPF subjects, 3D images of gas transfer toRBCs were reconstructed using a 1-point Dixon acquisition. Regional gas-transfer defects on RBC images werevisually scored by dividing each lung into 16 regions (32 per subject). Presence or absence of 129Xe RBC signalin each region was correlated with the extent of fibrosis in the same region on CT (scored as no, mild, or severefibrosis).

RESULTS

The RBC:Barrier ratio in IPF subjects was significantly reduced (0.16±0.03) when compared to healthyvolunteers (0.55±0.13, p

CONCLUSION

Gas-transfer MR spectroscopy and imaging using HP 129Xe can detect global and regional diffusion impairmentin IPF patients and may correlate with extent of pulmonary fibrosis depicted by CT. 129Xe MRI can provide aradiation-free method for sensitive assessment of regional gas transfer and may be a useful biomarker toassess response to therapy.

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Inhaled hyperpolarized 129Xe diffuses across the alveolar-capillary membrane and dissolves in the pulmonaryred blood cells (RBC). This closely mimics the diffusion of O2 and hence imaging of 129Xe in RBCs can depictpulmonary gas exchange.

MR: Assessing Lung Function

Talissa A. Altes MD (Presenter): Research Grant, Vertex Pharmaceuticals Incorporated Research Grant,Novartis AG Speaker, Koninklijke Philips NV Speaker, Guerbet SA

LEARNING OBJECTIVES

1) Understand the limitations of proton lung MRI and the strengths and weaknesses of hyperpolarized gas MRIof the lung. 2) Learn about potential research and clinical applications of hyperpolarized gas lung MRI in lungdiseases such as CF, asthma, and COPD.

19F Perfluoropropane/Oxygen Gas Contrast Enhanced MRI of Pulmonary Ventilation: ImageReduction, Analysis and Resulting Physiological Biomarkers

Cecil Charles PhD (Presenter): Research Grant, Merck & Co, Inc , Ahmed Halaweish PhD : Employee,Siemens AG , H. Page McAdams MD : Research Grant, General Electric Company Consultant, MedQIA Author,Reed Elsevier Author, UpToDate, Inc , Niel R. MacIntyre MD : Nothing to Disclose , Richard D. Moon MD : Nothing to Disclose , Maureen D. Ainslie MS, RT : Nothing to Disclose , William M. Foster PhD : Nothing toDisclose

PURPOSE

19Fluorine Gas MRI provides a dynamic assessment of pulmonary ventilatory function. The purpose of this workis the demonstrate extraction and generation of image based biomarkers of pulmonary ventilation for utilizationin clinical trial and clinical settings.


Imaging [45 Normals (28 Non smokers, 9 exsmokers, 8 smokers), 7 COPD] was performed on a Siemens TIMTrio 3T MRI scanner and consisted of conventional localizing scout and inspiratory/expiratory breath-held scans(1H) and 3D GRE-VIBE functional scans using Perfluoropropane/Oxygen gas mixtures (19F, TR/TE ,15/1.62 ms,NEX=2, Matrix=64x64, slice=15mm, pixel size=6.25x6.25 mm, flip angle= 70°). All acquisitions wereperformed at total lung capacity to facilitate anatomical correlation utilizing an in house developed gas deliveryand subject monitoring apparatus. A total of at least 7 sequential breath holds were performed, interleaved with3-4 breaths of the O2/PFP mixture (wash-in), or room air (wash-out). Using an in house developed pythonbased script, all 3D masked [masked using Slicer (www.slicer.org)] lung volumetric image datasets werereduced to a single table representing the x,y and z coordinates and pixel value then concatenated to a 4Dx,y,z,t,value table. Data analysis was accomplished using standard features of JMP (SAS Institute).

RESULTS

Image reduction facilitated the use of established statistical algorithms and functions to evaluate biomarkers.Each imaging session provides an array of ventilation assessments throughout the wash-in and wash-out times(seconds) of PFP gas including static and dynamic ventilation distribution, gas trapping, ventilationheterogeneity, ventilation defect persistence and clearance and regional efficiency of ventilation.

CONCLUSION

Dynamic evaluation of the pulmonary airspaces using PFP enhanced MRI provides a straight-forward andrelatively inexpensive means for evaluating ventilatory heterogeneity and providing a spatio-temporaldescriptor of 'slow to fast filling compartments' in pulmonary disorders. Simplification of data reduction presentsmany avenues for generation of pulmonary ventilation based biomarkers to evaluate the integrity and functionalstatus of the pulmonary airspaces.


19F-Enhanced MRI of Pulmonary function using PFP gas facilitates dynamic quantitative and qualitativeassessments of pulmonary ventilation and the generation of clinically viable imaging biomarkers.

MR: Imaging of Childhood Diseases

Edward Yungjae Lee MD, MPH (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) Review practical approach to pediatric patient preparation for thoracic MR imaging. 2) Discuss currentlyavailable MRI techniques for evaluating thoracic disorders in children. 3) Learn characteristic MRI findings tonarrow the differential diagnoses of various thoracic childhood diseases.

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Case-based Review of Nuclear Medicine: PET/CT Workshop—Cancers of the Thorax (In

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Case-based Review of Nuclear Medicine: PET/CT Workshop—Cancers of the Thorax (InConjunction with SNMMI) (An Interactive Session) Multisession Courses

OI NM CT CH OI NM CT CH



Tue, Dec 2 10:30 AM - 12:00 PM Location: S406A

ParticipantsKatherine Anne Zukotynski MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) Apply basic anatomic, pathologic, and physiologic principles to the interpretation of PET/CT with emphasis on cancers of thethorax. 2) Identify artifacts that can influence interpretation of PET/CT studies and analyze factors that can improve imagequality while minimizing patient risk. 3) Demonstrate understanding of issues on current and future practice patterns.

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Chest Tuesday Poster Discussions Scientific PostersCH AMA PRA Category 1 Credits ™: .50

Tue, Dec 2 12:15 PM - 12:45 PM Location: CH Community, Learning Center

ParticipantsModeratorHiroto Hatabu MD, PhD : Research Grant, Toshiba Corporation Research Grant, AZE, Ltd Research Grant, Canon Inc

Sub-Events Diffuse Peribronchovascular Opacities on CT: Profiling and Pathological Backgrounds of this UniqueFinding (Station #1)

Takeshi Johkoh MD, PhD (Presenter): Research Consultant, Bayer AG Research Consultant, F. Hoffman-LaRoche Ltd , Kiminori Fujimoto MD, PhD : Nothing to Disclose , Hiroaki Arakawa MD : Nothing to Disclose , Tomonori Tanaka MD : Nothing to Disclose , Junya Fukuoka : Nothing to Disclose , Noriyuki Tomiyama MD, PhD : Nothing to Disclose

PURPOSE

Diffuse peribronchovascular opacities on CT, also called "twitter sign" were defined as areas with ground-glassattenuation or airspace consolidation which diffusely distribute along relatively central bronchus and pulmonaryarteries on CT (Fig). Although various diseases share this abnormality, disease spectrum, frequency, andpathological backgrounds have been still unclear. The purpose of the study was to profile the diseases whishshow this unique finding and to demonstrate its pathological backgrounds


From 2008 to 2012, at four institutes, 42 patients showed diffuse peribronchovascular opacities on CT. Clinicaldiagnosis, clinical course and prognosis were abstracted from each hospital record. The patients ranged from 28to 70 years of age (mean42), and included 22 males and 20 females. Two observers independently evaluatedCT findings .Three cases were done surgical lung biopsy and two cases were done autopsy. In these five cases,precise radiologic pathologic correlation was done.

RESULTS

Clinical diagnosis include 17 drug induced penumonitis (40%), 10 collagen vascular disease (24%), sevencryptogenic organizing pneumonia (17%), three non-specific interstitial pneumonia (7%), two acute respiratorydistress syndrome (ARDS) (5%), two acute interstitial pneumonia (5%), and one pneumocystispneumonia(2%). Ten cases (24%) showed acute process, 27 (48%) showed subacute one, and remaining five(12%) showed chronic one. Forty cases (95%) showed good response to treatment and recovered. In twoautopsy cases, peribronchovascular opacities corresponded to organization, fibrosis, and cellular infiltrationalong central bronchus and pulmonary arteries. In all cases with autopsy and surgical biopsy, pathologicaldiagnosis was organizing pneumonia supervening with fibrosis.

CONCLUSION

Although the diseases with diffuse peribronchovascular opacities are rare, they seem to share common clinicaland pathological findings such as subacute or acute onset, good prognosis, and organizing pneumonia withfibrosis. A new disease entity may be defined by using imaging method.


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Diseases with diffuse peribronchovascular opacities on CT share common clinical and pathological findings suchas such as subacute or acute onset, good prognosis, and organizing pneumonia with fibrosis

Assessment of Efficacy of Automatic 2D-fusion Module to Identify Unknown Body using ForensicImaging—Comparison of Ante-mortem Chest X-ray and Post-mortem Chest CT (Station #2)

Norihiro Shinkawa MD (Presenter): Nothing to Disclose , Ryuichi Nishii MD, PhD : Nothing to Disclose , Hiroki Tamura : Nothing to Disclose , Ichijo Hodaka : Nothing to Disclose , Nobuhiro Yukawa : Nothing toDisclose , Shigeki Nagamachi MD, PhD : Nothing to Disclose

PURPOSE

Identification of unknown deceased body has been performed mainly based on DNA profiling, fingerprinting ordental X-ray, however preparation of referred ante-mortem samples under controlled condition are complicated.Recently, post-mortem whole body CT has been widely used. And chest X-ray is also widely available not onlyfor chest diseases but also for medical checkup. The purpose of this study is to develop novel method foridentification unknown body using forensic imaging. As the initial examination, we assess the concordancebetween post-mortem chest CT and ante-mortem chest X-ray.


Among 82 subjects performed post-mortem CT in our institute from April 2010 to February 2014, 15 subjects(11 male and 4 female, 65±19 years) who underwent chest X-ray (as an ante-mortem imaging) more than 1year ago were enrolled in this investigation. To compare chest coronal CT focused on the soft tissue attenuationand chest X-ray among same person and others, total of 225 tests were performed using automatic 2D-fusionmodule of the image analysis workstation Vincent(Fujifilm Medical System, Japan).

RESULTS

For the automatic 2D-fusion module, anatomical landmarks were placed in both apex and sub-carina (3-pointmethod), or both medial margin of the thorax at the horizontal level of the sub-carina in addition to above 3point(5-point method). Each CT was superimposed on X-ray using 3-point or 5-point method. Distance score ofthe portion gap of landmark (mm) between post-mortem CT and ante-mortem X-ray was assessed using themodule in the workstation. In the 3-point method, when employing same person's CT and X-ray, mean distancescore of position gap were 4.13±2.99, in contrast 5.61±3.08 when employing those images of different person(P=0.06). In the 5-point method, when employing those images of the same person, mean distance score ofposition gap were 4.70±2.57, in contrast 6.77±2.73 when employing those images of different person(P<0.01).

CONCLUSION

To identify the unknown deceased body, post-mortem CT was considered to be useful by comparing withante-mortem chest X-ray. Using 5-point method, automatic 2D-fusion module of the Vincent workstation wasuseful tool to identification of post-mortem CT.


This novel imaging analysis method is promising to develop newly-proposed computer assisted diagnosticimaging for swift and precise identification of unknown deceased body.

Pulmonary Fibrosis in ANCA-associated Vasculitis: Radiologic Patterns at Diagnosis and Follow-up(Station #3)

Anne Laure Brun MD (Presenter): Nothing to Disclose , Cloe Comarmond : Nothing to Disclose , David Saadoun : Nothing to Disclose , Philippe A. Grenier MD : Nothing to Disclose

PURPOSE

Pulmonary fibrosis (PF) is a rare but therapeutically challenging manifestation observed in patients withANCA-associated vasculitis (AAV), particularly microscopic polyangiitis (MPA). The aim of the current study wasto describe imaging patterns and evolution of PF in a large multicentric series of 42 patients with AAV.


This retrospective study is based on 42 patients with AAV (fourty MPA, two granulomatosis with polyangiitis)and PF diagnosed and followed up in 16 medical centers, between January 1996 and June 2013. Tworadiologists blinded to the clinical and histopathological data, reviewed initial chest computed tomographic(HRCT) scans to establish the type [usual interstitial pneumonia (UIP), non specific interstitial pneumonia(NSIP), combined pulmonary fibrosis-emphysema (CPFE)], and severity of PF. Patterns and coarsenessevolution were also studied in 30/42 patients with a median follow-up of 30 months.

RESULTS

The initial HRCT pattern included typical UIP (n=18, 43%), atypical UIP (n=6, 14%), fibrotic NSIP (n=3, 7%),CPFE (n=9, 21.4%), NSIP (n=4, 9.5%) and undetermined patterns in 2 patients (4.8%). Patients with NSIP andfibrotic NSIP had a lower coarseness score compared to patients with CPFE, atypical or typical UIP (mediancoarseness score of 3.25 [0-5] and 6 [4-10] versus 8 [4-15], 9 [4-12] and 10 [3-15], respectively.

After a median follow-up of 30 [2-75] months, PF had progressed in 22/30 (73%) patients and was stable in 8patients (27%). The severity of PF based on extension and/or coarseness scores had worsened for all but one

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UIP, all but one NSIP, and two on six CPFE. Three on four atypical UIP and one on two fibrotic NSIP had turnedinto typical UIP patterns.

CONCLUSION

UIP is the main pattern associated with AAV but other initial patterns may be encountered at diagnosis,including NSIP and CPFE. Thus, AAV should be part of the etiologic investigation of all patients presenting withNSIP, CPFE or UIP patterns.


UIP is the main pattern of PF in patients presenting with AAV and PF, but other patterns may be encountered atdiagnosis, including NSIP and CPFE.

Pain Perception in Patients Undergoing CT Guided Lung Biopsies (Station #4)

Zonia Ghumman (Presenter): Research support, Toshiba Corporation , Hassan Shoushtari MD : Nothing toDisclose , Ravi Menezes PhD : Nothing to Disclose , Demetris Andrea Patsios MBBCh : Nothing to Disclose , Yasser Karimzad BSc : Nothing to Disclose , Narinder S. Paul MD : Research funded, Toshiba Corporation

PURPOSE

To identify patients at increased risk for pain related to CT guided fine needle aspiration biopsy (CT-FNAB) ofthe lung.


IRB approved prospective recruitment of patients referred for CT-FNAB from February-May 2013. Patientscompleted 3 questionnaires: 30 minutes prior to CT-FNAB (Q1), 30 minutes post CT-FNAB (Q2) and ≤72 hourspost CT-FNAB (Q3). The validated Brief Pain Inventory (BPI) was included to assess how pain interfered in thepatients' daily activities and was rated based on pain severity (PS) and pain interference (PI). The BPI usednumerical rating scales from 0 (no pain/interference) to 10 (severe pain/interference). The radiologistdocumented use of IV analgesia (fentanyl 50-100mcg) and sedation (midazolam 1-2mg) during CT-FNAB (Q4).

RESULTS

The study cohort included 50 patients (29 males, 21 females), with a mean age of 65.2 years ([40, 83], SD9.5). BPI scores [mean (range)] showed PS and PI scores pre-procedure = 1.14 (0-6.8) and 0.93 (0-7.3), and48-72 hours post-procedure = 1.05 (0-6.3) and 0.58 (0-6.7) respectively. Most patients had low mean PS andPI scores pre- and post-procedure. A subset of 9/50 patients (18%) had chronic discomfort from pre-existingconditions and scored the highest in both domains. Mean PS and PI domains pre-procedure for this populationwere 3.69 (1.5-6.8) and 3.78 (0-7.3), while mean PS and PI domains post-procedure were 3.33 (0-6.3) and2.14 (0-6.7). Patients in the prone position (36/50, 72%) experienced significantly more discomfort thanpatients in the supine position (p=0.013, Mann-Whitney test). Additional IV analgesia and sedation was onlyrequired in 5 patients (10%) all of whom were prone during CT-FNAB.

CONCLUSION

Patients with pre-existing painful conditions and those who require prone positioning during CT-FNAB are athigher risk for procedure related pain. Patients with co-morbid painful conditions can be identifiedpre-procedure using a short, validated pain score and provided with individualized pain management. Patientsthat need to be prone during CT-FNAB can be positioned strategically with extra cushioning and givenincreased analgesia for improved pain management.


Pain is a side effect of CT-FNAB that can be minimized if modifiable risk factors like patient positioning andanalgesic control are identified correctly and adjusted accordingly.

CHS-TUB

Chest Tuesday Poster Discussions Scientific PostersCH AMA PRA Category 1 Credits ™: .50

Tue, Dec 2 12:45 PM - 1:15 PM Location: CH Community, Learning Center

Sub-Events Idiopathic Pulmonary Fibrosis (IPF)/ Usual Interstitial Pneumonia (UIP) without Honeycombing onCT: CT findings in 30 Patients Diagnosed by Surgical Lung Biopsy (Station #1)

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Takeshi Johkoh MD, PhD (Presenter): Research Consultant, Bayer AG Research Consultant, F. Hoffman-LaRoche Ltd , Fumikazu Sakai MD, PhD : Research Consultant, Bayer AG Research Consultant, F. Hoffman-LaRoche Ltd Research Consultant, Takeda Pharmaceutical Company Limited Research Consultant, AstraZenecaPLC Research Consultant, Merck KGaA Research Consultant, Johnson & Johnson Research Consultant, Merck &Co, Inc Research Consultant, Kyowa-Kirin Co, Ltd Research Consultant, Bristol-Myers Squibb CompanyResearch Consultant, Pfizer Inc Speaker, DAIICHI SANKYO Group Speaker, Eisai Co, Ltd Speaker, KYORINHoldings, Inc Speaker, Shionogi & Co, Ltd Speaker, Dainippon Sumitomo Pharma Co, Ltd Research Grant, BayerAG Research Grant, Eisai Co, Ltd Research Grant, LTT Bio-Pharma Co, Ltd , Takashi Ogura MD : Nothing toDisclose , Hiroyuki Taniguchi : Research Consultant, Bayer AG Research Consultant, F. Hoffmann-La RocheLtd Research Consultant, Pfizer Inc , Tetsuo Yamaguchi : Nothing to Disclose , Masasho Bando MD, PhD : Nothing to Disclose

PURPOSE

In the ATS-ERS-JRS-ALAT 2011 IPF/ UIP guideline, CT diagnostic criteria do not include CT findingscorresponding to the two pathological hallmarks; lobular heterogeneity and perilobular predominance. The aimsof the study were to describe CT findings of IPF/UIP without honeycombing and to clarify CT findingscorresponding to lobular heterogeneity and perilobular predominance.


The study included 30 patients with IPF/UIP who had the multidisciplinary diagnosis and did not showhoneycombing on CT. The patients ranged from 55 to 70 years of age (mean 64.3), and included 22 males andeight females. Two observers independently evaluated the existences, distributions, and extents ofground-glass attenuation, airspace consolidation, reticular shadow, nodules, and traction bronchiectasis on CT.The extent of each finding was graded as following 4-points scales; 0: no involvement, 1: less than 10%involvement of tortal lung, 2: 10-30% involvement, and 3: more than or equal to 30%. Moreover, theexistences of lobular heterogeneity and perilobular opacity were also evaluated. Lobular heterogeneity wasdefined as the existence of lobules which had more than four findings including normal appearance. Perilobularopacity was determined as either irregular pleural surface, irregular thickening of bronchovascular bundles, orirregular thickened interlobular septa. Furthermore, each case was incorporated into three categories(UIP,possible UIP, and inconsistent with UIP)in CT diagnostic criteria of ATS-ERS-JRS-ALAT guideline.

RESULTS

Lobular heterogeneity, perilobular opacity, reticular shadow, ground-glass attenuation, and tractionbronchiectasis were seen in all 30 patients. Lower lobe predominance and peripheral predominance were foundin 28(93%)and 27 patients(90%), respectively. In 29 patients (97%), the extent of areas with ground-glassattenuation(Mean score; 2.2)was larger than that of reticular shadow (Mean score; 1.1)(paired t-test; p<0.01).These 29 cases were categorized into the inconsistent with UIP pattern on CT.

CONCLUSION

Perilobular opacity and lobular heterogeneity on CT are seen in all patients with IPF/UIP. Detection of bothfindings is feasible for the diagnosis of IPF/UIP.


The detection of either perilobular opacity or lobular heterogeneity on CT is the clue for the diagnosis of IPF/UIP.

Inhalation Lung Injury by Hydrogen Chloride: Radiologic Spectrum with Serial Follow-up Study(Station #2)

Ji Yung Choo MD : Nothing to Disclose , Ki Yeol Lee MD, PhD : Nothing to Disclose , JungWon Kwak(Presenter): Nothing to Disclose , Sung-Joon Park MD : Nothing to Disclose , Je Hyeong Kim : Nothing toDisclose , Eun-Young Kang MD : Nothing to Disclose , Whan Oh : Nothing to Disclose

PURPOSE

Hydrogen chloride (HCL) is a colorless, irritating and corrosive gas and vary widely used in the industry.Because of its strong acidity, it is easy for people to misunderstand that HCL inhalation is always significantlyfatal. Despite of its general use, no imaging features after inhalation exposure have been previously described.In the present study, we analyzed high-resolution computed tomography findings of HCL inhaled lung injury andreviewed its pathophysiology through literature review.


Seven patients (24 to 65 years, mean age, 41.9 years) inhaled HCL vapor on their occupational workingprocess dealing with HCL. We retrospectively reviewed clinical symptoms, initial blood gas analysis andpulmonary function test as well as serial HRCT findings.

RESULTS

HCL inhaled lung injury showed 3 patterns of HRCT findings; bilateral symmetric consolidation and GGO withinterstitial thickening in central portion suggesting permeability pulmonary edema, irregular linear abnormalitiesor centrilobular nodules in both lower lungs. These abnormalities tended to grossly improve within one weekafter exposure. Centrilobular nodules with air trapping indicating bronchiolitis and bronchiectasis may remain assequelae on follow up study after 3-6 months.

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CONCLUSION

Airspace consolidation, followed by ground glass attenuation, interlobular septal thickening and centrilobularnodules were common on the initial CT scans. Serial follow-up CT scans included bronchiolitis obliterans,bronchiectasis and mosaic attenuation. It is meaningful that this study demonstrates the serial change in lungobserved by CT after inhalation injury by HCL single gas.


It is meaningful that all patients were fully recovered without significant sequelae in current study, unlikeaspiration pneumonitis of gastric acid.

Metastases in Mediastinal and Hilar Lymph Nodes in Patients with Lung Carcinoma : QuantitativeAssessments with DW- and STIR- MR Imaging—What is the Appropriate Method for Detection ofMetastases in Lymph Nodes on the DW- and STIR- MR Images? (Station #3)

Jun Nakayama MD (Presenter): Nothing to Disclose , Kazuo Miyasaka MD, PhD : Nothing to Disclose

PURPOSE

To evaluate DW- and STIR- MR imaging for detection of metastases in lymph nodes by using quantitativeanalyses.


78 patients with lung cancer who ranged in age from 46 to 84 were examined with DW- and STIR- MR imaging.Ratios of signal intensity in lung cancer and lymph node to that in spinal cord(LcScR1s and LnScR1s) and to thatin 0.9% saline phantom (LcSR1s and LnSR1s) were calculated from DW MR images with high b values. ADCs ineach lung cancer and lymph node were calculated from DW MR images obtained with low and high b values.The difference of LcScR1s and LnScR1s(D1), that of LcSR1s and LnSR1s(D2), and that of the ADC in lungcancer and lymph node(D3) were calculated. Ratios of signal intensity in lung cancer and lymph node to that inspinal cord(LcScR2s and LnScR2s) and to that in 0.9% saline phantom (LcSR2s and LnSR2s) were calculatedfrom STIR MR images. The difference of LcScR2s and LnSc2Rs(D4), that of LcSR2s and LnSR2s(D5) werecalculated. For quantitative analysis, the threshold value for positive test was determined on a per-node basisand tested for ability to enable a correct diagnosis on a per-patient basis. Results of quantitative analyses werecompared on a per-patient basis with McNemar testing.

RESULTS

Mean LnScR1, LnSR1, LnSR2, ADC in lymph node, D1, D2, D3, and D5 in the lymph node group with metastasiswas significantly different from those in the lymph node group without metastasis(P<.05). When LnScR1 of0.629, LnSR1 of 0.774, LnSR2 of 0.320, ADC of 1.681×10-3mm2/sec., D1 of 0.598, D2 of 0.761, D3 of0.296×10-3mm2/sec.. and D5 of 0.104 were used as the positive-test threshold, sensitivities were 87.5%,87.5%, 93.8%, 81.3%, 68.8%, 87.5%, 93.8%, and 87.5%, respectively. Specificities were 83.9%, 87.1%,87.1%, 80.6%, 68.7%, 87.5%, 96.8%, and 84.4%, respectively. In terms of the results of quantitativeanalyses of DW- and STIR- MR images on a per patient basis, the sensitivity, specificity of D3 were greater thanor equal to those of LnScR1, LnSR1, LnSR2, ADC, D1, D2, and D5.

CONCLUSION

Quantitative analyses by using LnScR1s, LnSR1s, LnSR2s, ADC, D1s, D2s, D3s, and D5s enable characterizationof lymph nodes. D3s measurement may be especially useful.


The difference of the ADC value in a lung cancer and a lymph node measurement may be especially useful fordifferenting between lymph nodes with metastasis and those without metastasis.

Patients with Emphysema: What is the Actual Risk of Pneumothorax-related Complications for thesePatients during Percutaneous Lung Biopsies? (Station #4)

J. Louis Hinshaw MD (Presenter): Stockholder, NeuWave Medical Inc Medical Advisory Board, NeuWaveMedical Inc Stockholder, Cellectar Biosciences, Inc , Scott Bissell Loomis MD : Nothing to Disclose , Meghan G. Lubner MD : Nothing to Disclose , Timothy J. Ziemlewicz MD : Nothing to Disclose , David H. Kim MD : Consultant, Viatronix, Inc Co-founder, VirtuoCTC, LLC Medical Advisory Board, Digital ArtForms, Inc , Perry J. Pickhardt MD : Co-founder, VirtuoCTC, LLC Stockholder, Cellectar Biosciences, Inc , Douglas Robert Kitchin MD : Nothing to Disclose , Fred T. Lee MD : Stockholder, NeuWave Medical, Inc Patent holder,NeuWave Medical, Inc Board of Directors, NeuWave Medical, Inc Patent holder, Covidien AG Inventor, CovidienAG Royalties, Covidien AG

PURPOSE

Although it is a commonly held belief that patients with emphysema are at increased risk forpneumothorax-related complications during lung biopsy, there is a paucity of data on the subject to determineif this is actually true, and if so, the magnitude of the increase in risk. This can make it difficult to accuratelyassess the risk vs the benefit of performing these procedures in patients with significant emphysema. Thepurpose of this study was to determine whether there is an association between emphysema and the numberand severity of pneumothorax-related complications encountered during CT-guided percutaneous lung biopsies.


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We reviewed all CT-guided lung biopsies performed between August 2006 and September 2013. Patients wereexcluded if no aerated lung was crossed. All other patients were included. Data collected included: number ofpneumothoracies, number of pneumothoracies requiring an intervention (e.g. temporary catheter placement foraspiration or pleural blood patch placement), and number of pneumothoracies requiring chest tube placementand hospital admission. Presence of underlying emphysema along the biopsy path was recorded as none, mild,moderate or severe.

RESULTS

835 total patients were included in the study. The pneumothorax rate, rate of pneumothoraces requiring anintervention, and rate of pneumothoraces requiring chest tube placement and hospital admission weresignificantly higher in patients with moderate to severe emphysema as compared to those with none to mildemphysema ((86/194) 44.3% vs (212/641) 33.1%, p=0.005; (50/194) 25.8% vs (78/641) 12.2%, p=0.0001;and (19/194) 9.8% vs (20/641) 3.1%, p=0.0003, respectively)).

CONCLUSION

Moderate to severe emphysema is associated with a significantly increased rate of pneumothorax-relatedcomplications during percutaneous lung biopsies. More specifically, moderate to severe emphysema isassociated with an ~2.5 times higher rate of pneumothorax-related complication requiring intervention and an~3 times higher rate of chest tube placement and hospital admission. Understanding the magnitude of theserisks will allow improved decision making and informed consent for these patients.


This study provides an objective measure of the increased risk of lung biopsy in patients with emphysema, andthus promotes improved decision making and informed consent for these patients.

MSES33

Essentials of Chest Imaging Multisession CoursesCH AMA PRA Category 1 Credits ™: 1.50


Tue, Dec 2 1:30 PM - 3:00 PM Location: S100AB

Sub-Events The Mediastinum: A Case-based Approach

Jared Dean Christensen MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) Review common pitfalls in the diagnosis of mediastinal disease. 2) Discuss the role of radiography, CT, MR,and PET for characterizing mediastinal masses.

ABSTRACT

Mediastinal pathology is often incidentally detected at imaging and can present a diagnostic challenge. Imagingfeatures are often non-specific and definitive diagnosis frequently requires tissue. However, a systematicapproach to mediastinal interpretation can facilitate disease detection, help narrow the differential diagnosis,and direct appropriate management. This presentation will review the role of chest radiography, CT, MR, andPET imaging in the evaluation of mediastinal disease utilizing a case-based approach.

Micronodular Lung Disease

Ioannis Vlahos MRCP, FRCR (Presenter): Research Consultant, Siemens AG Research Consultant, GeneralElectric Company

LEARNING OBJECTIVES

This course provides a practical schema for interpreting micronodular lung disease. This is based onunderstanding how pathological processes affect the lung microanatomy which in turn is reflected in variantHRCT appearances. The emphasis is on understanding terminology, differentiating pathology, maximizing theuse of technology and avoiding interpretative pitfalls.

Pulmonary Edema

Melissa L. Rosado De Christenson MD (Presenter): Author, Thieme Medical Publishers, Inc Author, Amirsys,Inc Author, American Registry of Pathology Author, Oxford University Press

LEARNING OBJECTIVES

1) To define pulmonary edema and list its various types. 2) To identify typical radiographic and CT findings ofpulmonary edema. 3) To recognize conditions that mimic pulmonary edema.

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ABSTRACT

Pulmonary edema is the abnormal accumulation of extravascular lung water and is often classified ascardiogenic and non-cardiogenic types. Interstitial edema manifests on radiography with perihilar haze,subpleural edema, peribronchial cuffing, and septal thickening. Alveolar edema may manifest with consolidationon radiography and with ground-glass and acinar opacities or consolidation on chest CT. Interstitial edematypically exhibits rapid onset and resolution. Alveolar edema may have a rapid onset, but clears slowly.

SSJ05

Chest (Interventional I) Scientific PapersIR CT CH AMA PRA Category 1 Credits ™: 1.00


Tue, Dec 2 3:00 PM - 4:00 PM Location: S404CD

ParticipantsModeratorJo-Anne O. Shepard MD : Consultant, Agfa-Gevaert Group ModeratorFereidoun G. Abtin MD : Nothing to Disclose

Sub-Events Incidence and Predictors of Pulmonary Hemorrhage in Patients Undergoing Percutaneous ComputedTomography (CT)-Guided Transthoracic Needle Lung Biopsy (TTNLB): Single Institution Experienceof 1,175 Cases

Ryan Tai MD (Presenter): Nothing to Disclose , Ruth M. Dunne MBBCh : Nothing to Disclose , Beatrice Trotman-Dickenson FRCR, MRCP : Nothing to Disclose , Rachna Madan MD : Nothing to Disclose , Francine L. Jacobson MD, MPH : Nothing to Disclose , Andetta Rotilla Hunsaker MD : Nothing to Disclose

PURPOSE

To evaluate the incidence of pulmonary hemorrhage during TTNLB and investigate possible predictors forsignificant hemorrhage.


Records of 1,113 patients who underwent 1,175 TTNLB procedures from January 1, 2008 to April 22, 2013 wereretrospectively reviewed after IRB approval. Studied patient-related factors included pulmonary artery systolic(PASP) and pulmonary artery (PAP) pressures from echocardiogram and cardiac catheterization data;medications including anticoagulants, antiplatelets, and steroids; coagulation studies; and history of pulmonaryhypertension, bleeding diathesis, or immunodeficiency. CT images and reports were reviewed for biopsy-relatedfactors including lesion size, location, morphology, and distance to pleura; needle gauge; angulation to pleura;number of passes; pulmonary artery (PA) size; and chronic lung disease. Post-biopsy images were evaluatedfor pulmonary hemorrhage, which was graded: 0, none; 1, ≤2cm around needle tract; 2, >2 cm but sublobar;3, lobar; 4, >lobar or hemothorax. Primary outcomes were pulmonary hemorrhage or documented hemoptysis.Univariate analysis with chi-square, Fisher's exact, and student's t tests was used to evaluate study variables aspredictors for pulmonary hemorrhage.

RESULTS

Grade 1 hemorrhage occurred in 282 cases (24%). Significant hemorrhage, defined as greater than grade 1hemorrhage, occurred in 200 cases (17%). Twenty (1.7%) had documented hemoptysis and four (0.3%) wereadmitted due to hemorrhage. Significant hemorrhage was more likely to occur in females (p=0.0017), witholder age (p=0.0005), emphysema (p=0.0036), coaxial technique (p=0.039), and lesion size <3cm(p<0.0001), and less likely with subpleural lesions (p<0.0001). Hemorrhage occurred more frequently insubsolid lesions and less commonly in consolidation (p=0.0002). PA size, elevated PAP or PASP,immunodeficiency, and use of antiplatelets, anticoagulants, or steroids were not predictors for pulmonaryhemorrhage.

CONCLUSION

Significant pulmonary hemorrhage is more likely in females, with coaxial technique, older age, and smaller andsubsolid lesions, and less likely with subpleural lesions. Patients with suspected pulmonary hypertension maynot be at increased risk for pulmonary hemorrhage after TTNLB.


Pulmonary hemorrhage is common after TTNLB, but rarely requires intervention. TTNLB can be performedsafely in patients with suspected pulmonary hypertension.

Preliminary Clinical Experience with a Dedicated Interventional Robotic System for CT-guided

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Biopsies of Lung Lesions: A Comparison with the Conventional Manual Technique

Michele Anzidei MD (Presenter): Nothing to Disclose , Renato Argiro : Nothing to Disclose , Andrea Porfiri MD : Nothing to Disclose , Fabrizio Boni : Nothing to Disclose , Mario Bezzi MD : Nothing to Disclose , Carlo Catalano MD : Nothing to Disclose

PURPOSE

To evaluate the clinical performance of a robotic system for CT-guided biopsy of lung lesions in comparison tothe conventional manual technique.


100 patients (63 males, 37 females, age range 48-88 years, mean age 65 +/-4 years) referred for CT-guidedlung biopsy of previously diagnosed lung lesions were randomly assigned to group A (robot-assisted procedurewith the ROBIO™ EX system, Perfint Healthcare - India) or group B (conventional procedure). Biopsies wereperformed by two operators with 2 and 8 years of experience. The size, distance from entry point and positionin lung of target lesions were evaluated to assess potential homogeneity differences between the two groups.Procedure duration, dose length product (DLP), precision of needle positioning, diagnostic performance of thebiopsy, rate of complications and operator preference were evaluated for significant differences between thetwo groups to assess the clinical performance of the robotic system as compared to the conventional technique.

RESULTS

All biopsies were successfully performed. The size (p=0.41), distance from entry point (p=0.86) and position inlung (p=0.32) of target lesions were similar in both groups (p=0.05). Procedure duration and radiation dosewere significantly reduced in group A as compared to group B (p=0.001). Precision of needle positioning,diagnostic performance of the biopsy and rate of complications were similar in both groups (p=0.05).

CONCLUSION

Robot-assisted CT-guided lung biopsy can be performed safely and with high diagnostic accuracy, reducingprocedure duration and radiation dose in comparison to the conventional manual technique.


CLINICAL RELEVANCE: The precision in lesions targeting, the diagnostic performance of the biopsy samplingand the rate of complications in the robot-assisted procedures were superimposable to those of conventionalbiopsies. The use of the robot significantly reduced procedure duration and radiation dose in comparison to theunassisted technique. APPLICATION: Operators with different levels of experience may benefit from robotassistance in daily clinical routine, but the use of interventional robotic systems will be probably even morebeneficial in clinical settings in which less expert, non-interventional operators perform simple imaging-guidedprocedures.

CT-guided Localization of Small Pulmonary Nodules Using Microcoils prior to Video-assistedThoracoscopic Surgical Resection

Tianhao Su (Presenter): Nothing to Disclose , Long Jin : Nothing to Disclose

PURPOSE

To describe and optimize small peripheral pulmonary nodule localization method prior to video-assisted surgical(VATS) resection.


This study enrolled 92 patients with 101 pulmonary nodules. Microcoils were placed next to the nodules usingtwo random methods (with or without leaving microcoil end on the surface of pleura) under computedtomography guidance. The complications and efficacy of the implantation were evaluated. VATS resection oflung tissue containing pulmonary lesion and microcoil were performed by the direction of the microcoil marker.Histopathologic analyses of the pulmonary lesions were documented.

RESULTS

CT-guided microcoil implantation were successful in 99 (99/101, 98.0%) nodules within 1cm from the nodulesbut without disrupting them, while 2 (2/101, 2%) microcoils were found to be dislodged during operation.There were no difference between entire implantation (58/99, 58.6%) and leaving-microcoil-end implantation(41/99, 41.4%) method for the complications and efficacy. All nodules were removed by VATS successfully.Asymptomatic pneumothorax occurred in 16 patients, and mild pulmonary hemorrhage occurred in 9 patients,none of these patients needed further surgical treatment. The histopathologic results of the pulmonary lesionsincluded adenocarcinomas (n =77), neuroendocrine carcinoma (n =1), metastatic carcinoma (n =1). atypicalhyperplasia (n =11), hamartoma (n =1), granuloma (n =1), reactive lymph node (n =5), fibrotic hyperplasia(n =2), carbon power deposit (n =2).

CONCLUSION

Preoperative localization of small pulmonary nodules using percutaneous CT-guided microcoils implantation wasuseful and safe in successful VATS resection of pulmonary lesion.

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A refined localization method of pulmonary nodule using microcoil is a minimal and safe interventionalapproach, and is recommended prior to VATS in order to make definitive resection easy and possible.

Value of CT-guided Core-needle Biopsy in Diagnosis of Nonresolving Air Space Consolidation

Zhiwei Wang MD (Presenter): Nothing to Disclose , Xiaoguang Li MD : Nothing to Disclose

PURPOSE

To evaluate the value of CT-guided core-needle biopsy in diagnosis for patients with nonresolving pulmonary airspace consolidations


From March 2008 and June 2013, 69 patients (42 men, 27 woman; age range, 17 to 77 years; mean age,46.2±16.4 years) presenting with nonresolving pneumonia persisting more than 2 months (mean, 4.7 months;range, 2 to 16 months) underwent CT-guided core needle biopsy using an automated core needle (18-gauge).42 patients had underwent fiberscopic exminations with negative results before CT-guided biopsy. Histologicand bacteriologic evaluations were obtained from CT-guided biopsy. The diagnostic performance of CT-guidedbiopsy was assessed through comparison of surgical pathology or clinical follow-up. CT-guided biopsycomplications were recorded.

RESULTS

Specimens adequate for histopathologic evaluations were obtained in 67 (97.1%) cases. Specific diagnoseswere established in 60 (89.6%) patients, while 7 (10.4%) were nonspecific. The specific diagnoses wereadenocarcinoma (n=13), lymphoma (n=13), organizing pneumonia (n=11), infectious pneumonia (tuberculosis,n=13; aspergillus, n=6; cryptococcosis, n=2 ), and lipoid pneumonia (n=2). A mixture of chronic inflammationand fibrosis (n=6) was the most common nonspecific diagnosis. No malignancy was diagnosed on a subsequentbiopsy in that cases showed non-specific chronic inflammation and fibrosis. Immediate pneumothorax waspresent in 6 patients of cases, but only 1 patients required pleural drainage.

CONCLUSION

Among patients with nonresolving pulmonary air space consolidation, CT-guided core needle biopsy is safe andshows high degree of diagnostic accuracy.


CT-guided core needle biopsy is an appropriate diagnostic method for patients with nonresolving pulmonary airspace consolidation.

C-arm Cone-Beam CT Virtual Navigation Guided Percutaneous Transthoracic Localization of SmallPulmonary Nodule

Taeho Kim MD (Presenter): Nothing to Disclose , Chang Min Park MD, PhD : Nothing to Disclose , SangMin Lee : Nothing to Disclose , Hyun-Ju Lee MD, PhD : Nothing to Disclose , Jin Mo Goo MD, PhD : Research Grant, Guerbet SA

PURPOSE

To describe out initial experience with cone-beam CT virtual navigation guided percutaneous Lipiodollocalization of small pulmonary nodules in 31 consecutive cases.


From February 2013 to August 2013, 29 consecutive patients (15 male, 14 female; mean age, 61 years) with31 small pulmonary nodules (mean size, 14.14mm; range, 4.8-35mm) underwent preoperative Lipiodollocalization under CBCT virtual-navigation guidance system and included our study population. Lipiodol (meanamount, 0.19 mL; range, 0.15-0.2 mL) was injected around the pulmonary nodules through 21-gauge needle.Procedure details-including radiation dose, diagnostic accuracy and complication rates of CBCTvirtual-navigation-guided percutaneous Lipiodol localization-were described.

RESULTS

All nodules were localized within 12 mm (mean distance, 2.26 mm; range, 0-12mm) from the lipiodol marking(mean diameter, 10.83 mm; range, 6-19 mm). The CT findings of pulmonary nodules were 16 pure groud glassnodules, 13 part solid nodules, and 2 solid nodules. The mean number of CT acquisitions, total procedure time,and estimated radiation exposure during lipiodol marking were 3.5, 15.9 minutes, and 5.72 mSv ± 2.64,respectively. Post-procedural complications occurred in 4 (12.9%) cases, all of which was pneumothorax. Alllipiodol markings were easily visible on intraoperative fluoroscopy, and all the target nodules were completelyresected. There were no difficulties on pathologic examination and their results of the target nodules included19 invasive adenocarcinoma, 5 adenocarcinoma-in-situ, 4 atypical adenomatous hyperplasia, 1 metastaticchondrosarcoma and 2 benign lesions.

CONCLUSION

CBCT virtual-navigation-guided percutaneous lipiodol marking can be accurate, effective and safetypre-operative localization procedure, enabling highly accurate resection and safe diagnosis of small or faint

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pre-operative localization procedure, enabling highly accurate resection and safe diagnosis of small or faintpulmonary nodules.


Cone-beam CT virtual navigation guided percutaneous transthoracic localization of small pulmonary nodulecould accurately and effectively play an important role before the video assisted thoracic surgery.

How to Discriminate Malignancies Falsely-diagnosed as Non-specific Benign Lesions afterPercutaneous Transthoracic Needle Biopsy from True Benign Lesions

Jung Im Kim MD (Presenter): Nothing to Disclose , Chang Min Park MD, PhD : Nothing to Disclose , SangMin Lee : Nothing to Disclose , Kwang Gi Kim PhD : Nothing to Disclose , Jin Mo Goo MD, PhD : Research Grant, Guerbet SA

PURPOSE

To identify the distinguishing features of malignancies falsely-diagnosed as non-specific benign lesions inpathologic examinations obtained from percutaneous transthoracic needle biopsy(PTNB) from true benignlesions.


From January 2009 to December 2011, 1108 consecutive patients (633 males and 475 females; mean age,62.4 years) with 1116 lung lesions (mean size, 2.7cm ± 1.7) underwent C-Arm Cone-Beam CT (CBCT)-guidedPTNB using an 18-gauge coaxial cutting needle. Among them, 285 lesions (mean size, 2.4 cm ± 1.4) in 283patients (154 males and 129 females; mean age, 59.2 years) were diagnosed as non-specific benign lesions atpathologic evaluation. The malignancy rate of these non-specific benign pathologies was investigated. Toevaluate the discriminating clinical, radiological and pathological findings of these malignanciesfalsely-diagnosed as non-specific benign lesions from true benign lesions, univariate and multivariate logisticregression analyses were performed.

RESULTS

Among 285 lesions, 24 (8.4%) were finally diagnosed as malignant, 202 (70.9%) as benign and 59 (20.7%) asindeterminate. The negative predictive value (NPV) of the non-specific benign lesions was 89.4% (202/226). For81 lesions in which the pathologic results were granulomatous inflammation and 141 lesions with negative CTreports for lung cancer, NPVs were 100% and 99.3%, respectively. Multivariate analysis revealed that positiveCT reports for lung cancer (odds ratio (OR), 29.7; P<0.001) and granulomatous inflammations on PTNB (OR,0.03; P=0.018) were significant discriminating factors of these malignancies falsely-diagnosed as benign lesionsfrom true benignancies with excellent differentiating accuracy (area under the ROC curve, 0.944).

CONCLUSION

Among pulmonary lesions showing non-specific benign pathologies on PTNB, positive CT reports for lung cancerand pathologic results of granulomatous inflammations on PTNB were significant discriminating factors formalignancies falsely-diagnosed as non-specific benign lesions.


Among non-specific benign biopsies, false negative and true negative lesions can be accurately discriminatedthrough evaluation of diagnostic CT and pathologic reports of PTNB.

SSJ06

Emergency Radiology (Chest Emergencies) Scientific PapersVA ER CT CH AMA PRA Category 1 Credits ™: 1.00


Tue, Dec 2 3:00 PM - 4:00 PM Location: N229

ParticipantsModeratorJamlik-Omari Johnson MD : Nothing to Disclose ModeratorMartin Lee David Gunn MBChB : Medical Advisor, TransformativeMed, Inc Spouse, Consultant, Wolters Kluwer nv Grant,Koninklijke Philips NV

Sub-Events Dual-source CT of Chest in Blunt Thoracic Trauma: Reduced Aortic Motion Using a Novel IterativeTemporal Resolution Optimization Algorithm

Teresa I-Han Liang MD (Presenter): Nothing to Disclose , Patrick McLaughlin FFR(RCSI) : Nothing toDisclose , Shamir Rai BSC : Nothing to Disclose , Darra Thomas Murphy MD, FRCPC : Nothing to Disclose , Luck Jan-Luck Louis MD : Nothing to Disclose , Tim O'Connell MD, Meng : President, Resolve Radiologic Ltd

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Luck Jan-Luck Louis MD : Nothing to Disclose , Tim O'Connell MD, Meng : President, Resolve Radiologic Ltd , Ana-Maria Bilawich MD : Nothing to Disclose , John R. Mayo MD : Speaker, Siemens AG , Savvas Nicolaou MD : Nothing to Disclose

PURPOSE

Motion artifacts commonly reduce diagnostic confidence in patients with suspected blunt aortic injury. In thisstudy we evaluate a novel iterative temporal resolution optimization (TRO) algorithm in patients with bluntchest trauma undergoing contrast enhanced ultra high pitch dual source CT.


Twenty-two patients who presented to a level one trauma centre between February 18 to March 25, 2014 withblunt thoracic trauma were included. All patients were scanned using a standardized ultra high pitch dual sourceCT protocol (UHP) using a single CT system. Aortic Motion artifact was scored using a five-point Likert scalemodified from CCTA literature at multiple locations of the heart and aorta by two readers (Score of 1 = absenceof motion artifacts or noise-related blurring in any vessels; score of 5 = severe or circumferential motionartifact, prominent mural discontinuity). Mean and standard deviation of CT values within aorta, muscle and airwere recorded and signal to noise (SNR) and contrast to noise (CNR) ratios were generated as a quantitativeindex of image quality. Student t-test and Wilcoxon rank sum test were used for statistical analysis and p<0.05was considered significant.

RESULTS

Aortic motion scores were significantly lower on UHP-TRO as compared with UHP images for both readers(Aortic valve 3.5±3 vs 5±2; Aortic sinus 1±1 vs 4±3; Sinotubular junction 1±1 vs 4±2; Ascending aorta 1±1vs 3±2; p<0.0001). Motion scores were not significantly different at the aortic arch, isthmus and descendingaorta on UHP-TRO as compared with UHP images (Arch 1±0 vs 1±0.75; Isthmus 1±0 vs 1±0.75; Descendingaorta 1±0 vs 1±0.75). Mean SNR was 19.5% higher on UHP as compared with UHP-TRO (26.42 vs 21.27,p=0.01) and mean CNR scores were 27.7% higher on UHP images (13.4 vs 9.65, p=0.002).

CONCLUSION

Temporal Resolution optimized reconstruction of ultra high pitch dual-Source CT of the chest significantlyimproves motion artifact of the aorta in blunt thoracic trauma at the sacrifice of a mild reduction in SNR andCNR.


Iterative temporal resolution optimized reconstruction of ultra high pitch Dual-Source CT images of the chestqualitatively improves motion artifact in blunt thoracic trauma patients facilitating more accurate assessment ofthe aorta.

Motion Artifact Reduction from High-pitch Dual-source CT Pulmonary Angiography

Paul Michael Bunch MD (Presenter): Nothing to Disclose , Urvi Pravin Fulwadhva MD : Nothing to Disclose , Jeremy Robert Wortman MD : Nothing to Disclose , Andrew Primak PhD : Employee, Siemens AG , Aaron D. Sodickson MD, PhD : Research Grant, Siemens AG

PURPOSE

To compare quantitative measures of cardiac pulsation and respiratory motion artifact in CT pulmonaryangiograms (CTPA) performed using a high-pitch dual-source protocol and a single-source protocol.


In this retrospective, IRB-approved, HIPAA-compliant study, 50 CTPA exams were included using each of twoprotocols: 1) a high-pitch dual-source (DS) protocol and 2) a routine single-source (SS) protocol. Neitherprotocol used ECG gating. Inclusion criteria were patient age >18 years, both arms elevated above the scanregion, and no prior lobectomy or pneumonectomy. All scans were performed in the Emergency Department ona Siemens Definition Flash scanner. Each scan was evaluated for motion artifact producing a "double image"appearance, and when present, the greatest anatomic overlap interval was measured perpendicular to the axisof the ascending aorta, left ventricular lateral wall, and diaphragm. Measurements were performed on axialimages for aortic and cardiac motion and on coronal reformatted images for diaphragmatic motion. Statisticalanalysis was performed using one way ANOVA.

RESULTS

There was no statistically significant difference in patient gender, age, or effective diameter between the twocohorts. High-pitch DS CTPA scans used a mean pitch of 2.9 (range 1.6-3.0), resulting in a mean scan durationof 0.8 seconds (range 0.6-1.7). Routine SS technique used pitch 0.75 for a mean scan duration of 4.6 seconds(range 3.6-5.8). DS outperformed SS technique with respect to quantitative measures of ascending aortic,cardiac, and diaphragmatic motion. Mean distances between motion-artifact double images were reduced at theascending aorta from 4.1 mm with SS to 0.3 mm with DS, at the left ventricular lateral wall from 5.3 mm withSS to 1.2 mm with DS, and at the diaphragm from 2.2 mm with SS to 0.1 mm with DS, all with p<0.001.

CONCLUSION

High-pitch dual-source CTPA is an effective means to significantly reduce artifacts resulting from ascendingaortic, cardiac, and diaphragmatic motion.

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High-pitch dual-source CTPA significantly reduces cardiac and respiratory motion artifact without the need forECG synchronization, which may result in increased diagnostic confidence during evaluation for pulmonaryembolus as well as cardiac and aortic causes of chest pain.

Dual Source, Ultra High Pitch CT Pulmonary Angiography (CTPA) Reduces Motion and Allows forAccurate Evaluation of the Proximal Coronary Arteries in Approximately 50% of Patients Imaged forSuspected Pulmonary Embolism

David M. Thomas BSC (Presenter): Nothing to Disclose , Sarah Anne Barrett MBBCh : Nothing to Disclose , Patrick McLaughlin FFR(RCSI) : Nothing to Disclose , John R. Mayo MD : Speaker, Siemens AG , Ana-Maria Bilawich MD : Nothing to Disclose , Savvas Nicolaou MD : Nothing to Disclose , Graham Wong MD, MPH : Nothing to Disclose , Luck Jan-Luck Louis MD : Nothing to Disclose

PURPOSE

As rotation time, coverage and pitch increase, modern CT systems are more likely able to produce motion freeimages of the coronary arteries during CTPA scans. The purpose of this study was to compare coronary arterymotion and diagnostic acceptability between dual source ultra high pitch (UHP), single source (SS) and dualsource dual energy (DE) CTPA studies.


362 consecutive patients underwent CTPA scans for suspected pulmonary embolism between Sept 1, 2013 andJan 31, 2014. 238 UHP, including 194 at 100kV (UHP-100kV) and 44 at 120kV (UHP-120kV), 57 SS scans, and37 DE scans were analyzed. Coronary arteries were separated into nine segments, and coronary artery motionwas qualitatively scored using a scale from 1-4 (non-interpretable to diagnostic with no motion artifacts) toassess the quality of each protocol for visualization of the coronary arteries. CTDI and DLP values were collectedfor each scan to determine the effective radiation dose. Signal intensity, noise, and signal to noise ratio (SNR)of the aorta, main pulmonary artery, and paraspinal muscles were also assessed.

RESULTS

The UHP-120kV and UHP-100kV scans had the lowest amount of motion, with 38.8% and 30.1% of coronarysegments being evaluable compared to 4.2% of SS segments. Proximal coronaries were more diagnostic thandistal coronaries UHP-120kV (53.5% vs 24%, median score 2 vs 1, p0.05), and both were higher than theUHP-100kV group (20.04 vs 15.80, p

CONCLUSION

UHP-120kV CTPA significantly reduced coronary artery motion and allows for accurate evaluation of theproximal coronary arteries compared to SS CTPA, without a statistically significant impact on SNR. UHP-100kVresulted in 77.2% less radiation exposure than SS although it came at the expense of an 18.8% reduction inaverage SNR.


UHP CTPA protocols can be used to assess the proximal coronary arteries while maintaining the ability to rule inor out pulmonary embolism in patients with chest pain.

CTA in the ED: Impact of Contrast Timing Technique on Scan Duration

Martin Lee David Gunn MBChB (Presenter): Medical Advisor, TransformativeMed, Inc Spouse, Consultant,Wolters Kluwer nv Grant, Koninklijke Philips NV , Bruce E. Lehnert MD : Nothing to Disclose , Anda Maria Cornea MD, PhD : Nothing to Disclose , Christopher Allen Potter MD : Nothing to Disclose

PURPOSE

To compare the impact of contrast timing technique on scan duration and arterial enhancement for thoracic CTangiography.


Retrospective, single center, IRB approved study that evaluated consecutive patients who had undergone singlepass CT angiography of the thorax on a GE LightSpeed 16 CT scanner using 3 contrast timing techniques. GroupA consisted of 86 patients who underwent CT pulmonary angiography (CTPA) using a timing bolus. Group Bconsisted of 74 patients who underwent a fixed-delay biphasic non-gated 'double rule out' CTPA and aortic CTAprotocol. Group C consisted of 58 patients who underwent thoracic aortic CTA using a bolus triggering (tracking)technique. The primary endpoint was comparing the duration (in seconds) between the acquisition time of thelast scout image and the first axial post-contrast image in all three groups. The secondary endpoint wasvascular enhancement (HU) of the main pulmonary artery (MPA) and thoracic aorta. Statistical techniquesincluded a 3-way ANOVA for three group analysis and t-tests to compare specific protocols. p < 0.05 wasconsidered statistically significant.

RESULTS

There was a statistically significant (p<0.0001) difference in the average delay between the last scout imageand axial acquisition in the three groups: group A (timing) 330 seconds (CI 302-358), group B (triggering) 250seconds (CI 221-279), and group C (fixed delay) 160 seconds (CI 136-184); group A vs B (p=0.002), B vs C(p<0.0001), and A vs C (p<0.0001). Comparing MPA enhancement between group A (416HU, CI 388-444) andgroup C (442HU, CI 411-473) yielded no statistically significant difference (p=0.207). Comparing aorticenhancement between group B (363HU, CI 338-389) and group C (425HU, CI 399-451) yielded a significantdifference (p=0.001), with greater enhancement in group C. Similar volumes of contrast were used in the threegroups.

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CONCLUSION

CTA using a fixed delay contrast enhancement technique is almost 3 minutes faster to perform than a timingbolus, with no impairment in vascular enhancement. This appears to be due to time taken by the technologiststo perform the necessary steps. Three minutes is about 10% of the average CT scan slot duration.


Choosing a bolus triggering or a fixed delay could shorten the scan duration for urgent ED CTAs and allow formore patients, and potentially less stable patients, to get scanned.

Exponentially Decelerated Contrast Media Injection Rate Combined with A Novel Patient-specificContrast Formula Reduces Contrast Volume Administration During Computed TomographyPulmonary Angiography

Charbel Saade MS (Presenter): Nothing to Disclose , Hussain Al-Mohiy : Nothing to Disclose , Mukbil H. Hourani MD : Nothing to Disclose

PURPOSE

To investigate opacification of the pulmonary vasculature during CTPA using a patient-specific contrast formulaand exponentially decelerated contrast media injection rate.


CTPA was performed on 150 patients with suspected PE using a 256 channel computed tomography scannerand a dual barrel contrast injector. Patients were randomly assigned to two equal protocol groups: protocol A,the department's conventional protocol, employed a patient-specific contrast formula based on measuredpatient cardiovascular dynamics. Protocol B involved the use of a patient-specific contrast formula combinedwith exponentially decelerated contrast media injection rate. Both protocols used a 50 mL saline flush at 4.5mL/s and a craniocaudal scan direction. Patient age and gender were equally distributed across both groups.The mean cross-sectional opacification profile of eight central and eleven peripheral pulmonary arteries andveins were measured for each patient and arteriovenous contrast ratio (AVCR) calculated for each lungsegment. Protocols were compared using Mann-Whitney U non-parametric statistics. Jackknife alternativefree-response receiver operating characteristic (JAFROC) analyses were used to assess diagnostic efficacy.Inter-observer variations were investigated using Kappa methods

RESULTS

A number of pulmonary arteries demonstrated increases in opacification (p<0.02) for protocol B compared withA whilst opacification in the heart and all veins was reduced in protocol B (p<0.03). Subsequently, increasedAVCR in protocol B compared with A was observed at all anatomic locations (p<0.0002) where this ratio couldbe calculated. An increase in JAFROC figure of merit (p<0.0002) and inter-observer variation was observed withprotocol B compared with A with the latter metric increasing from (κ = 0.3) to (κ = 0.73) respectively. Meancontrast volume was reduced in protocol B (29±4 mL) compared to A (33±9 mL).

CONCLUSION

Significant improvements in visualisation of the pulmonary vasculature can be achieved with a low contrastvolume CT acquisition using an exponentially decelerated contrast media injection rate and a patient-specificcontrast formula


Matching contrast injection timing with vessel dynamics significantly improves vessel opacification and reducescontrast dose in the assessment of pulmonary embolism during computed tomography pulmonary angiography.

Comparison of Routine Chest Dual Energy CT Protocol with Single Energy CT Pulmonary AngiographyProtocol: Vascular Enhancement and Incremental Value

Alexi Otrakji MD (Presenter): Nothing to Disclose , Efren Jesus Flores MD : Nothing to Disclose , Roberto Lo Gullo MD : Nothing to Disclose , Jo-Anne O. Shepard MD : Consultant, Agfa-Gevaert Group , Mannudeep K. S. Kalra MD : Nothing to Disclose , Subba Rao Digumarthy MD : Nothing to Disclose , Margaret Kave BS, RT : Nothing to Disclose

PURPOSE

To assess if "contrast enhanced routine chest dual energy CT protocol" (DECT-RC) can provide acceptablevascular enhancement and additional parenchymal information compared to "single energy CT pulmonaryangiography" protocol (SECT-PA).


Our IRB approved retrospective study included 200 adult patients who underwent either DECT-RC (n= 100patients, M: F 47:53,mean age 62±15years, mean weight 76±19kg) or SECT-PA (n=100 patients, M:F 43:57,mean age 59±17years, mean weight 84±24kg). All CT examinations were performed on dual source MDCT(Siemens Definition Flash) or single source 64-row MDCT (GE 750HD Discovery). For DECT-RC, we generatedimages 60kev, pulmonary blood volume images (PBV) and virtual non-contrast images (VNC) images intransverse plane at 2.5mm thickness. Transverse SECT-PA images were reconstructed at both 1.25 and 2.5mmthicknesses. Two thoracic radiologists assessed main, lobar, segmental and subsegmental pulmonary arterial

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thicknesses. Two thoracic radiologists assessed main, lobar, segmental and subsegmental pulmonary arterialenhancement and filling defects in addition to diagnostic confidence, pulmonary and mediastinal abnormalitieson 60 kev, PBV and VNC images. CTDI vol, and DLP were recorded for each patient.

RESULTS

Radiation dose for DECT-RC (7.2 ± 2.1mGy,260.4 ± 83.2 mGy.cm,3.6 ± 1.2 mSv) was significantly lower thanSECT-PA protocol (15 ± 7.9 mGy,499.3±276.4 mGy.cm,7 ± 3.9 mSv) (p=0.0040). Optimal to excellentenhancement in pulmonary arteries was noted with DECT-PA (85%, 85/100 patients) and in 82% of SECT-PA(82/100 patients) (p>0.05). Limited to unacceptable pulmonary arterial enhancement was noted in % (15/100patients) with DECT-RC and % (18/100 patients) with SECT-PA protocols. PBV images were deemed to providehelpful incremental value in making the diagnosis in 72% of patients (72/100) mostly in patients with perfusiondefects from air trapping (better seen on PBV), consolidation, atelectasis, and pulmonary embolism. Theincremental value of VNC images were helpful in 4/100 patients only with high attenuation lung nodules (n=1)and mediastinal lymph nodes (n=3).

CONCLUSION

Contrast enhanced routine chest protocol with DECT has the potential to replace SECT pulmonary angiographyprotocol for providing required pulmonary arterial enhancement as well as helpful additional information forevaluation of lung lesions.


Routine chest CT with DECT can provide similar or better information compared to single energy CT pulmonaryangiography without incurring any radiation penalty.

RC401

Contemporary Imaging of Lung Cancer Refresher/InformaticsOI MR MI CT CH AMA PRA Category 1 Credits ™: 1.50


Tue, Dec 2 4:30 PM - 6:00 PM Location: N230AB

ParticipantsModeratorJeremy J. Erasmus MD : Nothing to Disclose

Sub-Events Non-small Cell Lung Cancer Staging: Concepts and Controversies

Ioannis Vlahos MRCP, FRCR (Presenter): Research Consultant, Siemens AG Research Consultant, GeneralElectric Company

LEARNING OBJECTIVES

1) Summarize the origins, basis and rationale of the current TNM classification of lung cancer. 2) Discuss thestrengths and limitations of the current system and how to practically address these 3) Highlight areas wherecurrent radiology, oncological, surgical and pathological best practice and evolving knowledge in these area areprogressing beyond the current staging system.

Contemporary Concepts in Small Cell Lung Cancer

Fergus Vincent Gleeson MBBS (Presenter): Alliance Medical Ltd Consultant

LEARNING OBJECTIVES

1) To learn the clinical manifestations, staging and prognostic factors of small cell lung cancer. 2) To becomefamiliar with the role of PET-CT in the investigation and management of small cell lung cancer. 3) To reviewunusual presentations of small cell lung cancer and their investigation and treatment.

ABSTRACT

Small cell lung cancer, SCLC, accounts for approximately 15% of all lung cancers, with its overall incidencedecreasing, although it is increasing in women, with the male to female incidence ratio now 1:1. Small cell lungcancer has a more rapid doubling time than non-small cell lung cancer, with most patients presenting withhematogenous metastases, and only approximately one-third presenting with limited-stage disease confined tothe chest. Small cell lung cancer uncommonly presents with a solitary pulmonary nodule, and the disease doesnot appear to have benefited from Lung Cancer Screening. There are multiple neurologic and endocrineparaneoplastic syndromes associated with small cell lung cancer, with marked improvement on treatment of theunderlying tumour. Historically SCLC was staged according to the Veteran's Administration Lung Group's 2stage classification of 1) extensive-stage disease or 2) limited-stage disease, and this classification used toguide therapy. More recently it has been recommended that SCLC is staged according to the International

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Association of the Study of Lung Cancer (IASLC) and the AJCC Cancer Staging Manual 7th edition, using thesame staging system for NSCLC and SCLC. Whilst contrast enhanced CT scan of the chest and abdomen remainroutine as the initial method for staging SCLC, FDG PET-CT now plays a more important role in staging andmanagement. SCLC is a highly metabolic disease, and PET-CT both upstages and downstages disease,potentially altering management

PET Imaging of Lung Cancer: Beyond Standard Metabolic Assessment

Eric Michael Rohren MD, PhD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) Review advanced image processing and metabolic parameters in FDG-PET/CT. 2) Discuss non-FDGradiotracers and their potential applications in non-small cell lung cancer. 3) Illustrate the role of advancedPET/CT in case examples.

ABSTRACT

Assessment of non-small cell lung cancer with PET is typically performed using F-18 fluorodeoxyglucose (FDG).The uptake and retention of FDG by the tumor is taken to be a measure of metabolism, which in turn canprovide useful information on staging, grading, and prognosis. Advances in the field of PET/CT imaging mayprovide additional information for the evaluation and care of patients with lung cancer. Advancedsemi-quantitative analyses including total lesion glycolysis (TLG) and metabolic tumor volume (MTV) have beenemployed to capture additional information from FDG-PET/CT studies, which in some cases is additive tostandard metabolic parameters such as SUVmax. New tracers are under development, with some nearingapproval in the U.S. and elsewhere. These include tracers targeting proliferation, receptor expression, andprotein catabolism, investigating molecular events and processes beyond glucose metabolism.

MRI: Advances in Nodule Characterization and Lung Cancer Staging

Kyung Soo Lee MD, PhD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) To review most popular MRI techniques that are used in thoracic MR imaging. 2) To demonstrate howeffective MR imaging is in nodule characterization and lung cancer staging, particularly focused ondiffusion-weighted imaging (DWI) and diffusion-weighted whole-body imaging with background body signalsuppression (DWIBS).

ABSTRACT

Diffusion-weighted MR imaging helps characterize lung nodule, and enables staging and prognosis prediction inlung cancer. Diffusion-weighted whole-body imaging with background body signal suppression (DWIBS) isknown to be specific in nodal staging and effective in whole body MR imaging. Both whole body MRI and PET-CTmay be used in extra-thoracic lung cancer staging, but each modality has its own and different merits in lungcancer staging. Whole body MRI-PET may be the future oncologic imaging modality.

URL's

http://blog.naver.com/lks7629

CT Perfusion Imaging in Lung Cancer

Friedrich D. Knollmann MD, PhD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) To identify suitable indications for the use of CT perfusion imaging in lung cancer. 2) To apply CT perfusionimaging to lung tumors. 3) To recognize important features of a valid CT perfusion imaging protocol. 4) Tointerpret the results of a CT perfusion study in lung tumors.

ABSTRACT

CT perfusion (CTP) imaging has become a tenable proposition with the advent of multislice CT. Preliminary datahave indicated a potential role in the assessment of treatment response in lung cancer, but the method is notwidely used. In this course, the rationale for using CT perfusion imaging as a quantitative imaging biomarker inlung cancer is discussed. A review of CT protocols includes factors that have impeded a wider adoption of themethod in the clinical sphere, such as the reproducibility of measurements, and validation efforts. Solutions tothese problems, such as improved anatomic coverage with wider detectors and table motion, reduced radiationexposure with iterative reconstruction, advanced postprocessing with dual blood supply algorithms, motionregistration and correction, and volumetric perfusion analysis are addressed. With these methods, tumorclassification, assessment of tumor response, and prognostic testing are promising applications of CTP imaging.

Thoracic Oncologic Imaging: Treatment Effects and Complications

Brett Wilson Carter MD (Presenter): Author, Reed Elsevier Consultant, St. Jude Medical, Inc

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Brett Wilson Carter MD (Presenter): Author, Reed Elsevier Consultant, St. Jude Medical, Inc

LEARNING OBJECTIVES

1) Understand the role of imaging in the evaluation of patients who have been treated for thoracic malignancies.2) Recognize the manifestations of radiation therapy in the chest and be able to differentiate expected changesfrom residual or recurrent disease. 3) Identify intrathoracic complications from radiation therapy,chemotherapy, and surgery.

ABSTRACT

Imaging plays an important role in the evaluation of patients who have been treated with radiation therapy,chemotherapy, and/or surgery for intrathoracic malignancies such as lung cancer, esophageal cancer, malignantpleural mesothelioma, and thymoma. Following thoracic radiation therapy, radiation pneumonitis (1-6 monthsfollowing therapy) and radiation fibrosis (6-12 months following therapy) are typically identified in the lungs.However, complications such as esophagitis, esophageal ulceration, and radiation-induced cardiovasculardisease may develop. Patients treated with chemotherapy may develop pulmonary and cardiovascularcomplications such as drug toxicity, organizing pneumonia, thromboembolic disease, vasculitis, andcardiomyopathy. Knowledge of the spectrum of expected treatment-related changes, potential treatmentcomplications and the appearance of tumor recurrence is critical in order to properly monitor patients, identifyiatrogenic complications, and avoid misinterpretation.

RC412

Thoracic Aorta: Key Concepts (An Interactive Session) Refresher/Informatics

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Tue, Dec 2 4:30 PM - 6:00 PM Location: S402AB

Sub-Events Transcatheter Aortic Valve Replacement (TARV)

Paul Schoenhagen MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) Discuss Pathophysiology and Prevalence of Symptomatic Severe Aortic Stenosis. 2) Discuss TranscatheterTreatment Options (TAVR). 3) Discuss Critical Role of Imaging in the Context of TAVR.

ABSTRACT

If left untreated, symptomatic, severe aortic stenosis (AS) is associated with a dismal prognosis. Open-heartsurgical valve replacement is the treatment of choice and is associated with excellent short and long-termoutcome. However, many older patients with multiple co-morbidities and anticipated increased surgical risk areexcluded from surgical intervention. For these patients, transcatheter aortic valve implantation (TAVI) isemerging as a viable treatment alternative. Transcatheter valvular heart procedures are characterized by lackof exposure and visualization of the operative field, therefore relying on image guidance, both for patientselection and preparation and the implantation procedure itself. This article describes the role of multi-detectorrow computed tomography (MDCT) for detailed assessment of the aortic valve, aortic root, and iliac arteries inthe context of TAVI.

URL's

http://www.thecdt.org/article/view/1583/3023

Handout:Paul Schoenhagen

http://media.rsna.org/media/abstract/2014/13011995/TAVR cloud.pdf

The Spectrum of Type A Dissections

Anne Shu-Lei Chin MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) Review the pathology, epidemiology, and natural history of acute type A aortic dissection. 2) Describe theimaging strategies and diagnostic information sought in patients with acute aortic syndromes. 3) Review therecent classification of acute aortic dissection. 4) Illustrate imaging findings of the spectrum of acute type Aaortic dissection, with a focus on recognizing subtle CT angiographic findings related to the lesser known 'Class3' aortic limited intimal tear or limited dissection.

ABSTRACT

The traditional Stanford classification distinguishes between dissections involving the ascending aorta (Type A)

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The traditional Stanford classification distinguishes between dissections involving the ascending aorta (Type A)from those that do not involve the ascending aorta (Type B). Type A aortic dissection is rare, but remains themost lethal of aortic disorders requiring prompt surgical intervention. The common pathologic denominator inpatients with acute dissection is an abnormal aortic media ('cystic medial necrosis') which can be found ingenetic/inherited diseases (e.g. Marfan's) but also in patients with severe hypertension. The CT imagingstrategy of suspected acute aortic syndrome should always include (i) non-enhanced images to assess forintramural hematoma (IMH); when the index of suspicion for aortic dissection is high, also consider (ii)EKG-gating for motion-free evaluation of the aortic root/ascending aorta, and (iii) including common femoralarteries in the CTA scan range to assess lesion extent and identify a percutaneous access route. The spectrumof aortic dissection has recently been classified as the following: Class 1 classic dissection with true and falselumen separated by an intimal flap; Class 2 IMH; Class 3 discrete or limited dissection; Class 4 penetratingatherosclerotic ulcer (PAU); and Class 5 iatrogenic/traumatic. A clarification and modified conceptualclassification of aortic dissection will be provided, along with illustrative examples of these aortic lesions.Particular focus will be given to the lesser known Class 3 'limited intimal tear' which is described as a subtle andeccentric bulge of the aortic wall. While it has been reported to elude current imaging techniques, emphasis willbe made on recognizing subtle CTA imaging findings characteristic of this uncommon but important dissectionvariant.

Surgical Procedures and Complications

Terri Jo Vrtiska MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) Describe common indications for surgical intervention in thoracoabdominal aortic disease includinganeurysm, vasculitis, infection, trauma and connective tissue disorders. 2) Identify key CTA features of thenormal postoperative aorta. 3) Present the characteristic CTA findings for complications of postoperative aorticrepair including disease progression, thrombosis, stenosis, infection, pseudoaneurysm, aorto-enteric fistula andaortic rupture.

ABSTRACT

Surgical procedures and complications of the thoracoabdominal aorta

RC501

Waiting to Exhale: What's the Latest with Inhalation Lung Diseases? (An Interactive Session) Refresher/Informatics

CT CH



Wed, Dec 3 8:30 AM - 10:00 AM Location: E353B

ParticipantsModeratorJeffrey P. Kanne MD : Research Consultant, Perceptive Informatics, Inc

Sub-Events Smoking Related Lung Disease

Jeffrey P. Kanne MD (Presenter): Research Consultant, Perceptive Informatics, Inc

LEARNING OBJECTIVES

1) Identify immunologic reactions to cigarette smoke in the lungs. 2) Describe the histopathologic features ofsmoking-related lung disease. 3) Illustrate the high-resolution CT findings of smoking-related lung disease.

ABSTRACT

Smoking remains the leading caues of preventable death in the United States. The risks of developiong lungcancer, COPD, and cardiovacular disease greatly increase in cigarette smokers. However, the link betweensmoking and other lung diseases is better understood. This presentation will review the clinical, histopathologic,and high-resolution CT findings of the spectrum of smoking-related interstitial lung diseases. PulmonaryLangerhans cell histiocytosis, respiratory bronchiolitis-desquamative interstitial pneumonia spectrum, acuteeosinophilic pneumonia, and pulmonary fibrosis will be discussed.

Hypersensitivity Pneumonitis

Justus E. Roos MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) To review the most common clinical manifestations of hypersensitivity pneumonitis. 2) To demonstrate therange of histologic features of hypersensitivity pneumonitis and correlate them with radiologic findings. 3) To

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illustrate abnormalities indicative of hypersensitivity pneumonitis and their differential considerations at chestradiographs and CT.

Occupational Lung Disease

Jonathan Hero Chung MD (Presenter): Research Grant, Siemens AG Royalties, Amirsys, Inc

LEARNING OBJECTIVES

1) Briefly describe the prevalence and background of occupational lung diseases. 2) List the two maincategories of occupational lung disease based on imaging. 3) Describe and recognize the imagingmanifestations of occupational lung diseases. 4) Describe the thoracic complications of occupational inhalationalexposure.

Aspiration

Santiago E. Rossi MD (Presenter): Advisory Board, Koninklijke Philips NV Speaker, Pfizer Inc Royalties,Springer Science+Business Media Deutschland GmbH

LEARNING OBJECTIVES

1) Discuss the most common risk factors, clinical manifestations and implications of aspiration. 2) Review theradiographic and both common and atypical CT findings of aspiration pneumonia including aspiration of solidforeign bodies and aspiration of liquids such as infectious material, gastric acid , partially digested food, lipidaspiration and chronic.

ABSTRACT

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RC516

AAWR/RSNA Instructional Session: Integration of Radiology and Radiation Oncology inFighting Lung Cancer (In Conjunction with the American Association for WomenRadiologists) Refresher/InformaticsRO OI IR CH AMA PRA Category 1 Credits ™: 1.50


Wed, Dec 3 8:30 AM - 10:00 AM Location: S102C

ParticipantsModeratorFeng-Ming Kong MD, PhD : Nothing to Disclose

Sub-Events Imaging in Early Diagnosis and Detection

Norman B. Thomson MD (Presenter): Stockholder, Nuance Communications, Inc

LEARNING OBJECTIVES

1) Understand new and evolving screening and staging imaging techniques for early detection of lung cancer. 2)Understand the controversies, risks, and benefits of Low Dose Computed Tomography screening of lung cancerin high risk individuals.

Imaging Guided Radiation Therapy for Lung Cancer

Feng-Ming Kong MD, PhD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) Review the role of imaging in treatment decision making. 2) Understand and expand the role of imagingguided radiation therapy (IGRT). 3) Explore the potential of mid-treatment PET-CTguided personalized adaptivetreatment.

The Role of Imaging in Surgical Resection

Carsten Schroeder MD, PhD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

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1) Determine key studies for surgical decision making and role of imaging. 2) Understand thesurgical/anatomical decision making process and its dependency on imaging. 3) Provide an interdisciplinaryapproach to surgical procedure planning.

Imaging to Assess Response and Toxicity Following Radiation Therapy

Laurie E. Gaspar MD (Presenter): Consultant, Eli Lilly and Company

LEARNING OBJECTIVES

1) Analyze imaging to assign the grade of toxicity following radiation therapy. 2) Analyze imaging to assesstreatment response. 3) Comprehend common pitfalls of imaging following radiation therapy.

RC525

Quantitative Imaging: Diffuse Lung Disease Assessment Using CT Refresher/InformaticsBQ PH CT CH AMA PRA Category 1 Credits ™: 1.50


Wed, Dec 3 8:30 AM - 10:00 AM Location: S405AB

Sub-Events The Role of Quantitative CT in the Assessment of Diffuse Lung Disease

Jonathan G. Goldin MBChB, PhD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) Identify the application of quantitative imaging principles in the assessment of patients with Diffuse LungDisease. 2) Identify conditions required for successful application of quantitative imaging principles. 3) Analyzequantitative imaging techniques and apply this knowledge to protocol development and patient management inthe setting of both clinical workup and clinical trials involving patients with Diffuse Lung Disease.

Quantitation in the Assessment of COPD

David Augustine Lynch MBBCh (Presenter): Research support, Siemens AG Scientific Advisor, PAREXELInternational Corporation Consultant, Boehringer Ingelheim GmbH Consultant, InterMune, Inc Consultant,Gilead Sciences, Inc Consultant, F. Hoffmann-La Roche Ltd Consultant, Veracyte, Inc Research support, Johnson& Johnson Research support, AstraZeneca PLC

LEARNING OBJECTIVES

1) Describe the methodology and limitations of non-invasive imaging in quantifying lung structure. 2) Describethe opportunities for non-invasive imaging in understanding the structure of the lung, and how that relates tophenotyping subjects for clinical trials and longitudinal studies. 3) Understand the clinical relevance ofquantitative imaging of COPD. 4) Learn how to interpret quantitative CT results in the lung.

ABSTRACT

COPD is characterized on CT by emphysema, bronchial wall thickening, and small airway abnormalities. Thesemorphologic findings may be quantified and grouped into phenotypes, with different clinical presentations andprognosis. Clinicians are increasingly using these quantitative imaging techniques to study COPD. This coursewill provide information on the results of large-scale clinical trials ongoing in COPD. The limitations and sourcesof variation of current quantitative imaging methods will be discussed. Relationships between quantitative CTmeasures, genetic markers, and clinical abnormalities will be stressed.

Standardization of Imaging and Measurement Protocols

Matthew Sherman Brown PhD (Presenter): Director, MedQIA Imaging Core Laboratory

LEARNING OBJECTIVES

1) Understand sources of quantitative lung CT measurement variation including technical, physiologic, andalgorithmic. 2) Review strategies for standardization across multiple sites and imaging platforms. 3) Assess theimpact on sample size in multicenter clinical trials.

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Chest (Emphysema/Airway) Scientific PapersCT CH AMA PRA Category 1 Credits ™: 1.50


Wed, Dec 3 10:30 AM - 12:00 PM Location: S404CD

ParticipantsModeratorDavid Augustine Lynch MBBCh : Research support, Siemens AG Scientific Advisor, PAREXEL International CorporationConsultant, Boehringer Ingelheim GmbH Consultant, InterMune, Inc Consultant, Gilead Sciences, Inc Consultant, F.Hoffmann-La Roche Ltd Consultant, Veracyte, Inc Research support, Johnson & Johnson Research support, AstraZeneca PLC ModeratorBrett M. Elicker MD : Nothing to Disclose

Sub-Events Visual Features for Automated Detection of Centrilobular Nodularity and Emphysema

Jason M. Zhao MD, PhD : Nothing to Disclose , Shoshana Ginsburg MS (Presenter): Nothing to Disclose , Stephen Humphries : Nothing to Disclose , Kunihiro Yagihashi MD : Nothing to Disclose , David Augustine Lynch MBBCh : Research support, Siemens AG Scientific Advisor, PAREXEL International CorporationConsultant, Boehringer Ingelheim GmbH Consultant, InterMune, Inc Consultant, Gilead Sciences, IncConsultant, F. Hoffmann-La Roche Ltd Consultant, Veracyte, Inc Research support, Johnson & JohnsonResearch support, AstraZeneca PLC , Joyce Denise Schroeder MD : Research Grant, Siemens AG

PURPOSE

Centrilobular nodularity (CN) and centrilobular emphysema (CLE) are important early markers of smokingrelated lung injury on CT. However, visual detection of these lesions is subject to substantial observer variation.This study aims to develop a relatively simple method for automated detection and quantification of CN and CLEby designing a set of visual features that are intuitive to understand and highly predictive of the presence ofCLE and CN.


1247 circular ROIs (35-pixel diameter) from the inspiratory CT scans of 40 smoking and 19 nonsmokingsubjects enrolled in the COPDGene study were manually selected and labeled by one chest radiologist andindependently confirmed by another. Of these ROIs, 463 depicted normal lung, 374 contained CN, and 410depicted CLE patterns. Within each ROI, our algorithm identified clusters of low and high attenuation areas(LAAs and HAAs) and extracted 18 visual features including cluster amount, area, intensity, background,contrast, and gradient. Feature selection was performed to identify the best performing features. Sensitivitieswere calculated using a Logistic Linear Regression classifier cross-validated on randomly selected patientsample sets (60% for training, 40% for testing).

RESULTS

Our preliminary analysis shows sensitivities of 78%, 83%, 85% for detecting Normal, CN, CLE ROIs,respectively. Misclassification of CN for Normal or vice versa occurred at a rate of 12-14%; misclassificationbetween CLE and CN or between CLE and Normal occurred less frequently at 4-8%. The three top-performingfeatures were the intensity range of HAA clusters, the mean intensity of LAA clusters, and the mean backgroundof LAA clusters. The sensitivities of using only these three features reached 70%, 80%, 83% for Normal, CN,CLE ROIs, respectively.

CONCLUSION

This novel set of visual features provides good sensitivity and specificity for automatically classifying Normal, CNand CLE ROIs on CT scans.


The visual feature based approach simplifies automated detection of CN and CLE in CT scans and may lead toautomated quantification of CN and CLE burden.

Relationship between Lung Function Parameters and CT Measurements of Emphysema, Airways, andTracheal Collapse in Subjects with Mild COPD

Leticia Gallardo Estrella MSc (Presenter): Nothing to Disclose , Esther Pompe MD : Nothing to Disclose , Firdaus Mohamed Hoesein MD : Nothing to Disclose , Pim A. De Jong MD, PhD : Nothing to Disclose , Bram Van Ginneken PhD : Stockholder, Thirona BV Co-founder, Thirona BV Research Grant, MeVis MedicalSolutions AG Research Grant, Canon Inc Research Grant, Toshiba Corporation Research Grant, RiverainTechnologies, LLC , Eva Marjolein Van Rikxoort PhD : Stock holder, Thirona BV Co-founder, Thirona BV , Harry De Koning : Research Grant, F. Hoffmann-La Roche Ltd Equipment support, Siemens AG MedicalAdvisory Board, F. Hoffmann-La Roche Ltd , Matthijs Oudkerk MD, PhD : Nothing to Disclose , Jan-Willem J. Lammers MD, PhD : Nothing to Disclose

PURPOSE

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Excessive expiratory tracheal collapse may be related to chronic obstructive pulmonary disease (COPD).However, the relationship between tracheal changes, CT measurements, and lung function is not very wellknown. This study aims to assess the correlation between pulmonary function tests (PFT) and CTmeasurements of emphysema, airways, and tracheal collapse in patients with and without COPD.


A database of 1032 male subjects who received inspiration CT (16x0.75mm, 120-140 kVp, 30-160 mAs),expiration CT (90 kVp, 20 mAs) and PFT on the same day was constructed. 389 participants (38%) had COPD,defined as ratio of forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC) <70%. Thenumber of patients per GOLD stage (0-3) was 643, 247, 122, 20. CT parameters assessed were trachealcollapsibility (TCo), defined as the highest ratio of cross-sectional area of the trachea in expiration andinspiration; emphysema score (ES), computed as the percentage of lung voxels below -950 HU in inspirationscans; air trapping (AT), defined as the ratio of mean lung density in expiration and inspiration; and square rootof the wall area of a hypothetical airway of 10-mm internal perimeter of segmental and subsegmental airways(Pi10). Correlations were evaluated using the Spearman correlation coefficients and differences between normaland COPD subjects with a Students' t-test.

RESULTS

ES, Pi10 and AT correlated (p < 0.01) with FEV1 (r= -0.17, r= -0.53, r= -0.36) and FEV1/FVC (r=-0.48,r=-0.34, r=-0.51). TCo did not correlate with FEV1 (r= 0.01), but with FEV1/FVC (r=-0.14). Mean ± standarddeviation (SD) ES, Pi10, AT, and TCo in the no-COPD group were 0.82 ± 0.98, 2.29 ± 0.44, 81.57 ± 5.76, and0.67 ± 0.13. Mean ± SD ES, Pi10, AT, and TCo in the COPD group were 2.80 ± 4.04, 2.65 ± 0.55, 87.18 ±4.93, and 0.7 ± 0.14. These values were significantly different between both groups ( p < 0.0001).

CONCLUSION

ES, Pi10, and AT are significantly different between normal and COPD subjects and are correlated to PFT. TCo isalso significantly different between normal and COPD subjects but does not show a strong correlation with PFT.


Emphysema, tracheal collapse, and airway morpholgy obtained from chest CT data may be used to discriminatebetween normal and mild COPD subjects.

Novel Computed Tomography Disease Probability Measure Analysis Technique Provides SensitiveImaging Biomarkers of Chronic Obstructive Pulmonary Disease Phenotypes in Subjects withMild-to-Moderate Disease

Miranda Kirby PhD (Presenter): Nothing to Disclose , Wan C. Tan : Nothing to Disclose , Jean Bourbeau : Nothing to Disclose , James Hogg MD : Nothing to Disclose , Youbing Yin : Nothing to Disclose , Harvey Owen Coxson PhD : Research Grant, GlaxoSmithKline plc Contract, GlaxoSmithKline plc Contract,Olympus Corporation Steering Committee, GlaxoSmithKline plc

PURPOSE

Chronic obstructive pulmonary disease (COPD) poses a substantial and under-appreciated burden on society.The advent of novel computed tomography (CT) image analysis tools can facilitate clinical phenotyping andprovide quantitative information that may have prognostic value. It has been proposed that registration of CTimages acquired at end-inspiration to end-expiration will allow the quantification of emphysema and smallairway disease. One analysis method uses fixed CT density thresholds to assess lung structure (Galbán NatMed. 2012). In contrast, another emerging method, the disease probability measure (DPM), uses continuous,voxel-by-voxel assessment of lung density to determine the extent of emphysema and air trapping. Ourobjective was to compare measurements derived from the threshold-based approach to DPM measurements insubjects with and those at risk of COPD.


We evaluated 150 subjects between 45-90yrs from the population-based Canadian Cohort of Obstructive LungDisease (CanCOLD) study. At Risk subjects were smokers without COPD; COPD subjects were classifiedaccording to GOLD criteria. All subjects underwent inspiratory/expiratory CT, spirometry and bodyplethysmography. CT emphysema (Emph) and air trapping (AirTrap) measurements were generated for boththe threshold-based and DPM methods (Apollo software, VIDA Diagnostics Inc).

RESULTS

Emphysema measurements were associated with measurements of airflow obstruction (FEV1) (Emph: r=-0.48,p<0.0001; DPMEmph: r=-0.57, p=0.0001) and the diffusing capacity of the lung (DLCO) (Emph:r=-0.45,p<0.0001; DPMEmph: r=-0.53, p=0.0005). Air trapping measurements were associated with FEV1 (AirTrap:r=-0.20, p=0.03; DPMAirTrap: r=-0.23, p=0.01) and RV/TLC (AirTrap: r=0.25, p=0.008; DPMAirTrap: r=0.40,p<0.0001). Although the threshold-based and DPM measurements distinguished between At Risk and severelyobstructed subjects (GOLD III, p<0.0001), only DPMAirTrap distinguished subjects with early or mild diseasefrom moderate COPD (At Risk vs. GOLD II: p=0.0007; GOLD I vs. GOLD II: p=0.03).

CONCLUSION

While both DPM and the threshold-based measurements were associated with functional measurements, onlythe DPM approach provided a way to differentiate COPD subjects with early or mild disease.


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DPM may provide a way to sensitively phenotype COPD patients with mild disease which may improve patientoutcomes by preventing disease progression.

Ultra-low Radiation Dose Chest CT for Lung Cancer Screening: Accuracy for Lung Densitometry andEmphysema Detection

Felix G. Meinel MD (Presenter): Nothing to Disclose , U. Joseph Schoepf MD : Research Grant, BraccoGroup Research Grant, Bayer AG Research Grant, General Electric Company Research Grant, Siemens AG , Xin Sui MD : Nothing to Disclose , Wei Song MD : Nothing to Disclose , Huadan Xue MD : Nothing toDisclose , Zhengyu Jin : Nothing to Disclose , Bernhard Schmidt PhD : Employee, Siemens AG , Thomas G. Flohr PhD : Employee, Siemens AG , Rui Wang : Nothing to Disclose

PURPOSE

To determine whether ultra-low radiation dose (ULD) chest CT allows for quantification of lung density andemphysema detection in lung cancer screening participants and to assess the influence of iterativereconstruction (IR) in this indication.


Fifty-two patients were prospectively enrolled in this study and scanned twice using a low-dose (LD) CT protocol(reference parameters 120 kV, 50 eff. mAs) and an ULD CT protocol (reference parameters 80 kV, 4-5 eff.mAs). Images were reconstructed using filtered back projection (FBP) for LD CT datasets and using FBP and IRfor ULD CT datasets. Radiation dose was recorded. Image noise, total lung volume, mean lung density, 15thpercentile of lung density and emphysema index were measured in each reconstructed image series. Themeasurements were compared using one-way analysis of variance (ANOVA) for repeated measures.Measurement bias was assessed using Bland-Altman analysis. We additionally calculated the test characteristicsof ULD CT to detect patients with more-than-minimal emphysema, which we defined as an emphysema index≥3 %.

RESULTS

The effective doses of LD and ULD CT were 2.1 ± 0.5 and 0.13 ± 0.04 mSv, respectively. Compared to LD CT,the emphysema index was overestimated by 7 % on ULD CT reconstructed with FBP, and by 2 % using IR. The15th percentile of lung density was underestimated by 21 HU on ULD CT using FBP, and by 6 HU using IR. Norelevant bias was observed for total lung volume and mean lung density measurements using the ULD CTprotocol with FBP or IR. Four patients (8 %) had more-than-subtle emphysema with an emphysema index ≥ 3%. The emphysema index measured at ULD CT with FBP / IR had 100 % / 100 % sensitivity and 92 % / 96 %specificity in identifying the patients with more-than-subtle emphysema using an emphysema index cutoff of>12.1% for FBP and >6.7% for IR.

CONCLUSION

ULD chest CT performed for lung cancer screening allows for quantification of lung density and emphysemadetection. By reducing image noise, IR improves the accuracy of ULD CT in this setting.


Ultra-low dose chest CT for lung cancer screening retains the potential for quantification of lung density andemphysema detection while reducing radiation dose by >90% compared to low dose CT.

Fourier-decomposition Pulmonary Magnetic Resonance Imaging Ventilation Defects in Ex-smokers:Relationship to Emphysema and 3He Ventilation Defects

Dante Capaldi BSC (Presenter): Nothing to Disclose , Khadija Sheikh : Nothing to Disclose , Fumin Guo : Nothing to Disclose , Sarah Svenningsen BSC : Nothing to Disclose , David McCormack MD : Nothing toDisclose , Grace Parraga PhD : Nothing to Disclose

PURPOSE

Fourier-decomposition of pulmonary magnetic resonance imaging (FDMRI) exploits free-breathing 1H MRI andnon-rigid registration to generate ventilation images. FDMRI was recently compared with SPECT-CT and 3HeMRI in a porcine model, but there have been no demonstrations in subjects with COPD. Our objective was toevaluate ex-smokers using FDMRI, 3He MRI, CT, and pulmonary function tests. We hypothesized thatventilation defects measured using FDMRI would be spatially and quantitatively correlated with 3He MRIventilation defects and emphysematous bullae.


13 ex-smokers (66±9yr) provided written informed consent to imaging, spirometry, and plethysmography. 3Heand dynamic free tidal-breathing 1H MRI were acquired over a period of two minutes on a 3T system (GEHC).For FDMRI, non-rigid registration was performed using modality independent neighbourhood descriptor (MIND)deformable registration that employs a local image descriptor as the similarity measurement. Hyperpolarized3He (VDPHe) and FDMRI (VDPFD) ventilation defect percents and CT attenuation values < -950 Hounsfield units(RA950) were compared using linear regression and Dice Similarity coefficients (DSC).

RESULTS

In all ex-smokers (GOLD stage I, n=2; stage II, n=5; stage III/IV, n=4; no COPD, n=2), there were visuallyobvious ventilation defects. MRI and CT for a representative ex-smoker (75yr female pack-year=41,FEV1=46%pred, RA950=26%, VDPHe=36%) in Figure 1 shows the qualitative agreement in the right upperlobe for ventilation defects and a large emphysematous bulla. For all subjects, there was a significant andpositive correlation for VDPFD with VDPHe (r2=.64, p=.001) and RA950 (r2=.62, p=.001) and the DSC was

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.71±.10.

CONCLUSION

In ex-smokers, FDMRI ventilation defects were spatially and quantitatively correlated with 3He MRI ventilationdefects. Emphysema, quantified by RA950, was spatially and significantly correlated with VDP. For subjects withemphysematous bullae, the long time-constants for lung filling/emptying may be related to ventilation defectsdetected using free-breathing FDMRI and breath-hold 3He MRI.


In 13 ex-smokers, some with emphysematous bullae, FDMRI ventilation defects were spatially andquantitatively related to emphysema and hyperpolarized 3He MRI ventilation defects.

Longitudinal Assessment of Tissue Loss and Air-trapping in Functionally Stable Lung TransplantRecipients Using Quantitative CT Measurements

Mario Silva MD (Presenter): Nothing to Disclose , Daniela Kienzl : Nothing to Disclose , Christina Mueller-Mang MD : Nothing to Disclose , Peter Jaksch : Nothing to Disclose , Klepetko Walter MD : Nothing to Disclose , Alexander A. Bankier MD, PhD : Author with royalties, Reed Elsevier Consultant,Olympus Corporation

PURPOSE

To investigate lung parenchyma and airway changes in functionally stable lung transplant recipients usingquantitative CT.


Annual paired CT scans at total lung capacity (TLC) and functional residual capacity (FRC) were collected frompatients with double lung transplantation in stable clinical appearance and pulmonary function tests. Onlypatients with 5 consecutive follow up were included in our study. For each scan we calculated quantitative lungvolume (Vol), mean lung density (MLD), standard deviation of MLD (MLD-SD) as surrogate of heterogeneity,and lung weight. For the airway metrics we evaluated wall thickness, wall percentage and Pi10. This was doneusing dedicated software (MeVis, Frauenhofer, Germany). For statistical analysis, the longitudinal evolution ofthe metrics was compared within individual patients and relative changes were compared between individuals.Depending on normal distribution, evaluated by Kolmogorov-Smirnov normality test, comparisons wereperformed either using analysis of variance for repeated measurements or the Friedman test. Linear regressionanalysis was used for data modeling.

RESULTS

A total of 100 inspiratory and expiratory CT scans from 20 patients were included. VolTLC slightly decreasedover time (p=0.066), while the VolFRC increased (p=0.042); these trends, as reflected by the differences inslopes of the regression lines, did not reach statistical significance (F=3.58, p=0.107). MLD was stable overtime (p=0.550), whereas MLDFRC decreased (p0.05).

CONCLUSION

On quantitative CT, functionally stable lung transplant recipients show a consistent pattern of longitudinal tissueloss, combined to increasing gas trapping. None of these changes are detected by the lung function testcurrently used as reference standard for following these patients.


Quantitative CT parameters can identify preclinical parenchymal changes in stable lung transplant recipients.Therefore, quantitative CT could be used for predicting the long-term transplantation outcome.

Post-processing of 3rd and 4th Generation Bronchial Luminal Cross-sectional Area at End-expirationSignificantly Differs in Asthmatics: A Newly Discovered Biomechanical Difference Found in SevereAsthma Research Program (SARP) Subjects

Sung Shine Shim (Presenter): Nothing to Disclose , Mark L. Schiebler MD : Shareholder, CellectarBiosciences, Inc , Ronald L. Sorkness : Nothing to Disclose , Nizar Jarjour : Nothing to Disclose , Jeffrey P. Kanne MD : Research Consultant, Perceptive Informatics, Inc , Sean B. Fain PhD : Research Grant, GeneralElectric Company Research Consultant, Marvel Medtech, LLC

PURPOSE

We sought to determine if asthmatics show differential airway morphologic changes based on the sizes of theirrespective bronchial generation and degree of collapse at end expiration using post processing of their HRCTimages.


VIDATM software was used to analyze 185 severe asthma research program (SARP) patients HRCT scans bytheir respective bronchial generations. The data was reviewed for airway remodeling in normal volunteers (33),non-severe asthmatics (63) and severe asthmatics (89). A total of 4501 airways were analyzed at both FRC andTLC. The following generations (total number) were reviewed: 1st (183), 2nd (365), 3rd (542), 4th (1538), 5th(1575) and 6th (298). We analyzed wall area percentage (WA%) and wall thickness percentage (WT%), anddeltalumen for each generation between non-severe, severe and normal subjects. The SPSS statistical packagewas used to determine the significance of variation between these groups at each generation of bronchi.

RESULTS

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We found that greater WT% and WA% was seen in the severe asthma group than in the non-severe asthmagroup. Quantitatively, WA% and WT% showed a steady increase through each bronchial generation. In normalsubjects, there is a gradual change in airway deltalumen from generation 1st to 6th. However, in asthmatics(non-severe and severe), we found that the deltalumen was greater in the 3rd and 4th generation airways (pvalue<0.001) than the 5th and 6th. The maximal difference in deltalumen in asthmatics was found at the 4thgeneration.

CONCLUSION

1. Deltalumen at 3rd and 4th generation airways in the SARP cohort was significantly increased when comparedto that of control group. 2. WA% and WT% showed a steady increase in values from central to the more distalairways for all groups. 3. Each generation of airway of the asthmatic subjects, compared with those of thenormal subjects, behaved differently. In asthmatics, the deltalumen showed an increase for 1-4th generationand then was found to decrease in the more distal airways (5-6th generation). However, in the normal cohort,there was a steady increase in this parameter.


These data show that there is a loss of the normal graded collapse of the asthmatic airway at FRC. This changein airway compliance may play a role in the limitation of FEV1 in these individuals and may promote air trappingin the secondary lobule.

Determination of Expiratory Air-trapping and Expiratory Collapse of the Large- and Medium-sizedBronchi during the Episode of Acute Asthmatic Attack

Thitiporn Suwatanapongched MD : Nothing to Disclose , Chayanin Thongprasert MD (Presenter): Nothingto Disclose , Siwaporn Lertpongpiroon MD : Nothing to Disclose , Sumalee Kiatboonsri MD : Nothing toDisclose

PURPOSE

To determine the frequency and severity of expiratory air trapping (ATexp) during acute asthmatic attack(AAA), by using a semi-quantitative CT scoring method, and to evaluate the relationship between the CT scoreand bronchial wall thickness (BWT), expiratory bronchial collapse (BCexp) and clinical characteristics.


The frequency, pattern and extent grading of ATexp and the degree of BWT and BCexp (% reduction inbronchial cross-sectional area or luminal width) were retrospectively determined from the twelve zones of thesix-chosen levels of 36 paired inspiratory-expiratory CT performed during AAA. Pearson correlations betweenthe total-ATexp score (summed scores of pattern grading x extent grading) with BWT, BCexp and clinicalcharacteristics and performance of the score under receiver-operating-characteristic (ROC) analysis werecalculated.

RESULTS

All patients had ATexp. The total-ATexp score (mean±SD, 110.1±43.4; range, 8-166) was higher in the lowerlung zones (p=0.002) and was correlated with patient's age (r=0.331, p=0.049), BMI (r=-0.375, p=0.024),%predicted peak expiratory flow rate (PEFR) (r=-0.332, p=0.048), and BWT (r=0.338, p=0.048), but was notcorrelated with BC exp. Patients with age >60 years (p=0.025), BMI <28 kg/m2 (p=0.039), and severe AAA(p=0.039) had higher total-ATexp scores. With area under ROC curve of 0.724 (95% CI, 0.582-0.866), thetotal-ATexp score of 110 could distinguish severe AAA (PEFR <60 %predicted) from less-severe AAA (sensitivity,92.9%; specificity, 59.1%).

CONCLUSION

ATexp invariably occurred during AAA with a greater severity in the lower lungs and in patients with age >60years, BMI <28 kg/m2, and severe AAA. The total-ATexp was not correlated with BCexp.


The findings suggested the role of small airways in AAA. Hence, newly developed drugs or devices enablingdrugs to target the small airways should have benefits in these patients.

Digital Tomosynthesis for the Airway Evaluation: Performance Comparison with ChestRadiography Using CT as Reference

Ji Yung Choo MD (Presenter): Nothing to Disclose , Ki Yeol Lee MD, PhD : Nothing to Disclose , Jung Won Choi : Nothing to Disclose , Seun Ah Lee MD : Nothing to Disclose , Je Hyeong Kim : Nothing to Disclose , Seung Heon Lee : Nothing to Disclose , Eun-Young Kang MD : Nothing to Disclose , Whan Oh : Nothingto Disclose

PURPOSE

To compare the diagnostic performance of digital tomosynthesis (DTS) with that of chest radiography for thedetection and evaluation of neoplastic and non-neoplastic airway abnormalities, using multi-detector computedtomography (CT) as reference.


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The institutional review board approved this study and all patients provided informed consent. In this study, 91subjects (46 study patients, 45 control patients) underwent chest radiography, DTS and CT within a week ineach subject. Two blinded chest radiologists independently evaluated the chest radiographs and DTS images forthe presence of airway lesion (detection), localization (scoring from trachea to segmental bronchus) andseverity (narrowing or obstruction (less than 10% of the proximal diameter of the lesion)) using CT asreference. Weighted kappa statistics, McNemar tests were used for statistical analysis.

RESULTS

In evaluation of location and severity of the airway abnormalities, strength of agreement of DTS by kappa valuewas good to very good (value of k, 0.763-0.957) and superior to the radiographic findings (value of k,0.433-0.581; moderate). Overall, sensitivity of DTS was higher (observer 1, 92.5%, observer 2, 99%) thanradiography (observer 1, 87.2%; observer 2, 73.8%). The diagnostic accuracy of DTS (observer 1, 95.5%;observer 2, 99%) for the presence of airway abnormalities was significantly better than with radiography(observer 1, 89.4%; observer 2, 83.8%; all p<0.05).

CONCLUSION

DTS is more accurate and sensitive modality than chests radiography for the detection and evaluation of airwaylesions which are easily obscured by soft tissue structures in the mediastinum on chest radiography.


DTS seems to be an appropriate modality for work up or manage of the airway abnormalities with low radiationdose than CT and higher image quality than radiography.

CHS-WEA

Chest Wednesday Poster Discussions Scientific PostersCH AMA PRA Category 1 Credits ™: .50

Wed, Dec 3 12:15 PM - 12:45 PM Location: CH Community, Learning Center

ParticipantsModeratorJin Mo Goo MD, PhD : Research Grant, Guerbet SA

Sub-Events Feasibility of Differentiating Metastatic Lymph Nodes of Non-small-cell Carcinoma from BenignNodules using Spectral CT Imaging (Station #1)

Ying Guo (Presenter): Nothing to Disclose

PURPOSE

To investigate the feasibility of differentiating metastatic lymph nodes of non-small-cell carcinoma from benignnodules by using spectral CT imaging


48 patients which were diagnosis of non-small-cell carcinoma with 74 lymph nodules (pathologically proved 34malignant and 40 benign) were enrolled in this study and underwent spectral CT scan using GSI protocol forunenhanced and enhanced CT scan on arterial phase and portal phase. Roi was placed in nodules withmaximum enhancement .CT attenuation values in the monochromatic images at 11 set of keVlevels(40-140keV, 10keV interval), iodine density ,effective Z values and values normalized to artery weremeasured and evaluated. Slope of spectral curve was calculated by an equation of (CT40kev -CT70kev)/30.Student's t-test was used for comparison of continuous variable.Sensitivity, specificity, and area under the ROCcurve (AUC) were compared to assess the detectability of metastatic lymph nodes. Sensitivity, specificity, andarea under the ROC curve (AUC) were used to assess the detectability of nodules.

RESULTS

Iodine density,effective Z value, slope of spectral curve of metastatic lymph nodules were statistically lowerthan that of benignant nodules both in unenhanced phase and in artery phase scans, same result were found aswell as CT values in 40kev-55kev images in artery phase.The area under receiver operating characteristic curvewas large than 0.7. Effective Z value and iodine density in unenhanced phase and normalized iodine density inartery phase had the highest sensitivity(95%). normalized Effective Z value in artery phase, slope of spectralcurve and normalized Effective Z value in unenhanced phase had the highest specificity.

CONCLUSION

Spectral CT imaging is an effective approach to differentiate metastatic lymph nodes of non-small-cellcarcinoma from benign nodules.

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carcinoma from benign nodules.


Spectral CT characteristic measurements is promising for differentiating benign and malignant findings

CT Evaluation of V/Q Mismatch in Patients with COPD using Dual-energy Xenon Ventilation CT andLung Perfused Blood (PBV) Image (Station #2)

Masahiro Kobayashi MD (Presenter): Nothing to Disclose , Nobuyuki Shiraga MD : Nothing to Disclose , keiko matsumoto : Nothing to Disclose , Keishi Sugino : Nothing to Disclose , Kenichi Suzuki : Nothing toDisclose , Sakae Honma MD, PhD : Nothing to Disclose , Ehiichi Kohda MD : Nothing to Disclose

PURPOSE

To assess and evaluate the feasibility of combined dual-energy CT lung ventilation/perfusion imaging in patientswith chronic obstructive pulmonary disease (COPD), comparing with low attenuation area (LAA) and clinicalseverity of COPD.


Institutional review board approval and written informed consent were obtained. Twenty eight patients withchronic obstructive pulmonary disease (COPD, mean age:71.8 years, range 56-87 years) underwent xenonventilation CT and pulmonary CTA using dual-energy CT. Xenon ventilation images and lung perfused bloodvolume (PBV) images were obtained by three-material decomposition algorithm. Ventilation, perfusion andmorphological information were visually interpreted. Mean xenon enhancement values, mean lung PBV valuesand %LAA were also calculated and correlated each other.

RESULTS

In most of all low xenon distributed areas, iodine perfusion also decreased. However, in 37 regions of 16/28patients, areas of low xenon distribution without decrease of iodine perfusion were noted, which indicateventilation/perfusion (V/Q) mismatch. Comparing with LAA images, in those V/Q mismatch areas, LAA were notfound and thus thought to be air way dominant type COPD. There were negative significant correlationsbetween mean xenon enhancement values and %LAA, between mean lung PBV values and %LAA (r=-0.45,p<0.05, r=-0.42, p<0.05, respectively). In contrast, there were no significant correlations between mean xenonenhancement values and lung PBV values, also between lung PBV values and clinical severity using GOLDstage.

CONCLUSION

Dual-energy lung ventilation/perfusion imaging using xenon ventilation CT and lung PBV is feasible and providelung morphological and functional information.This method can visualize V/Q mismatch in patients with COPDwith much higher spatial resolusion than nuclear imaging. Evaluation of V/Q mismatch may predict prognosis ofCOPD because lung blood perfusion is known to decrease earlier than pulmonary emphysema (LAA) change.Thus, additional studies and long term observations are required for evaluation of those areas. With its higherresolusion of space and time, dual-energy lung ventilation/perfusion imaging has the potential to be the newassessment tool for COPD patients.


Combined dual energy xenon ventilation CT and lung PBV visualize V/Q mismatch in patients with COPD, whichhas the potential to be new assessment tool for COPD.

Respiratory Bronchiolitis with Fibrosis: Study of the Prevalence, Radiological features andProgression (Station #4)

Collette Louise English BMBS, FRCR (Presenter): Nothing to Disclose , Andrew Churg : Nothing to Disclose , Mark Teh MBBS : Nothing to Disclose , John R. Mayo MD : Speaker, Siemens AG , Stephen Lam : Nothing to Disclose , Ana-Maria Bilawich MD : Nothing to Disclose

PURPOSE

A CT pattern of patchy areas of reticular changes around areas of emphysema seen in smokers withoutevidence of intersititial lung disease has been described. Pathologically it has been labelled smoking-relatedinterstitial fibrosis (SRIF), respiratory bronchiolitis-intersititial lung disease with fibrosis or airspaceenlargement with fibrosis. Recently, in order to avoid confusion with other interstial lung disease, it issuggested that this pattern be called respiratory bronchiolitis with fibrosis (RBF). The frequency of this lesionand whether it is stable or progresses to more severe disease is not known. The aim of our study was toestimate the prevalance of RBF in a cohort of smokers and where possible, to demonstrate the stability of thispattern over an interval period of time.


This was a retrospective study of a sample of 200 consecutive participants who were current or former smokersbetween 50-75 years of age without a history of lung cancer. CTs were reviewed by two radiologists withspecific training in chest radiology. Presence of RBF and characteristics including lobar predominance werenoted. Subsequent CTs were reviewed where available and interval change or stability was documented.

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RESULTS

13 out of the 200 patients (7%) were noted to have evidence of reticular change around areas of emphysema.100% of the patients had changes in the upper lobes and 2 patients (15%) had additional changes in the lowerlobes. 46% of patients showed no progression of changes. The remaining 54% had only very mild progressionwith time intervals ranging from 2 to 6 years between CT scans. The progressive changes typically appeared tobe increasing severity of emphysema rather than increasing evidence of fibrosis.

CONCLUSION

In this study we demonstrate a prevalance of 7% of RBF in a cohort of smokers and its lack of significantinterval progression. RBF probably accounts for a significant number of the cases identified as interstitial lungdisease in cigarette smokers on large HRCT surveys. It is important to recognise this CT pattern as a benignentity and not as coexisiting diffuse intersitial fibrosis.


It is important to recognise this CT pattern as a benign entity and not as coexisiting diffuse intersitial fibrosis.

CT-Guided Pulmonary Nodule Localization Prior to Thoracoscopic Resection (Station #5)

Nour-Eldin Abdelrehim Nour-Eldin MD, MSc (Presenter): Nothing to Disclose , Nagy Naguib Naeem Naguib MD, MSc : Nothing to Disclose , Thomas Lehnert MD : Nothing to Disclose , Martin Beeres MD : Nothingto Disclose , Boris Bodelle MD : Nothing to Disclose , Thomas Josef Vogl MD, PhD : Nothing to Disclose

PURPOSE

To assess the feasibility and safety of CT-guided pulmonary nodule-marker using hooked guide wireimmediately before thoracoscopic resection


A retrospective study design. In 79 consecutive patients (49 males, 30 females; mean age: 56.6, range: 29-71years, in the period between: January 2011 and January 2014) a total of 82 pulmonary nodules were markedwith a hooked 22-F guide-wire under CT-guidance under local anesthesia. Immediately after the procedure, thepatient was transferred to the operating room and thoracoscopic pulmonary wedge resection was performed.The position of the guide wire was demonstrated to the thoracic surgeon before surgical resection. In thecurrent study the following parameters were assessed: lesion size, lesion distance to the pleura, the time ofintervention, complications, and thoracoscopic success rate. Technical success was defined as the positioning ofthe tip of the hooked guide wire within 1 cm from the lesion.

RESULTS

Mean lesion size was 6 mm (range 4-18 mm) and mean lesional distance to the pleura was 15 mm (range 2-40mm). The hooked pulmonary nodule guide wire was positioned successfully in all 82 pulmonary nodules within4-12 min (mean 8 min). Minimal pneumothoraces were observed in 5 patients (7.6%) with no requirements ofchest drains. Focal perilesional pulmonary hemorrhage was developed in 3%. Both hemorrhage andpneumothorax were correlated to subcentemetric lesions (p= 0.02). All 82 pulmonary nodules could be resectedthoracoscopically. However, in one patient (1.3%), the guide-wire was dislocated during thoracoscopy. Theposition of the lesion was identified intraoperatively by the focal pleural puncture. The resection volume wassignificantly correlated to the guide-wire position (p= 0.04).

CONCLUSION

CT-guided pulmonary nodule localization prior to thoracoscopic resection could allow a safe and accuratesurgical guidance guide for the localization of small pulmonary nodules during thoracoscopic resection.


This technique could facilitate the identification and allow adequate resection of small pulmonary nodules duringthoracoscopic resection.

Prognostic Value of Whole-body Metabolic Tumor Burden on Post-surgical FDG-PET Imaging forNon-small Cell Lung Cancer Patients (Station #6)

Chenpeng Zhang MD, PhD (Presenter): Nothing to Disclose , Cassie A Simon : Nothing to Disclose , Daniel Eric Appelbaum MD : Nothing to Disclose , Yonglin Pu MD, PhD : Researcher, Eli Lilly and CompanyResearcher, General Electric Company

PURPOSE

The prognostic value of whole-body metabolic tumor burden (MTBWB) in NSCLC measured as either metabolictumor volume (MTVWB) or total lesion glycolysis (TLGWB) in the body on baseline FDG PET/CT has beenestablished. However, the prognostic value of MTBWB after surgery has not been reported in the literature. Thisstudy aims to evaluate the prognostic value of (MTBWB) in post-surgical FDG-PET/CT scans of the patients.


147 patients (73 females and 74 males with mean age of 66.9 years) with histologically proven NSCLC were

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147 patients (73 females and 74 males with mean age of 66.9 years) with histologically proven NSCLC wereselected for this IRB approved retrospective study. All patients underwent surgery for curative purpose andpost-surgical 18F-FDG-PET/CT scans. Seventy-three patients had died (49.7%) during follow-up. Medianfollow-up time among survivors was 18.32 months. The MTVWB, TLGWB and SUVmaxWB) of tumors in thewhole body were measured from FDG-PET images with semi-automated 3D contouring software. Cox regressionfor survival analysis was undertaken using clinical, pathological and PET imaging variables. Overall survival(OS) served as the primary endpoint of the study, calculated from the date of the post-surgical PET/CT scan tothe date the patients died from any cause.

RESULTS

The mean (SD), median and range of the MTVWB, TLGWB and SUVmaxWB of tumors was 73.0(183.4), 12.9 and0-1696.3 ml; 324.3(792.1), 37.5, and 0-5584.8 ml x SUV; and 7.0(7.4), 5.2, and 0-34.1 respectively. Inunivariate analysis, there was a statistically significant association of OS with the MTVWB (hazard ratio (HR) =1.002;p<0.001), TLGWB (HR = 1.001;p<0.001). Four groups of the patients (MTVWB= 0 ml, MTVWB > 0 mland <13.44 ml, MTVWB ≥13.44ml and <60.14ml, MTVWB ≥ 60.14 ml) had mean OS of 65.7, 43.7, 34.5, and13.9 months, respectively. On multivariate Cox regression models, both MTVWB and TLGWB were significantlyassociated with the patient's OS independent of the patient's age, gender, tumor histology, SUVmaxWB, TNMre-stage and surgical procedures. The HRs were 1.002 (p<0.001) and 1.001 (p< 0.001) for MTVWB andTLGWB, respectively.

CONCLUSION

MTVWB and TLGWB as metabolic tumor burden measurements in post-surgical 18F-FDG-PET/CT areindependent prognostic markers.


The metabolic tumor burden measurement on post-surgical PET/CT scans can help clinicians to estimate thepatient's prognosis and may help them determine further treatment for the patients with non-small cell lungcancer.

CHS-WEB

Chest Wednesday Poster Discussions Scientific PostersCH AMA PRA Category 1 Credits ™: .50

Wed, Dec 3 12:45 PM - 1:15 PM Location: CH Community, Learning Center

Sub-Events Predictive Value of Embolic Burden and Right Ventricular Dysfunction Signs Assessed by ComputedTomography in Cancer-related Pulmonary Embolism: Data on 208 Consecutive Patients from theEPIPHANY Study (Station #1)

Juana Maria Plasencia-Martinez MD (Presenter): Nothing to Disclose , David Calvo-Temprano MD : Nothingto Disclose , Alberto Carmona-Bayonas MD : Nothing to Disclose , Carme Font MD : Nothing to Disclose , Paula Jimenez-Fonseca MD : Nothing to Disclose , Alejandro Puerta MD : Nothing to Disclose , Angel Dominguez-Perez : Nothing to Disclose , Pedro Arguis MD : Nothing to Disclose , Mariana Nelida BenegasUrteaga MD : Nothing to Disclose , Susana Hernandez Muniz MD : Nothing to Disclose , Carmen Beato MD : Nothing to Disclose , Angeles Vicente MD : Nothing to Disclose , Merce Biosca MD : Nothing toDisclose , Olga Madriano MD : Nothing to Disclose

PURPOSE

To assess the correlation between embolic burden, right ventricular overload and clinical outcomes incancer-related pulmonary embolism (PE).


EPIPHANY is an observational, multicenter study that recruits consecutive cases of cancer-related PE, includingboth incidental (detected by CT with conventional iv contrast) and acute symptomatic events (CT pulmonaryangiography [CTPA] in patients with symptoms). The embolic burden was assessed by the Qanadli obstructionindex (QI), and the location of PEs (main pulmonary artery, lobar vs. segmental and subsegmental). We alsomeasured the right ventricular-left ventricular (RV-LV) diameter ratio, the displacement (inversion orflattening) of the interventricular septum (IVS), the type of diagnosis (incidental vs. symptomatic), systolicblood pressure (SBP), pulse oxymetry, the European Cooperative Group (ECOG) performance status and TNMstage. The main outcome measure was the presence of symptoms and 30-day mortality.

RESULTS

208 patients were included in the study (male 48%, mean age 64.8 years). The rate of incidental andnormotensive (≥90 mmHg) PEs was 49% and 90%, respectively. The 30-day mortality rate was 21% (95% CI,15.4-26.5%). An abnormal IVS predicted mortality with an odds ratio of 2.6 (95% CI, 1-7), even afteradjustment for clinical characteristics. In the subgroup of normotensive patients, the mortality was higher inpatients with an IVS anomaly (31% vs. 18%, p=0.07). The RV-LV ratio was slightly correlated with SBP at firstassessment (r=-0.147, p=0.03), but was not a predictor of death. In the subgroup of symptomatic PEs

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diagnosed by CTPA, the QI was slightly correlated with oxymetry (r=-0.223, p=0.02) but not SBP. With acut-off of 40%, the QI was not associated with prognosis. Of note, a central location of PEs was not associatedwith either PE-symptoms, such as dyspnea, or with clinical outcome.

CONCLUSION

A flattening or inversion of the IVS is an independent risk factor of early mortality in patients withcancer-related PE. The discriminatory ability of the QI and the RV-LV ratio was low in this population.


An abnormal interventricular septum assessed by chest CT can predict the short-term survival of patients withcancer-related pulmonary embolism and should be reported regardless of the embolic burden.

CT Angiography: Correlation between D-dimer Values and the Location of Acute Pulmonary Embolism(Station #2)

Mateusz Piotr Kubak MD (Presenter): Nothing to Disclose , Arne Borthne MD, PhD : Nothing to Disclose , Peter M. Lauritzen MD : Nothing to Disclose , Espen Ruud : Nothing to Disclose , Haseem Ashraf MD : Nothing to Disclose

PURPOSE

Improved spatial and temporal resolution CT pulmonary angiography (CTPA) allows accurate diagnosis of acutepulmonary embolism (APE). In low risk patients a d-dimer below the cut-off value of 0.5 mg/L may exclude APE,thereby eliminating the need for CTPA. Our purposes are to: 1) investigate the correlation of APE location andd-dimer levels, and 2) to optimize the cut off value of d-dimer while maintaining a high sensitivity and negativepredictive value.


All 1053 patients with clinical suspicion of APE investigated with CTPA in our department in 2012 were eligible.Concurrent d-dimer values, required for inclusion were collected and CTPAs reviewed. The subjects wereallocated to four groups based on diagnosis and APE location (0=no emboli, I= peripheral emboli, II= emboli inlobar arteries, III = emboli in pulmonary trunk or main pulmonary arteries). The optimal cut-off values ofd-dimer in central and peripheral emboli were assessed.

RESULTS

Sufficient data were available for 822 subjects, while 229 lacked concurrent d-dimer and 2 were excluded dueto low quality images. 53% females, mean age 64 years (range 9-99). 639 were allocated to group 0, 51 togroup I, 51 to group II and 81 to group III. ROC (receiver operating characteristic) analysis revealed an areaunder the curve (AUC) of 0.78 for all APE (groups I, II and III). For central APE (group III) the AUC was 0.84.The optimal cut-off for all APE was 0.9 mg/L with a negative predictive value (NPV) of 97% and sensitivity of97%. For central APE the cut-off was 1.4 mg/L with a NPV and sensitivity of 98% and 99% respectively.Significant correlation was found between the d-dimer values and the location of the APE in the selectedsubgroups (0: 2.4, I: 2.8, II: 4.2, III: 7.8) Spearmans rho: 0.43, p<0.01.

CONCLUSION

A D-dimer cut-off of 0.9 mg/L yielded a NPV and sensitivity of 97% for all APE. For central APE a d-dimer cut-offof 1.4 mg/L yielded a NPV and sensitivity > 98%. Higher d-dimer values significantly correlated with morecentrally located APE.


Our findings may influence the approach to suspected acute pulmonary emboli, contribute to reduction ofinappropriate CTPAs and aid priority of patients with central APE for expedient investigation.

Demonstrating the Utility of Hyperpolarised Xenon MRI (Xe-MRI) and Quantitative ComputedTomography (QCT) in Chronic Obstructive Pulmonary Disease (COPD) (Station #4)

Tahreema Nihad Hashmi Matin MBBS (Presenter): Nothing to Disclose , Xiaojun Xu MSc, DPhil : Nothing toDisclose , Tom Doel DPhil : Nothing to Disclose , Jennifer Lee : Nothing to Disclose , Najib Rahman MSc,DPhil : Nothing to Disclose , Jim M. Wild PhD : Nothing to Disclose , Vicente Grau PhD : Nothing toDisclose , Annabel Nickol : Nothing to Disclose , Fergus Vincent Gleeson MBBS : Alliance Medical LtdConsultant

PURPOSE

To correlate hyperpolarised xenon MR lung imaging (Xe-MRI) and quantitative computed tomography (QCT)with pulmonary function tests (PFTs) and a patient-centred outcome measure (Dyspnoea-12 score) in subjectswith chronic obstructive pulmonary disease (COPD).


Fifteen patients with COPD (stage II - IV GOLD criteria classification) underwent Xe-MRI at 1.5T, QCT, PFTs anddyspnoea-12 breathlessness questionnaire. Whole lung percentage ventilated volume was obtained usingautomated segmentation of Xe-MRI ventilation images and average whole lung apparent diffusion coefficients(ADCs) calculated from Xe-MRI diffusion-weighted images (b=20.855sec/cm2). Percentage predicted forced

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(ADCs) calculated from Xe-MRI diffusion-weighted images (b=20.855sec/cm2). Percentage predicted forcedexpiratory volume in one second (FEV1), FEV1/forced vital capacity (FVC) ratio and transfer factor of the lungfor carbon monoxide (TLCO) was established for each participant. Dyspnoea-12 was analysed according tostandard methodology. QCT-derived metrics for emphysema and bronchial wall thickness were calculated frompercentage of lung tissue with density of <-950HU and Pi10 (the square root of wall area for an airway withlumen perimeter of 10mm). Pearson's correlation coefficients were used to evaluate the relationship betweenimaging measures, PFTs and dyspnoea-12 scores.

RESULTS

Xe-MRI whole lung average ADC showed significant correlation with: QCT percentage emphysema (r= 0.79, P=0.001), Pi10 (r= 0.68, P

CONCLUSION

This study correlates the non-ionising, functional imaging technique, Xe-MRI with QCT-derived metrics includingPi10 and clinical outcomes. The findings provide evidence to support the role of Xe-MRI and QCT forcomprehensive structural and functional evaluation of the lungs in COPD.


The excellent correlation of Xe-MRI whole lung average ADC with structural QCT-derived measures of COPD andTLCO, suggest it may be of value in the investigation, management, and trialing of new therapies in thesepatients.

Pulmonary Parenchymal Findings in Patients with Pulmonary Vein Stenosis followingRadiofrequency Catheter Ablation (Station #5)

Tima Davidson MD (Presenter): Nothing to Disclose , Orly Goitein MD : Nothing to Disclose , Elinor Goshen : Nothing to Disclose , Michael Glikson MD : Nothing to Disclose , Chrystalleni milonas : Nothingto Disclose , Sivan Lieberman MD : Nothing to Disclose , Simona Ben Haim : Nothing to Disclose

PURPOSE

Pulmonary vein stenosis (PVS) is a serious complication occurring in 1%-3% of radiofrequency catheter ablationprocedures for treating atrial fibrillation. The lung parenchyma may suffer a significant insult when PVS ispresent. The purpose of this study is to describe the CT appearance of pulmonary parenchymal findings (PPF) inpatients with PVS.


A clinical database of pulmonary vein ablation procedures (2006 - 2013) was reviewed for PVS cases.Retrospective analysis included reviewing the base line CT before the procedure, second CT for evaluating theclinical suspicion of PVS and follow up CT scans (total of 40 scans, between 4 days and 51 months). Studieswere evaluated for the presence of PPF.

RESULTS

The study cohort included 8 patients (pts) (average age 47; 88% males). Four pts had occlusion of both leftsuperior and inferior pulmonary veins (LSPV, LIPV), 3 pts had occlusion of LSPV and stenosis > 80% of theLIPV, and one pt had LIPV stenosis of 65%. Lower contrast opacification and 'sluggish flow', mimickingpulmonary emboli, were demonstrated in the left pulmonary artery in pts with occlusion of both LSPV and LIPV(4/8). Pulmonary parenchymal findings (PPF) were documented in pts with stenosis > 80% (7/8); in both leftlobes 5/7, in the left upper lobe 1/7 and in the left lower lobe 1/7. PPF included: peripheral extensiveconsolidations (7/7), ground glass opacities (7/7), peripheral interstitial thickening (7/7) and small left pleuraleffusion (5/7). In each of the seven pts, PPF were dynamic over time, demonstrating worsening (5/7),migration (6/7) or improvement (2/7), of the changes on the serial follow up scans. No pt showed completeresolution. PPF appeared as soon as 4 days following the ablation and persisted to up 51 months.

CONCLUSION

PPF were present in all pts with PVS > 80%. These changes were persistent and dynamic over time, tending todemonstrate gradual worsening .PPF can still be present a long time after the ablation procedure. Therefore,physicians should familiarize themselves with these findings in order to avoid erroneous diagnosis of pneumonia,lung cancer or pulmonary embolism in post ablation pts


Awareness to the possibility of persistent PPF related to a previous ablation procedure is of high importance.This could avoid incorrect interpretation which may lead to unnecessary intervention.

How functional MR Imaging Can Take the Hurdle of Mediastinal Lesion Characterization andImprove Prediction of Mediastinal Lesion Resectability: From Whole Lesion Assessment to TargetZone Delineation (Station #6)

Johan Coolen MD (Presenter): Nothing to Disclose , Frederik De Keyzer : Nothing to Disclose , Dirk Vanraemdonck MD, PhD : Nothing to Disclose , Eric Verbeken MD, PhD : Nothing to Disclose , Walter DeWever MD : Nothing to Disclose , Johan Vansteenkiste MD, PhD : Nothing to Disclose , Ilse Roebben BMEDSC : Nothing to Disclose , Christophe Dooms MD, PhD : Nothing to Disclose , Willy COOSEMANS MD, PHD : Nothing to Disclose , Paul De Leyn MD, PhD : Nothing to Disclose , Kristiaan Nackaerts MD,PhD : Speaker, Pfizer Inc Speaker, Novartis AG Advisory Board, Pfizer Inc Travel support, AstraZeneca PLCTravel support, Eli Lilly and Company , Johny A. Verschakelen MD, PhD : Nothing to Disclose , Steven Dymarkowski MD : Nothing to Disclose

PURPOSE

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Invasive surgical procedures (mediastinoscopy/-tomy) are cornerstones of mediastinal oncologic staging, butcan lead to patient discomfort and morbidity. In this study, we attempted to use a noninvasive MR imagingapproach to differentiate benign from malignant mediastinal lesions and at the same time attempt to providean imaging-based preoperative evaluation of lesion resectability.


76 consecutive patients (47 male, 29 female), with a suspicious mediastinal lesion on clinical or imaging-based(CT, PET, EBUS or EUS) examinations, were included. Additional to the anatomical MRI sequences on a 3T MRscanner, both a dynamic contrast-enhanced (DCE)- and a diffusion-weighted (DW) acquisition were performedone day prior to surgery. All MR images were evaluated by visual inspection and by calculating the mean ADCvalues of the whole lesion and of the most suspect zone (based on b1000 and ADC map). Finally, DCE curveswere evaluated. Histological examinations of operative specimens served as reference.

RESULTS

A total of 32 benign and 44 malignant lesions were included in this study. Diagnosis based on the mean ADCcalculated from the whole lesion, using a threshold of 2.1 x10-3 mm²/s to differentiate benign from malignant,was disappointing (sens 71%, spec 56% and acc 64%). Contrarily, the ADC-based evaluation of the target zoneevaluation alone performed better (sens 75%, spec 88% and acc 80%) with an optimal cut-off value of 1.5x10-3 mm²/s. However, the best results were found using a combination of DW (b1000 and ADC-mapinterpretation) with DCE-MRI leading to 65 correct and only 11 incorrect (6FN and 5 FP) diagnoses (sens 86%,spec 84% and acc 86%). Over all patients, a very good correlation was found between MR signs of localinvasion and surgical resectability (kappa 0.84, p<0.0001).

CONCLUSION

In the hard-to-image mediastinal region, noninvasive imaging techniques (DWI and DCE) might provideadditional information for preoperative lesion characterization and assessment of lesion resectability. However,volume and especially heterogeneity of the mediastinal lesions require the use of target zone calculations of theADC maps, and improvement seems possible by combining this with a visual DCE interpretation.


MR imaging using DW- and DCE-MRI analysis might help to noninvasively predict lesion resectability prior tosurgery, and could help to improve lesion characterization.

MSSR43

RSNA/ESR Emergency Symposium: Chest Emergencies (An Interactive Session) Multisession Courses

ER CH



Wed, Dec 3 1:30 PM - 3:00 PM Location: S402AB

Sub-Events Thoracic Injuries

Stuart E. Mirvis MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) The learner will be able to differentiate traumatic aortic injuries from congenital varients that mimic injury,to distinguish minor from major aortic injuries and to understand how injury classification can influencemanagement. 2) The participant will recognize the various CT appearances suggesting and verifying majorairway injury. 3) The participant will understand the various CT apperances of blood/bleeding in the chest andhow the location, quantity of blood/bleeding and patient clinical status determine initial treatment. 4) Thelearner will appreciate the spectrum of cardiac injuries that can be diagnosed on admission contrast-enhancedCT and those that require urgent intervention.

Non-Traumatic Thoracic Emergencies

Cornelia Maria Schaefer-Prokop MD (Presenter): Advisory Board, Riverain Technologies, LLC

LEARNING OBJECTIVES

1) To get familiar with protocols and diagnostic performance of comprehensive cardiothoracic CT examinationsto determine the presence of vascular life threatening events such as aortic dissection, acute coronary diseaseand pulmonary embolism. 2) To illustrate typical but also less classic CXR and CT findings of patients with

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pulmonary or mediastinal diseases causing acute dyspnoea and / or requiring immediate treatment and to learnabout key imaging findings in these patients allowing for a fast differential diagnosis. 3) To learn how to adaptCT protocols to CXR findings and to integrate imaging findings with lab findings, patient history and clinicalinformation for making the diagnosis.

ABSTRACT

Pulmonary symptoms such as chest pain, shortness of breath or wheezing are common non-traumaticsymptoms prompting ER visits. Because clinical symptoms are very non-specific, imaging plays a major role indifferentiating life threatening from less severe diseases and forming a diagnosis. The chest radiograph remainsthe first imaging despite its limited sensitivity for certain diseases and being prone to inter-observer variability.Comprehensive cardiothoracic CT examinations using most modern CT equipment are well evaluated in theirdiagnostic accuracy to determine the presence of vascular life threatening events such aortic dissection, acutecoronary disease and pulmonary embolism. Protocols, literature evidence and appropriate examples will bediscussed. In addition the course will highlight nonvascular emergencies such as mediastinal diseases (e.g.,esophageal perforation, mediastinitis or pericarditis) and pulmonary emergencies (e.g., pneumonia, edema,pneumothorax, exacerbation of diffuse lung diseases) for which a more comprehensive consideration of imagingfindings, lab findings, patient history and clinical information is needed for making the diagnosis.

Interactive Case Discussion

Cornelia Maria Schaefer-Prokop MD (Presenter): Advisory Board, Riverain Technologies, LLC , Stuart E. Mirvis MD (Presenter): Nothing to Disclose

SSM05

Chest (Interventional II) Scientific PapersIR CT CH AMA PRA Category 1 Credits ™: 1.00


Wed, Dec 3 3:00 PM - 4:00 PM Location: S406B

ParticipantsModeratorEdith Michelle Marom MD : Nothing to Disclose ModeratorLaura Elizabeth Heyneman MD : Nothing to Disclose

Sub-Events Percutaneous Lung Biopsies Using an Ultra Low-dose Protocol on 16-slice CT: A Preliminary StudyResult

Guan-Min Quan MD (Presenter): Nothing to Disclose , Yang Liu : Nothing to Disclose , Tao Yuan MD : Nothing to Disclose , Shengyong Wu MD, PhD : Consultant, Qmetrics Technologies

PURPOSE

To explore the value of the dose reduction technology during lung biopsies with an ultra-low-dose (ULD)protocol.


A total of ninety consecutive patients (BMI<33kg/m2)who underwent CT-guided (GE lightspeed CT,USA)percutaneous lung biopsy were enrolled and randomised into ULD group(120kV,10mA), low dosegroup(120kV,50mA)and the standard dose group(120kV,auto-mA); There was no significant difference aboutlesion features (size, location and the length of the needle path)( P>0.05). Volume CT dose index, dose lengthproduct were recorded and the effective dose was calculated.Positive rate of biopsy,the incidences of totalcomplications, incidence of intrapulmonary hemorrhage and the incidence of pneumothorax were alsorecorded.Radiation doses were compared by using ANOVA; Positive rate of biopsy and the incidences ofcomplications were compared by using chi-square test.

RESULTS

The effective dose were 0.31±0.07mSv in ULD groups, 2.69±1.34mSv in low dose group, 7.29±2.71mSv instandard dose groups(F=124.16,P=3.25×10-26). The effective dose of ULD groups were 11.5%, 4.3% of thelow dose groups and the standard dose groups.The positive rate of biopsy,the total incidences ofcomplications,the incidence of pneumothorax and pulmonary hemorrhage were 86.7%,16.7%,13.3% and 3.3%in ULD groups,93.3%,13.3%,3.3% and 10% in low dose groups,90.0%,16.7%,16.7% and 0% in standard dosegroups. The positive rate of biopsy(χ2=0.74, P=0.69),the accuracy in classification and grading of lungcancer(χ2=0.257, P=0.88), the incidences of total complications (χ2=0.17, P=0.92)had no significant differenceamong three groups.

CONCLUSION

Radiation dose during CT-guided percutaneous lung biopsies are reduced greater through the use of a ULD CTprotocol without significant difference in technical success and the incidences of complications compared withthe low dose groups and the standard dose groups.

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Fig.1 Image of a 76-year-old woman (BMI of 24) with squamous cell carcinoma.Low-dose protocol(120KV,50mA).The effective dose was 2.42mSv.Images scoring 5. Fig.2 Image of a 40-year-old man (BMI of22) with adenocarcinoma.Ultra-low-dose protocol (120KV,10mA).The effective dose was 0.2mSv.Imagesscoring 5. Fig.3 Image of a 70-year-old man (BMI of 21.8) with adenocarcinoma.Standard dose protocol(120KV,150mA).The effective dose was 4.5mSv.Images scoring 5.

The Preliminary Study of Perfusion CT in Guiding Percutaneous Lung Biopsies Using Low-doseProtocol and ASIR Technology

Guan-Min Quan MD : Nothing to Disclose , Yang Liu : Nothing to Disclose , Shengyong Wu MD, PhD(Presenter): Consultant, Qmetrics Technologies , Tao Yuan MD : Nothing to Disclose

PURPOSE

To explore the value of low dose perfusion CT in guiding percutaneous lung biopsies using low-dose protocol andadaptive statistical iterative reconstruction (ASIR) technology.


A total of 120 consecutive patients who underwent CT-guided percutaneous lung biopsy were enrolled andrandomised into group 1 (low dose perfusion),group 2(standard dose perfusion), group 3(contrastenhancement) and group 4(non-contrast-enhanced CT); there was no significant difference about lesionfeatures. Positive rate of biopsy, the accuracy in classification and grading of lung cancer and the incidences ofcomplications were recorded. Positive rate of biopsy, the accuracy in classification and grading of lung cancerand the incidences of complications,and radiation doses were compared between these groups.

RESULTS

The positive rate of biopsy and the accuracy in classification and grading of lung cancer were 96.7% and 100%in group 1, 93.3% and 100% in group 2, 93.3% and 83.3% in group 3, 73.3% and 75% in group 4. Thedifferences about the positive rate of biopsy were not statistically significant between the group 1 and 3(χ2=0.351, P=0.554), the positive rate of biopsy of group 2 was the same with that of group 3. The accuracy inclassification and grading of lung cancer of group 1 was higher than that of group 3 (χ2=4.537,P=0.033). Theaccuracy in classification and grading of lung cancer of group 1 was the same with that of group 2. The positiverate of biopsy of group 1,2 and 3 were higher than that of group 4 (P<0.05). The incidences of totalcomplications were 10% in group 1, 20% in group 2, 16.7% in group 3, 46.7% in group 4. The incidences oftotal complications of group 1,2,3 were lower than that of group 4 (P<0.05). The incidences of totalcomplications of group1, 2 and 3 had no significant difference between each other (χ2=1.184, P=0.553). Theeffective dose were 4.25±0.72 mSv in group1, 9.94±1.93 mSv in group 2(t=-15.101,P=2.09×10-17).

CONCLUSION

The application of low dose perfusion CT during lung biopsies can improve the positive rate of biopsy and theaccuracy in classification and grading of lung cancer with the reduction of incidences of complications. Radiationdose during CT-guided percutaneous lung biopsies is reduced greater through the use of low dose perfusioncompared with standard dose perfusion group.


low dose CTP of squamous cell carcinomas case

Does Perfusion CT Play a Role in the Evaluation of Percutaneous Microwave Ablated Lung Tumors?

Nassim Parvizi MBBS, BSC (Presenter): Nothing to Disclose , Daniel Yiu Fai Chung MBBS, FRCR : Nothing toDisclose , Mark William Little MBBS, MSc : Nothing to Disclose , Fergus Vincent Gleeson MBBS : AllianceMedical Ltd Consultant , Ewan Mark Anderson MBBCh : Nothing to Disclose

PURPOSE

1. To assess changes in perfusion CT (pCT) parameters following microwave ablation (MWA) of lung tumors. 2.To determine the utility of direct visualization of perfusion maps and pCT parameters to confirm adequatetreatment and predict local tumor progression (LTP).


Patients with primary and metastatic lung tumors who underwent pCT studies immediately pre and post MWAwere included. LTP was defined as nodular, enhancing tissue in continuity within the ablation zone at 6 monthspost MWA. Perfusion maps of the tumors were constructed using Advantage Windows Workstation and CTperfusion 3 software (GE, Milwaukee, US). Regions of interest were drawn on sequential axial sections toextract the pCT parameters blood flow (BF), blood volume (BV) and mean transit time (MTT), from the entiretumor volume. Direct visualization of perfusion maps pre and post MWA was performed by two experiencedobservers blinded to outcome. Data was analyzed using the Student's t-test.

RESULTS

32 patients with a mean age of 73.5 (48-90) years, with 34 lung tumors (11 primary and 21 metastatic)underwent pCT scans immediately pre and post MWA. The median tumor diameter was 20mm (10-52mm). 4patients developed LTP, with a larger mean size at baseline compared to adequately treated tumors (28mm vs20mm, p=0.006). pCT outcome parameters for all patients pre and post MWA were BF 97 vs 62 ml/min/100g,

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BV 4.1 vs 2.5 ml/100mg (p=0.02) and MTT 5.3 vs 5.2 s respectively. BV was significantly reduced for patientswith no recurrence pre and post MWA 4.0 vs 2.4 ml/100mg (p=0.02), respectively. Direct visualization of pCTmaps gave information on treatment adequacy and potential LTP. There was moderate agreement for directvisualization between the two observers (kappa coefficient 0.5). Adequate treatment was correctly determinedin 26/34 lesions, with a sensitivity of 87% (CI 69-96%), specificity 75% (20-96%), PPV 96% (81-99%) andNPV 43% (10-81%).

CONCLUSION

BV is the most reliable quantitative pCT parameter for determining adequate treatment with MWA and inpredicting LTP. Direct visualization of the perfusion maps may allow identification of areas requiring furthertreatment at the time of the procedure.


Lack of ground glass opacification at the time of procedure hampers assessment of adequacy of microwaveablation in the lung. pCT may be a useful assessment tool immediately following MWA of lung tumors.

Pre-operative Lung Nodule Microcoil Localization without Pleural Marking: A Novel Modification of anEstablished Technique

Lan-Chau Thi Kha MD, MSc (Presenter): Nothing to Disclose , Kate Hanneman MD : Nothing to Disclose , Taebong Chung MD : Nothing to Disclose , Laura Donahoe MD : Nothing to Disclose , Narinder S. Paul MD : Research funded, Toshiba Corporation , Kazuhiro Yasufuku MD, PhD : Nothing to Disclose , Andrew Pierre MD : Nothing to Disclose , Shafique Keshavjee MD : Nothing to Disclose , Elsie Nguyen MD : Nothing to Disclose

PURPOSE

To evaluate the safety and efficacy of CT-guided percutaneous microcoil lung nodule localization prior tovideo-assisted thoracoscopic surgical (VATS) excision, comparing a novel approach without pleural marking toan established technique with pleural marking.


63 consecutive patients (66.6% female, mean age 61.6±11.4 years) with 64 lung nodules resected betweenOctober 2008 and January 2014 were retrospectively evaluated; 29.7% (n=19) had standard microcoildeployment with marking of the pleura and 70.3% (n=45) had microcoil deployment without marking of thepleura. Clinical, pathological and imaging characteristics, radiation dose, CT procedure and operating roomtime, complete resection rates, procedural and surgical complications were compared using two-sample t-testand Fisher's exact test.

RESULTS

There was no significant difference in pulmonary nodule size (12.6±6.3 vs. 11.8±4.5mm, p=0.55) or noduledepth from the pleural surface (9.3±6.2 vs. 7.1±6.7 mm, p=0.22) between procedures with pleural markingcompared to those without. However, mean procedure duration (53.6±18.3 vs. 72.8±25.3min, p=0.001) andtotal effective radiation dose (5.1±2.6 vs. 7.1±4.9mSv, p=0.039) were significantly lower in the group withoutpleural marking compared to those with pleural marking. There was no significant difference in totalcomplication rate between the two groups (p=0.48), including rate of pneumothoraces (p=0.77) and pulmonaryhemorrhage (p=1.00). Operating room time (p=0.91) and complete resection rates (100% with pleuralmarking, 98% without pleural marking, p=0.52) were similar. A single case of positive resection margins wasdue to severely fibrotic lungs that posed technical challenges during resection. Most frequent pathology includedlung adenocarcinoma (34.4%, n=22), metastases (25.0%, n=16), and adenocarcinoma in-situ (20.3%, n=13).

CONCLUSION

CT-guided pre-operative lung nodule microcoil localization performed without visceral pleural marking results inshorter procedure time and lower radiation dose, with no significant difference in operating time, completeresection rates or complications.


A modified pre-operative lung nodule localization technique without pleural marking is safe and effective, withshorter procedure time and lower radiation dose.

Does an Intra-parenchymal Blood Patch Decrease the Rate of Pneumothorax-related Complicationsin Patients Undergoing Image-guided Lung Biopsy?

J. Louis Hinshaw MD (Presenter): Stockholder, NeuWave Medical Inc Medical Advisory Board, NeuWaveMedical Inc Stockholder, Cellectar Biosciences, Inc , Scott Bissell Loomis MD : Nothing to Disclose , Meghan G. Lubner MD : Nothing to Disclose , Timothy J. Ziemlewicz MD : Nothing to Disclose , Perry J. Pickhardt MD : Co-founder, VirtuoCTC, LLC Stockholder, Cellectar Biosciences, Inc , Fred T. Lee MD : Stockholder, NeuWave Medical, Inc Patent holder, NeuWave Medical, Inc Board of Directors, NeuWave Medical,Inc Patent holder, Covidien AG Inventor, Covidien AG Royalties, Covidien AG , Douglas Robert Kitchin MD : Nothing to Disclose , David H. Kim MD : Consultant, Viatronix, Inc Co-founder, VirtuoCTC, LLC MedicalAdvisory Board, Digital ArtForms, Inc

PURPOSE

There have been multiple smaller studies evaluating the role of an intraparenchymal blood patch (IPB) duringlung biopsy, but they have shown mixed results and controversy remains as to the true efficacy of thistechnique. Therefore, the purpose of this study was to determine whether an autologous IBP reduces the rate ofpneumothorax-related complications during CT-guided lung biopsies.


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We reviewed all CT-guided lung biopsies performed between Aug 2006 and Sept 2013. Patients were excluded ifno aerated lung was crossed. Data collected included: Number of pneumothoracies, and number ofpneumothoracies requiring intervention (all catheter placements), as well as more advanced interventions (e.g.chest tube placement and hospital admission or pleural blood patch). The patients were assigned to two groups.Those that received an IBP and those that did not. The rate of pneumothorax, intervention, and advancedintervention were compared between the two groups.

RESULTS

839 patients were included in the study. Patients that received an IBP had a significantly decreased rate ofpneumothorax, pneumothorax-related intervention, and advanced intervention ((142/482) 29% vs (154/357)43%, p

CONCLUSION

Autologous IPB placement is associated with a decreased rate of pneumothorax, and, more importantly,pneumothorax requiring intervention after CT-guided lung biopsies. Although this benefit has not resulted in asignificant decrease in chest tube placement and hospital admission in our practice, this can be accounted forby the success of a pleural blood patch in obviating the need for hospital admission for many of these patients.


Autologous IPB placement has remained somewhat controversial due to mixed results in published series, butthis large series confirms that there is a benefit, with a decreased rate of pneumothorax, and, moreimportantly, pneumothorax requiring intervention after CT-guided lung biopsies.

Ultrasonography-guided Biopsy of Supraclavicular Lymph Nodes for Diagnosis of Metastasis andIdentifying Harboring Epidermal Growth Factor Receptor (EGFR) Mutation in Lung Cancer

Jooae Choe MD (Presenter): Nothing to Disclose , Mi Young Kim MD, PhD : Nothing to Disclose , Chang-Min Choi : Nothing to Disclose , Hwa Jung Kim : Nothing to Disclose , Jung Hwan Baek : Nothingto Disclose

PURPOSE

To evaluate the role of ultrasonography(US)-guided supraclavicular lymph node(SCN) for detecting metastasisand epidermal growth factor receptor(EGFR) mutation in lung cancer.


This retrospective study was approved by the institutional review board. We enrolled 253 consecutive patients(167 men, 86 women; 36-86 years) who underwent US-guided core biopsy (using 18G cutting needle) of SCNfrom Jan. 2011 to Dec. 2013. Two independent radiologists measured sizes of SCNs in short and longdimensions on US and chest CT images. Gold standard for the evaluation of target SCN was combination of CT,FDG-PET/CT, US-guided biopsy, pathology, and subsequent CT after treatment. TNM stages, SUV onFDG-PET/CT, and findings of SCNs on US and CT were compared between the positive(disease group) and thenegative(control group) for metastasis. Diagnostic performance was compared between US-guided biopsy andCT. The prevalence of EGFR mutations of SCNs harboring adenocarcinoma and biopsy-related morbidity wereevaluated.

RESULTS

Final diagnoses were adenocarcinoma (n = 183), squamous cell carcinoma (n = 54), other non-small cell lungcancer (n = 11), and small cell cancer (n = 5). Disease group (n = 207, 82%) was associated with higherfrequency of adenocarcinoma (n = 158, p = .009), higher TNM stages (p = 0.022 for T, p < .001 for N, p <.001 for M, respectively), larger mean short (10 vs 6 mm)/long (15 vs 11 mm) dimensions on US (p < .001),larger mean short (10 vs 7 mm)/long (15 vs 11 mm) dimensions on CT (p < .001), and higher SUVs (7.2 vs2.7, p < .001) than control group (n = 46, 18%). Interclass correlation coefficient was 0.827 to 0.917. SCNmetastasis was missed on CT in 57 patients(22.5%), and among them, 33 patients(13.0%) were positive formalignant cells on US-guided biopsy. Analysis of EGFR mutation in SCN was feasible in 122(71.5%) of 181patients. EGFR mutations were positive in 40 patients(32.8%) [28(23.0%) in exon 19, 10(8.1%) in exon 21,2(1.6%) in exon 18]. None of patients had biopsy related morbidity.

CONCLUSION

US-guided SCN biopsy is a reliable and safe method for tissue confirmation of metastatic lung cancers andevaluation of mutations. The metastasis rate of SCN is higher with adenocarcinoma, larger sizes, higher SUVs,and higher TNM stages.


US-guided biopsy might substitute invasive percutaneous or bronchoscopic biopsy of patients who have initiallyadvanced lung cancer with enlarged SCN.

SSM06

Chest (Thoracic Malignancy) Scientific PapersOI CT CH

SSM05-06



Wed, Dec 3 3:00 PM - 4:00 PM Location: S404CD

ParticipantsModeratorKiyoshi Murata MD : Nothing to Disclose ModeratorBrett Wilson Carter MD : Author, Reed Elsevier Consultant, St. Jude Medical, Inc

Sub-Events Non Small Cell Lung Cancer: Efficacy of CT Texture Analysis in Assessment of Histological Subtype

Roberto Lo Gullo MD (Presenter): Nothing to Disclose , Mannudeep K. S. Kalra MD : Nothing to Disclose , Alexi Otrakji MD : Nothing to Disclose , Lecia Sequist : Nothing to Disclose , Jo-Anne O. Shepard MD : Consultant, Agfa-Gevaert Group , Subba Rao Digumarthy MD : Nothing to Disclose , Zofia Piotrowska : Nothing to Disclose

PURPOSE

To assess the difference in CT texture, among histological subtypes of primary non small cell lung cancer(NSCLC) and to identify the most helpful metrics of CT histogram analysis.


This IRB approved study included 94 consecutive patients with biopsy proven primary NSCLC (45M; 49F; meanage 65 years; range26-86). The subtypes included 69 adenocarcinoma ( 27 EGFR mutants and 42 nonmutants)and 25 squamous cell carcinoma. CT examinations of patients were deidentified and exported to an offlineserver with a commercial texture analysis software (TexRAD limited, UK). The image analysis was performed ona single image with manually drawn large region of interest on dominant lung lesions after excluding areas ofcavitation and contrast and beam hardening artifacts. The analyzed features included mean HU values, percentpositive pixels (PPP), mean value of positive pixels (MPP), standard deviation (SD), normalized SD, skewness,kurtosis, and entropy. Data were analyzed with non parametric ANOVA Kruskal- Wallis test and T-test withWelch correction.

RESULTS

Significant differences in CT texture features were found between squamous and adenocarcinoma for entropy(p-value=0.002) and normalized SD (p=0.0073). There is significant difference in kurtosis (p=0.01) betweenEGFR mutation positive adencarcinoma and non EGFR mutant adenocarcinoma. There was no significantdifference for skewnes and mean values for positive pixels.

CONCLUSION

Entropy, normalized SD and kurtosis are the most useful texture parameters to differentiate histologicalsubtypes of NSCLC . Squamous and adenocarcinoma (EGFR mutant and nonmutant subtypes) have disntict CTtexture.


Image analysis using CT histogram allows tissue characterization and has potential clinical applications tochoose therapy and supplement other diagnostic tests.

Preoperative Staging of Non-small Cell Lung Cancer: Comparison of PET/MR and PET/CT

Sang Min Lee : Nothing to Disclose , Jin Mo Goo MD, PhD (Presenter): Research Grant, Guerbet SA , ChangMin Park MD, PhD : Nothing to Disclose

PURPOSE

To compare the accuracy of PET/MR and PET/CT in the preoperative staging of non-small cell lung cancer(NSCLC).


Institutional review board approval and informed consent from patients were obtained. From March 2013 toFebruary 2014, 50 patients (31 men and 19 women; mean age, 62.6 years ± 10.9; range 35-84 years) whohad proven or radiologically suspected lung cancer which appeared to be resectable on chest CT were enrolledin this study. After exclusion of nine patients (histology other than NSCLC [n=4]; no surgical resection [n=5]),41 patients were included in the analyses. PET/MR was performed for NSCLC staging followed by PET/CT on thesame day. In terms of MR sequences, T1 coronal, T2 HASTE axial, pre- and post-contrast VIBE axial imageswere obtained in 5 to 6 bed positions, and DWI in two bed positions were obtained as well. Tumor stages weredetermined by using the TNM and American Joint Committee on Cancer staging systems. Observers (threeradiologists and two nuclear medicine physicians) evaluated PET/MR and PET/CT separately and independently.The standard reference was pathologic results and extrathoracic metastases were confirmed pathologically orby follow-up imaging. The accuracies of PET/MR and PET/CT for NSCLC staging were compared by using theMcNemar test.

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McNemar test.

RESULTS

The primary tumor stages (n=36 patients) were correctly diagnosed in 26 patients (72.2%) on PET/MR and in26 patients (72.2%) on PET/CT (P=1.0). The node stages (n=39 patients) were correctly determined in 24patients (61.5%) on PET/MR and in 22 patients (56.4%) on PET/CT (P=0.688). Metastatic lesions in the brain,bone, liver, and left pleura were detected in 4 patients (9.8%). PET/MR depicted all metastatic lesions whilePET/CT missed solitary brain metastasis in one patient. The accuracies of overall stages were 53.7% (22/41) onPET/MR and 53.7% (22/41) on PET/CT. There were no significant differences in accuracies of overall stagesbetween PET/MR and PET/CT (P=1.0).

CONCLUSION

PET/MR is comparable to PET/CT in the preoperative staging of NSCLC and has the potential to provide imagingexams for NSCLC staging workup at one time.


Except for the advantage of reduced radiation dose and the potential of one-stop examination including brainevaluation, PET/MR does not appear to be superior to PET/CT in the staging of NSCLC. Therefore, streamliningof PET/MRI protocols may be necessary in this respect.

Newly Developed DWI Using Fast SE Sequence vs. DWI using EPI Sequence vs. FDG-PET/CT:Diagnostic Capability of N-Stage in Patients with Non-small Cell Lung Cancer

Yoshiharu Ohno MD, PhD (Presenter): Research Grant, Toshiba Corporation Research Grant, KoninklijkePhilips NV Research Grant, Bayer AG Research Grant, DAIICHI SANKYO Group Research Grant, Eisai Co, LtdResearch Grant, Terumo Corporation Research Grant, Fuji Yakuhin Co, Ltd Research Grant, FUJIFILM HoldingsCorporation Research Grant, Guerbet SA , Shinichiro Seki : Nothing to Disclose , Mizuho Nishio MD, PhD : Research Grant, Toshiba Corporation , Hisanobu Koyama MD, PhD : Nothing to Disclose , Yoshimori Kassai MS : Employee, Toshiba Corporation , Masao Yui : Employee, Toshiba Corporation , Hitoshi Yamagata PhD: Employee, Toshiba Corporation , Takeshi Yoshikawa MD : Research Grant, Toshiba Corporation , Sumiaki Matsumoto MD, PhD : Research Grant, Toshiba Corporation , Yu Ueda PhD : Nothing to Disclose , Katsusuke Kyotani RT : Nothing to Disclose , Kazuhiro Kubo RT : Nothing to Disclose , Kazuro Sugimura MD, PhD : Research Grant, Toshiba Corporation Research Grant, Koninklijke Philips NV Research Grant, BayerAG Research Grant, Eisai Co, Ltd Research Grant, DAIICHI SANKYO Group

PURPOSE

Diffusion-weighted MR imaging using an echo-planar imaging (EPI) sequence has been suggested at least asvaluable as FDG-PET/CT for N stage assessment in non-small cell lung cancer (NSCLC) patients, although imagedistortion of DWI using EPI sequence may decrease diagnostic performance in this setting. Recently, wedeveloped the new DWI by means of the fast spin-echo (FSE) sequence to overcome this problem. The purposeof this study was to determine the utility of DWI using FSE (FSE-DWI) for N-stage assessment in NSCLCpatients as compared with DWI using EPI (EPI-DWI) and PET/CT.


66 consecutive operable NSCLC patients (37 men, 29 women; mean age 71 years) prospectively underwentFSE-DWI and EPI-DWI at a 3T system, integrated PET/CT, surgical treatment and pathological and follow-upexaminations. In each subject, both DWI sequences were applied with b-value at 300 sec/mm2. Then,probability of lymph node metastasis at each station was visually assessed by 5-point visual scoring systems onboth DWIs and PET/CT in each patient. To compare diagnostic capability of lymph node metastasis among allmethods, ROC analyses were performed. Then, sensitivity, specificity and accuracy were compared among allmethods by means of McNemar's test on a per station basis. Finally, diagnostic accuracy of the N-stage wasalso statistically compared each other by McNemar's test.

RESULTS

Area under the curve (Az) of FSE-DWI (Az=0.89) was significantly larger than that of EPI-DWI (Az=0.77,p<0.0001) and PET/CT (Az=0.83, p=0.03). On a per node basis, sensitivity (SE) and accuracy (AC) of FSE-DWI(SE: 80.0 <60/75> %, AC: 95.3 <427/448> %) were significantly higher than those of EPI-DWI (SE: 56.0<42/75> %, p<0.0001; AC: 91.5 <410/448> %, p<0.0001) and PET/CT (SE: 72.0 <54/75> %, p<0.0001;AC: 94.0 <421/448> %, p<0.0001). While assessing N-stage, sensitivity (96.9 <31/32> %) and accuracy(95.3 <61/64> %) of FSE-DWI were significantly higher than those of EPI-DWI (SE: 75.0 <24/32> %, p=0.02;AC: 86.0 <55/64> %, p=0.03) and PET/CT (SE: 75.0 <24/32> %, p=0.02; AC: 86.0 <55/64> %, p=0.03).

CONCLUSION

DWI using FSE is more sensitive and accurate method than DWI using EPI and PET/CT for N-stage assessmentin patients with non-small cell lung cancer.


DWI using the fast spin-echo sequence is more sensitive and accurate than DWI using the echo-planar imagingsequence and PET/CT for N-stage assessment in non-small cell lung cancer patients.

Diagnostic Impact of Digital Tomosynthesis in Oncologic Patient Management: Analysis on a LargePatient Series

Emilio Quaia MD : Nothing to Disclose , Elisa Baratella MD (Presenter): Nothing to Disclose , Gabriele Poillucci : Nothing to Disclose , Sara Kus : Nothing to Disclose , Antonio Giulio Gennari : Nothing toDisclose , Maria Assunta Cova MD : Nothing to Disclose

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PURPOSE

To assess the actual clinical impact of digital tomosynthesis in the management of oncologic patients withsuspected pulmonary lesions on chest radiography.


Two-hundred-thirty-seven patients (135 male, 102 female; age, 70.8±10.4 years) with a known primarymalignancy (colorectal, n=49; breast, n=46; bladder, n=22; kidney, n=22; lung, n=20; prostate, n=16;stomach, n=8; non-Hodgkin lymphoma, n=4; others, n=50) suspected pulmonary lesion(s) on chestradiography underwent digital tomosynthesis. Two readers (experience, 10 and 25 years) prospectivelyanalyzed chest radiography and digital tomosynthesis images and proposed a diagnosis according to aconfidence score: 1 or 2=definite or probable benign pulmonary or extra-pulmonary lesion, or pulmonarypseudolesion deserving no further diagnostic work-up; 3=indeterminate; 4 or 5=probable or definite pulmonarylesion deserving further diagnostic work-up by CT. DTS findings were proven by imaging follow-up by CT(n=124 patients) or chest radiography (n=106) or histology (n=7). Mean interpretation time and effective dosewere measured both for chest radiography and digital tomosynthesis.

RESULTS

Final diagnoses included 94 pulmonary lesions, 14 pulmonary scars and 14 pleural lesions in 122 patients, andpulmonary pseudolesions in the remaining 115 patients. Digital tomosynthesis resolved the chest radiographydoubtful findings in 123/237 (52%) patients, while 114/237 (48%) patients underwent CT. Digitaltomosynthesis vs chest radiography presented an higher sensitivity (88% vs 15%), specificity (95% vs 10%),overall accuracy (93% vs 21%) and diagnostic confidence (area under ROC curve, 0.914 vs 0.558). The meaninterpretation time for digital tomosynthesis (mean±SD, 220 ± 40 s) was higher (P<0.05; Wilcoxon test) thanfor chest radiography (110 ± 30 s) but lower than CT (600 ± 150 s). Mean effective dose was 0.06 mSv (range,0.03 - 0.1 mSv) for chest radiography, and 0.2 mSv (range, 0.1 - 0.3 mSv) for digital tomosynthesis.

CONCLUSION

Digital tomosynthesis avoided the need for chest CT in about one half of oncologic patients with suspectedpulmonary lesions on chest radiography with a slight increase in the interpretation time and effective dosecomparable to chest radiography.


Digital tomosynthesis is a problem-solving imaging technique to rule out suspicious pulmonary findings inoncologic patients with an high pre-test probability.

Prognostic Value of CT Texture Features in Non-small Cell Lung Cancers Treated with DefinitiveConcomitant Chemoradiotherapy

Su Yeon Ahn (Presenter): Nothing to Disclose , Chang Min Park MD, PhD : Nothing to Disclose , Sang-Joon Park MD : Nothing to Disclose , Hak Jae Kim : Nothing to Disclose , Chang Hoon Song : Nothing toDisclose , Jin Mo Goo MD, PhD : Research Grant, Guerbet SA

PURPOSE

To investigate whether CT texture parameters of primary tumors are associated with progression-free survival(PFS) and overall survival (OS) in non-small cell lung cancer (NSCLC) patients undergoing definitiveconcomitant chemoradiotherapy (CCRT).


Our institutional review board approved this retrospective study with waiver of patients' informed consents.From January 2006 to December 2009, 72 patients with non-operable NSCLCs (stage IIIA, 31; stage IIIB, 40;stage IV, 1) underwent definitive CCRT at our institution. For all patients, CT texture parameters of primarytumors including entropy, homogeneity, skewness, kurtosis, mean Hounsfield unit (HU), standard deviation(SD) and volume were extracted from contrast-enhanced chest CT taken prior to CCRT using an in-housesoftware program. Thereafter, each parameter was dichotomized based on optimal cutoff values calculatedfrom receiver-operating characteristics curve analysis. PFS and OS were compared between the dichotomizedsubgroups via Kaplan-Meier analyses with log rank test. Multivariate Cox regression analyses were performedto determine significant prognostic factors for survival.

RESULTS

Median OS and PFS were 23 months (range, 2-86 months) and 10 months (range, 8-12 months), respectively.There were no significant differences in OS and PFS according to tumor stage. As for PFS, homogeneity(p=0.019) and kurtosis (p=0.044) were significantly associated with PFS on univariate analysis. MultivariateCox regression analysis revealed that homogeneity (Adjusted hazard ratio (HR)=2.33, p=0.014) and kurtosis(Adjusted HR=2.76, p=0.026) were both significant independent predictors. As for OS, homogeneity (p=0.018),skewness (p=0.001) and kurtosis (p=0.036) were significantly associated with OS. Multivariate Cox regressionanalysis revealed that homogeneity (Adjusted HR=5.49, p =0.002), skewness (Adjusted HR=2.52, p=0.004),mean HU (Adjusted HR=5.19, p=0.001), and SD (Adjusted HR=2.24, p=0.03) were independent significantpredictors.

CONCLUSION

CT texture features were associated with PFS and OS in NSCLC patients undergoing definitive CCRT and may

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potentially be utilized as prognostic biomarkers.


Texture features of pretreatment contrast enhanced CT images in NSCLC patients may potentially be utilized asprognostic biomarkers of PFS and OS.

Improved Detection of Bone Metastases from Lung Cancer in the Thoracic Cage Using 5mm and 1mmaxial CT Images vs. a New CT-software Generating a Rib Unfolding Image Set: Comparison withStandard 18F-FDG-PET/CT

Georg Homann MD (Presenter): Nothing to Disclose , Deedar Farhad Mustafa MD, BEng : Nothing toDisclose , Juergen Hetzel : Nothing to Disclose , Werner Spengler MD : Nothing to Disclose , Claus Detlef Claussen MD : Nothing to Disclose , Konstantin Nikolaou MD : Speakers Bureau, Siemens AG SpeakersBureau, Bracco Group Speakers Bureau, Bayer AG , Marius Horger MD : Nothing to Disclose

PURPOSE

To evaluate the performance of a dedicated CT-software called 'bone reading' generating rib unfolded imagesfor improved detection of rib metastases in patients with lung cancer and suspicious focal uptake on18F-FDG-PET/CT in terms of sensitivity and specificity and reading time as compared with 5mm and 1mm axialCT-images.


50 consecutive patients with lung cancer that underwent 18F-FDG-PET/CT and chest-CT scanning between 2011and 2014 at our institution were retrospectively analyzed. Chest-CT scans with 5mm and 1mm slice thicknesswere interpreted blindly and separately focusing on detection of rib metastases (location, number, cortical vs.medullary, osteolytic vs. osteoblastic [sclerotic]). Subsequent image analysis of unfolded 1mm based CT ribimages was performed. This image data set can be spatially rotated (screwed) for optimized multi-angledviews. Finally, combined FDG-PET and "bone reading" image analysis was performed and correlated with theother results. Osteolytic and mixed osteolytic-osteoblastic, FDG-PET+ lesions were considered true positivewhereas suspicious osteoblastic lesions had to be confirmed at follow up. Follow-up chest-CT was present in allpatients.

RESULTS

From a total of 45 rib metastases at follow-up, 26 rib lesions were found positive on FDG-PET/CT. 9 lesions wereosteolytic, 9 were mixed osteolytic-osteoblastic whereas 27 were sclerotic. On patient-based analysis, CT(5mm), CT (1mm) and CT (1mm-'bone reading') yielded a sensitivity, specificity and accuracy of0.7/0.85/0.94[5mm], 0.8/0.84/0.96 [1 mm] and 1.0/0.8/0.98 ['bone reading'], respectively. On lesion-basedanalysis, the accuracy of the three evaluations was 0.34/0.66/0.93, respectively. Reading time for 5mm/1mmaxial images and "unfolded images" was 49.8 [± 30s (5mm/1mm)] and 18.7 [± 5.3 s (1mm-'bone reading')],respectively.

CONCLUSION

The use of the 'unfolded rib' software improves detection of rib metastases in patients with lung cancer ascompared to standard CT reading.


Early detection of metastases is crucial in lung carcinoma staging. Especially in complex anatomical regions asthe ribs the 'unfolded rib' software improves the detection rate significantly.

RC601

Chest Imaging: How Radiologic-Pathologic Correlation Informs Interpretation Refresher/InformaticsCT CH AMA PRA Category 1 Credits ™: 1.50


Thu, Dec 4 8:30 AM - 10:00 AM Location: E353C

ParticipantsModeratorJeffrey R. Galvin MD : Nothing to Disclose

LEARNING OBJECTIVES

1) Understand the basic structures and systems that allow the respiratory system to function. 2) Utilize the knowledge of basicrespiratory structures to improve their understanding of respiratory disease and therefore improve diagnostic accuracy. 3)Improve their understanding of disease that affects the lung interstitium, small airways, pulmonary vessels and lymphatics. 4)Learn an approach to the assessment of lung nodules including new information on small ground glass opacities.

Sub-Events Interstitial Lung Disease

Jeffrey R. Galvin MD (Presenter): Nothing to Disclose

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RC601A

LEARNING OBJECTIVES


Diseases of the Small Airways

Phillip M. Boiselle MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) To understand the normal anatomy of the small airways and their relationship to the secondary pulmonarylobule. 2) To identify characteristic HRCT patterns of small airways diseases along with their clinical andpathological correlates.

Vascular Disease

Aletta Ann Frazier MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES


Lymphoid Diseases

Tomas C. Franquet MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) To illustrate the imaging findings of some pulmonary lymphoid diseases. 2) To correlate these findings withhistopathologic features. 3) To present a differential diagnosis based on pathologic-radiologic correlation.

Lung Nodules

Seth Jay Kligerman MD (Presenter): Author, Reed Elsevier

LEARNING OBJECTIVES

1) Learn the revised terminology for adenocarcinoma of the lung. 2) Recognize imaging findings that will helpdifferentiate lung adenocarcinoma from other lung nodules. 3) Understand the pathologic findings and how itcorrelates to imaging

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ISP: Chest (Diffuse Lung Disease) Scientific PapersCT CH AMA PRA Category 1 Credits ™: 1.50


Thu, Dec 4 10:30 AM - 12:00 PM Location: E351

ParticipantsModeratorJeffrey P. Kanne MD : Research Consultant, Perceptive Informatics, Inc ModeratorSantiago E. Rossi MD : Advisory Board, Koninklijke Philips NV Speaker, Pfizer Inc Royalties, Springer Science+Business MediaDeutschland GmbH

Sub-Events Chest Keynote Speaker: Picture Perfect—Where the HRCT Diagnosis Is Virtually Certain

Jeffrey P. Kanne MD (Presenter): Research Consultant, Perceptive Informatics, Inc

A Novel Computer Algorithm for the Textural Classification of Idiopathic Interstitial Pneumonia - AProspective Cohort Study

Emma Jane Helm MBBS (Presenter): Nothing to Disclose , Abhir Bhalerao : Nothing to Disclose , Felix Woodhead : Nothing to Disclose , Rhian Hughes : Nothing to Disclose , Charles E. Hutchinson : Nothing to

RC601B

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RC601D

RC601E

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Woodhead : Nothing to Disclose , Rhian Hughes : Nothing to Disclose , Charles E. Hutchinson : Nothing toDisclose , David Parr : Nothing to Disclose

PURPOSE

To explore the use of a novel automated computerized method for textural analysis of the lung parenchyma inidiopathic interstitial pneumonia (IIP)


A total of 50 patients were prospectively enrolled and assessed using full pulmonary function testing (PFTs), ahealth status questionnaire (St George's Respiratory Questionnaire - STGRQ) and volumetric CT in fullinspiration. The CT data was automatically processed by a computerized method using texture features basedon 3D Minkowski Functionals and a machine learning classification approach. The computer algorithm calculatedtotal lung volume and the percentage of lung in the following radio-pathological categories: honeycombing,reticulation, indeterminate and normal. A total fibrosis score (TFS) was calculated by summating thehoneycombing and reticulation categories and expressing this volume as a percentage of total lung volume.Initial analysis was performed on the first 21 patients to complete the full study protocol (2 patients wereunable to perform PFTs). Linear regression was performed to explore the relationships between the measuredvariables.

RESULTS

There was strong correlation between CT calculated volume and total lung capacity (TLC) (r = 0.85*) and astrong negative correlation between TFS and percent predicted diffusion capacity for carbon monoxide (DLco; r= -0.76*). There was also a strong negative correlation between TFS and DLco/vA (r = -0.61*). There was amoderate negative correlation between TFS and FVC (percent predicted) (r = -0.43) and a moderate positivecorrelation between CT fibrosis score and STGRQ (r = 0.41). Asterisk indicates p-value

CONCLUSION

TFS was highly correlated with DLco and these preliminary results suggest that it may represent an objective,clinically meaningful measure of the severity of idiopathic interstitial pneumonia.


Our textural analysis software based on Minkowski Functionals has been successfully used to analyzeparenchymal disease in patients with idiopathic interstitial pneumonia and may offer an alternative outcomemeasure to lung function, particularly in those patients who are unable to perform physiologic tests

HRCT Classification and Survival in a Large Population of Subjects Enrolled in Multicenter Studies ofIdiopathic Pulmonary Fibrosis

Kunihiro Yagihashi MD (Presenter): Nothing to Disclose , David Augustine Lynch MBBCh : Researchsupport, Siemens AG Scientific Advisor, PAREXEL International Corporation Consultant, Boehringer IngelheimGmbH Consultant, InterMune, Inc Consultant, Gilead Sciences, Inc Consultant, F. Hoffmann-La Roche LtdConsultant, Veracyte, Inc Research support, Johnson & Johnson Research support, AstraZeneca PLC , Jason M. Huckleberry MD : Nothing to Disclose , Jordan Zach : Nothing to Disclose , Kevin Flaherty : Consultant,Boehringer Ingelheim GmbH Speakers Bureau, Boehringer Ingelheim GmbH Consultant, FibroGen, IncConsultant, F. Hoffmann-La Roche Ltd Consultant, Gilead Sciences, Inc Data Safety Monitoring Board, GileadSciences, Inc Consultant, Ikaria, Inc Consultant, ImmuneWorks Consultant, AstraZeneca PLC Consultant,Novartis AG Consultant, Takeda Pharmaceutical Company Limited Consultant, Vertex PharmaceuticalsIncorporated Consultant, Veracyte, Inc Grant, Bristol-Myers Squibb Company Speakers Bureau,GlaxoSmithKline plc Speakers Bureau, Forest Laboratories, Inc Royalties, UpToDate, Inc , Eric Yow : Nothingto Disclose , Kevin J. Anstrom : Nothing to Disclose , Marvin Schwarz : Nothing to Disclose , Yasuo Nakajima MD : Nothing to Disclose

PURPOSE

To identify the relationship between CT pattern and survival in a large population of subjects enrolled inmulticenter studies of idiopathic pulmonary fibrosis.


We retrospectively reviewed the HRCT findings in 538 participants in three studies sponsored by the IPFNETstudy network. CT appearances were classified by two thoracic radiologists according to ATS criteria as UIP,possible UIP, and inconsistent with UIP. Univariate and multivariate analysis with Cox proportional hazardsregression models were used for the correlation between CT and physiological features and survival.

RESULTS

Of the 538 cases, 304 (56.5%) had a UIP pattern on HRCT, 113 (21%) had possible UIP, and 121 (22.5%) hada pattern inconsistent with UIP. There were 38 deaths in the follow-up period. The UIP group was significantlyolder, more likely to be current or former smokers, had lower FVC% predicted, DLCO% predicted, and ashorter six-minute walk test compared to the other two groups. On univariate analysis, the survival for thegroups with possible UIP pattern and CT inconsistent with UIP was similar, but subjects with UIP had shortersurvival than the other groups (p = .032) (median survival in months - 49.9, 49.1, 44.3, respectively). The CTextent of reticular abnormality and honeycombing, and the presence of honeycombing were significantpredictors of survival (hazard ratios: 1.57, 1.51, and 2.58, respectively) (p=0.015, 0.0005, and 0.0185,respectively). Younger age, lower Borg dyspnea index scores after a walk test, lower total score on St. George'sRespiratory Questionnaire, and greater six-minute walk test distance were also significant predictors of survival(hazard ratios: 1.06, 1.24, 1.05, and 0.99, respectively) (p=0.0044, 0.0083,

CONCLUSION

In subjects enrolled in IPF clinical trials, survival of subjects with possible UIP pattern and findings inconsistentwith UIP was similar, but subjects with UIP had shorter survival.


Categorization of UIP by CT may influence prognosis.

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Categorization of UIP by CT may influence prognosis.

Can Chest CT Prevent Unnecessary Biopsy in Patients with Interstitial Lung Disease (ILD)? TheEffect of the ATS 2011 ILD Reporting Guidelines on Patient Management

Anna Rozenshtein MD (Presenter): Nothing to Disclose , Gregory D. N. Pearson MD, PhD : Nothing toDisclose , Belinda D'Souza MD : Nothing to Disclose , Beth H. Leopold BA : Nothing to Disclose , David Lederer MD, MS : Steering Committee, Gilead Sciences, Inc Advisory Board, Gilead Sciences, Inc SteeringCommittee, InterMune, Inc Advisory Board, InterMune, Inc

PURPOSE

We retrospectively evaluated the American Thoracic Society (ATS) 2011 criteria for Computed Tomography (CT)classification of Usual Interstitial Pneumonia (UIP) in a cohort of patients presenting to a tertiary referral centerfor evaluation of ILD.


The records of patients presenting to ILD clinic between 2010 and 2012 were reviewed. 3 fellowship trainedchest radiologists and a pulmonologist specializing in ILD independently reviewed CT scans in 187 patients, 86of whom had pathology results available. Based on the ATS 2011 criteria (Raghu et. al (2011) Am J Respir CritCare Med 183:788-824), patients were classified as Definite UIP, Possible UIP, or Inconsistent with UIP.Consensus was defined as agreement by 3 or more readers. Interobserver agreement was perfomed with Kappavalues.

RESULTS

Consensus CT diagnosis was reached independently in 163 of 187 (87%) of cases, and after discussion in anadditional 24 (13%) of cases. In 3 cases (2%) no consensus was reached. Interobserver agreement wasmoderate, with kappa value 0.49. Of the 86 patients with available pathology, 15 (17%) had UIP, 5 (6%) hadmixed UIP and Nonspecific Interstitial Pneumonia (NSIP), 31 (36%) had NSIP, 12 (14%) had HypersensitivityPneumonia (HP), and 24 (12%) had other diagnoses (totals>100% due to multiple pathologic diagnoses insome biopsies). Sensitivity was low, with only 8 of 20 (40%) of patients with either pathologic UIP or combinedUIP/NSIP having a consensus radiologic diagnosis of Definite UIP. Of the 15 patients with UIP on biopsy, 5 wereclassified on CT as Definite UIP, 4 Possible UIP, 5 Inconsistent, and 1 no consensus. Of the 5 patients withmixed UIP and NSIP on biopsy, 3 were classified on CT as Definite UIP, 1 Inconsistent, and 1 no consensus.Specificity, however, was high (98%), with only 1 of 66 patients without UIP on biopsy classified as Definite UIPon CT.

CONCLUSION

ATS 2011 criteria for UIP have poor sensitivity but excellent specificity for the diagnosis of UIP in ourretrospective cohort. As such, if used to triage patients with ILD for biopsy 40% of patients with pathologic UIPwould have avoided biopsy, while 2% of patients without UIP would have been triaged to no biopsy.


In our cohort, ATS 2011 criteria were excellent for triaging patients without UIP to biopsy, but would not haveprevented a biopsy recommendation in the majority of patients with pathologic UIP.

Dendriform Pulmonary Ossification in Pulmonary Fibrosis

Carlos S. Restrepo MD (Presenter): Nothing to Disclose , Michael James McCarthy MD : Nothing to Disclose , Amy Laura Mumbower MD : Nothing to Disclose , Rashmi S. Katre : Nothing to Disclose , Ameya Jagadish Baxi MBBS, DMRD : Nothing to Disclose , Jorge Carrillo MD : Nothing to Disclose

PURPOSE

Purpose: To determine the prevalence, imaging and demographic characteristics of Dendriform PulmonaryOssification (DPO) in patients with diffuse pulmonary fibrosis.


Methods and Materials: DPO is a rare condition characterized by branching bony spicules with bone marrow inthe lung parenchyma in association with interstitial pulmonary fibrosis and occasionally in other pulmonarydisease. The exact prevalence and demographic characteristics of patients with DPO is not known. The databaseof this single-center lung transplant program was retrospectively reviewed for patients having had lungtransplantation for pulmonary fibrosis during the last 15 years. 156 patients with pulmonary fibrosis werereviewed. A pre-transplant lung CT was available for analysis in 124 patients. DPO was considered present whenbilateral multiple small pulmonary parenchymal calcifications were present. Their predominant location anddistribution was determined as well as the overall predominant pattern of pulmonary fibrosis. The clinical anddemographic composition of this subsets of patient was compared with that of the population at large withpulmonary fibrosis.

RESULTS

Results: The gender distribution of patients with pulmonary fibrosis was 61% males,39% females with averageage at the time of pre-lung transplant CT of 55.7 years. DPO was seen in 11s patients (8.9%). Nine of theeleven patients were males (81.8%). The average age of DPO patients was 59. CT pattern of pulmonary fibrosisin patients with DPO was NSIP in 5 and UIP in 6 cases, whereas in the overall pulmonary fibrosis populationNSIP was seen in only 24% and UIP / possible UIP in 76% . Distribution of DPO was bilateral in all cases andpredominantly in the periphery of the mid and lower lung zones. . Even though nodular and branchingcalcification were usually present in the same patients, at least one dendriform or branching calcification waspresent in every patient.

CONCLUSION

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Conclusion: DPO in patients with diffuse pulmonary fibrosis has a prevalence of less than 10%, typicallyaffects males, and may be found in patients with either UIP or NSIP pattern of pulmonary fibrosis.


Clinical relevance: Dendriform pulmonary ossification (DPO) is an uncommon complication of patients withdiffuse pulmonary fibrosis, and can mimic numerous conditions in which multiple lung calcifications are present.

Shear Wave Imaging and ARFI Technique: Potential Tools for Analyzing Early Fibrotic Changes inthe Sub Pleural Space - Experimental Data and First Clinical Results

Reinhard I. Kubale MD (Presenter): Nothing to Disclose , Jonas Stroeder MD : Nothing to Disclose , Heinrike Wilkens : Nothing to Disclose , Arno Buecker MD : Consultant, Covidien AG Speaker, Covidien AGCo-founder, Aachen Resonance GmbH Research Grant, Siemens AG

PURPOSE

Elastography can provide information about tissue's mechanical property. The new variant of shear waveimaging (SVI) enables a quick examination not only of breast tumours but also of tendons and liver stiffness.Purpose of this study is to evaluate its feasibility for depicting subpleural parenchymal lung disease and toevaluate influencing physical factors.


In a group of 30 normal patients proved by HRCT shear wave images, ARFI measurements and displacementmaps are analyzed for reproducibility and variation of displacement of lung structures in the subpleural space(Siemens S3000). The effect of frequency, depth of pleural structures and aperture of the scan heads wereanalyzed. In 25 patients with subpleural fibrotic changes proved by CT and in one sided lung transplant patientswith fibrosis the displacement maps are are scored and compared with HRCT.

RESULTS

A good quality of the displacement map was seen in 28/30 of patients with normal lungs. 25/30 patients had aclear delineation between normal lung and pleura. Problems are seen in the basal area due to muscles anddepth. 21/25 patients with fibrotic changes had a focal or general reduced displacement in the subpleural spacecorrelating with CT (fig. 1). False positive results are caused by sub pleural metastasis and pneumonia in 2cases.

CONCLUSION

Although quantitative measurements of the shear wave velocity in the subpleural space showed a greatvariation, semiquatitative analysis of the displacement map of subpleural lung parenchyma could be a usefultool for diagnosis and noninvasive follow-up controls of early stages of lung fibrosis. Factors that should bestandardized are - Frequency and aperture size of the scan head and its elements - compression and amount ofinspiration


Elastography of the subpleural space can be a useful tool for early depiction of sub pleural fibrosis.

A Computerized Score for the Automated Differentiation of Usual Interstitial Pneumonia fromRegional Volumetric Texture Analysis

Adrien Raphael Depeursinge PhD (Presenter): Nothing to Disclose , Anne Shu-Lei Chin MD : Nothing toDisclose , Ann N. C. Leung MD : Nothing to Disclose , Glenn Rosen PhD : Nothing to Disclose , Daniel L. Rubin MD, MS : Nothing to Disclose

PURPOSE

A confident CT diagnosis of classic usual interstitial pneumonia (UIP) can eliminate the need for an invasivesurgical biopsy to confirm this diagnosis. This task is often challenging, particularly in less specialized practicecenters without access to experts experienced in interstitial lung disease. We propose a novel computationalapproach for the automated classification of classic versus atypical UIP. A score is derived from regionalvolumetric texture analysis of CT images.


CT examinations of 33 patients with biopsy proven UIP from -anonymous- were retrospectively reviewed in thisstudy. Two thoracic radiologists with more than 15 years of experience worked in consensus to classify eachpatient as classic (15 patients) versus atypical (18 patients) UIP based on the American Thoracic Societyguidelines. The responses of 3-D wavelets are localized using a simple digital atlas of 36 subregions of thelungs. The decision function of support vector machines (SVM) trained in a feature space spanned by theregional texture features is used as a score to stratify patients with UIP into classic and atypical subtypes.Receiver operating characteristics (ROC) analysis was used to evaluate the ability of the score to discriminatebetween classic versus atypical UIP.

RESULTS

An area under the ROC curve (AUC) of 0.81 was obtained using a leave-one-patient-out cross-validation, withhigh specificity for classic UIP. We compared this performance with a global characterization of the volumetrictexture properties of the lungs, which led to an AUC of 0.72. This highlighted the importance of localizing tissuetexture properties, which is consistent with the medical knowledge.

CONCLUSION

We propose a novel computational method for the automated classification of classic versus atypical UIP based

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We propose a novel computational method for the automated classification of classic versus atypical UIP basedon regional volumetric texture analysis. Overall, the proposed approach successfully predicts UIP subtypes formore than 4 out of 5 patients (AUC=0.81) with high specificity for classic UIPs.


With further validation, our system may be useful in the clinical setting for identifying patients with classic UIPfor which an unnecessary surgical biopsy can be avoided.

The Effect of Different Levels of Iterative Reconstruction on Qualitative and QuantitativeAssessment of Smoking Related Lung Disease

Rekha Raju (Presenter): Nothing to Disclose , Donya Ahmed Al-Hassan MD : Nothing to Disclose , Jonathon Avrom Leipsic MD : Speakers Bureau, General Electric Company Speakers Bureau, EdwardsLifesciences Corporation Consultant, Heartflow, Inc Consultant, Circle Cardiovascular Imaging Inc , Don D. Sin MD, FRCPC : Nothing to Disclose , Harvey Owen Coxson PhD : Research Grant, GlaxoSmithKline plcContract, GlaxoSmithKline plc Contract, Olympus Corporation Steering Committee, GlaxoSmithKline plc , Cameron John Hague MD : Nothing to Disclose , Kevin Kai Ming Ho MBBS : Nothing to Disclose , Natasha Krowchuk : Nothing to Disclose , Jennifer Deryn Ellis MD : Nothing to Disclose

PURPOSE

The purpose of this research is to examine the role that differing levels of adaptive statistical iterativereconstruction (ASIR) have on the qualitative and quantitative assessment of smoking related lung disease.


52 patients undergoing clinically indicated low dose computed tomographic (CT) exams of the chest (100 kVp,and 65mAs), with reconstruction of data with different levels of blended ASIR (0, 40 and 100%) wereconsented. Qualitative assessment of CT datasets were performed by two thoracic trained radiologists blindedto clinical history, spirometry and quantitative data for presence of emphysema (%/lung zone) and degree ofrespiratory bronchiolitis (RB). Quantitative analysis was performed to assess emphysema and airway measuresof COPD (Apollo, VIDA Diagnostics). IRB approval was obtained.

RESULTS

The application of ASIR results in alterations in both qualitative and quantitative assessment of smoking relatedlung disease. As levels of ASIR increased both readers scored more RB (p

CONCLUSION

The use of ASIR alters both the qualitative and quantitative assessment of smoking related lung disease.Increasing levels of ASIR result in a potential overestimation of the degree of respiratory bronchiolitis.Quantitative assessment demonstrates decreased levels of emphysema, increased airway thickness anddiminished ability to count distal airways as levels of ASIR increase.


While iterative reconstruction algorithms such as ASIR are becoming widespread in their clinical use as anavenue to reduce radiation dose, their application with regards to assessment of smoking related lung diseaseboth qualitatively and quantitatively needs to be utilized with caution.

Comparison of Fibrosis Extent on CT, Pulmonary Function Test, and Survival Rate between UsualInterstitial Pneumonia (UIP) and Combined Pulmonary Fibrosis and Emphysema (CPFE)

Kum Ju Chae (Presenter): Nothing to Disclose , Hyunnyeong Jung MD : Nothing to Disclose , Gong Yong Jin MD, PhD : Nothing to Disclose , Young Sun Lee : Nothing to Disclose , Su Bin Chon : Nothing toDisclose , Keun-Sang Kwon : Nothing to Disclose , Young Min Han MD : Nothing to Disclose

PURPOSE

To compared CT findings, pulmonary function tests (PFT), and survival rate of usual interstitial pneumonia (UIP)with those of combined pulmonary fibrosis and emphysema (CPFE)


This study was approved by the institutional review board and informed consent was waived. From January2004 to December 2009, among 105 patients who underwent open lung biopsy due to interstitial lung disease,55 patients diagnosed as UIP or CPFE pathologically were finally included in this study. We reviewed the CTfindings and clinical characteristics including pulmonary function test of 55 patients; biopsy proven UIP withtypical or probable UIP pattern in CT (n=38), biopsy proven UIP or CPFE with CPFE pattern in CT (n=17). Theextent of honeycombing on CT was visually assessed using five point scale by two observers independently.Clinical characteristics including PFT were analyzed by Student t-test. Differences of 5-year survival rateaccording to extent of honeycombing on CT for each group were calculated from Kaplan-Meier analysis.

RESULTS

The five year survival rate between UIP and CPFE group was not significantly different (P=0.406). Also,physiologic variables such as FEV1, FVC, FEV1/FVC and DLCO in two groups were not independent risk factors todetermine survival rate. The extent of honeycombing on CT between two groups wasn't significantly different(P=0.140). However, the extent of honeycombing over 25% on CT was an important prognostic factor todetermine survival rate (P=0.041, 95% CI;1.032-4.456) regardless of UIP or CPFE patients; median survivalrate of honeycomb extent over 25% (17.3 months), <25% (57.2 months).

CONCLUSION

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The larger extent of honeycombing at CT is associated with poor prognosis of CPFE and UIP patients.


1. Quantification of honeycombing extent on CT in UIP and CPFE patients is important for prognosis prediction.2. CPFE patients proved to be have two pathologic patterns (UIP and CPFE).

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Chest (Miscellaneous) Scientific PapersCT CH AMA PRA Category 1 Credits ™: 1.50


Thu, Dec 4 10:30 AM - 12:00 PM Location: S404CD

ParticipantsModeratorSatinder Pal Singh MD : Nothing to Disclose ModeratorSudhakar N. Pipavath MD : Nothing to Disclose

Sub-Events Diffusion-weighted MR Imaging of the Thymus in Patients with Generalized Myasthenia Gravis:Usefulness of ADC Values in Distinguishing Lymphoid Hyperplasia, Normal Thymus, and Thymoma

Adriano Massimiliano Priola MD (Presenter): Nothing to Disclose , Sandro Massimo Priola : Nothing toDisclose , Maria Teresa Giraudo : Nothing to Disclose , Dario Gned MD : Nothing to Disclose , Lorena Ducco : Nothing to Disclose , Federica Moretti : Nothing to Disclose , Andrea Veltri MD : SpeakersBureau, Eli Lilly and Company Speakers Bureau, Bayer AG

PURPOSE

To prospectively evaluate the efficacy of diffusion-weighted (DW) magnetic resonance imaging (MRI) in patientswith myasthenia gravis (MG) for distinguishing thymic lymphoid hyperplasia (TLH), normal thymus (NT), andthymoma (THY) by using the apparent diffusion coefficient (ADC), in order to suitably select patients for surgery.


The IRB approved the study, and informed consent was obtained. We evaluated 88 subjects (45 male, 43female) with generalized MG and anti-AchR antibodies that underwent surgery. They were divided into aTLH/NT group (A, 64 patients; TLH, 49; NT, 15) and a THY group (B, 24 patients), based on the histologicalfindings. DW-MRI was performed at b values of 0, 150, 500, and 800 s/mm2. All measures were performedindependently by two radiologists and inter-reader agreement was assessed by calculating the intraclasscorrelation coefficient (ICC). Discrimination abilities were individuated according to the Area under the ROCcurve (AUROC) and optimal cut-points were individuated by using the Youden Index (YI). Differences on ADClevels between groups and subgroups of group A were evaluated by Mann-Whitney U test and Kruscal-Wallistest, respectively.

RESULTS

The inter-reader agreement was excellent (ICC, 0.944). The mean ADC values were significantly differentbetween groups (A, 1.92±0.21 x 10-3 mm2/sec; B, 1.36±0.33 x 10-3 mm2/sec; p<0.001) and betweensubgroups of group A (TLH, 1.86±0.17 x 10-3 mm2/sec; NT, 2.10±0.23 x 10-3 mm2/sec; p=0.002). AUROC ofADC in discriminating between groups was 0.931, and the optimal cut-point for this distinction was 1.625 x10-3 mm2/sec (YI, J=0.760) with sensitivity of 96.8% and specificity of 79.1%. AUROC of ADC in discriminatingbetween subgroups of group A was 0.794, and the optimal cut-point for this distinction was 2.01 x 10-3mm2/sec (YI, J=0.458) with sensitivity of 76.7% and specificity of 79.2%.

CONCLUSION

DW-MRI is an useful tool in patients with generalized MG. The ADC value can be used for distinguishing TLH,NT, and THY in order to select appropriately patients for surgery (THY/TLH) and patients to treat with medicaltherapy (NT) since, for non-thymomatous MG, acceptable complete remission rates after thymectomy areobserved in TLH but not in NT.


The ADC value can be used for distinguishing TLH, NT, and THY in order to select appropriately patients forsurgery (THY/TLH) and patients to treat with medical therapy (NT).

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Differential Diagnosis of Benign and Malignant Pleural Effusion with Spectral CT

Zhang Xirong MMed (Presenter): Nothing to Disclose , Jia Yongjun MMed : Nothing to Disclose , Yang Chuangbo MMed : Nothing to Disclose , Ma Chunling MMed : Nothing to Disclose , Lu Shuanhong MMed : Nothing to Disclose

PURPOSE

To investigate the value of spectral CT in the differential diagnosis of benign pleural effusion and malignantpleural effusion.


14 patients with benign pleural effusion(8 with pneumonia,5 with pulmonary tuberculosis and 1 withpneumocystosis) and 15 patients with malignant pleural effusion(5 with adenocarcinoma of lung,4 withsquamous cell carcinoma of lung,2 with adenosquamous carcinoma of lung and 4 with transitivity carcinoma oflung) underwent non-contrast spectral CT imaging. These patients were later verified by pathology. Variousparameters for the effusion were measured: CT numbers of the polychromatic 140kVp, monochromatic imagesat 40keV and 100keV; the material contents on the water-, fat- and blood-based material decompositionimages, and the effective atomic number Z. These values from the benign and malignant pleural effusion werestatistically compared with t test.

RESULTS

The CT values of benign and malignant pleural effusion from the conventional 140kVp images showed nodifference (12.61±3.39 vs. 14.71±5.03, p=0.20). The water-density, fat-density and blood-density betweenbenign pleural effusion and malignant pleural effusion also did not show difference (P=0.18, 0.39,0.43,respectively). On the other hand, CT values of the benign pleural effusion and malignant pleural effusion atboth the monochromatic 40keV and 100keV spectral images were statistically different: 43.15±3.79 vs.39.42±2.60 at 40keV (p=0.005) and 9.11±1.38 vs. 6.52±2.04 at 100keV (p<0.001).The effective atomicnumber values of benign pleural effusion was 7.87±0.08,statistically different from that of the malignant pleuraleffusion (7.90±0.02)(P<0.05).

CONCLUSION

The spectral CT provides CT number measurements at both high and low energy levels and effective atomicnumber from a single scan to assist the differential diagnosis of benign pleural effusion from malignant pleuraleffusion.


CT numbers at different energy levels from Spectral CT may be used to better differentiate benign pleuraleffusion from malignant pleural effusion.

Tissue Characterization using Multispectral X-ray: Description of a Novel Metric for Categorization ofPleural Effusions

Shailaja Sajja MS (Presenter): Nothing to Disclose , Samuel Richard PhD, BSC : Employee, CarestreamHealth, Inc , David Foos MS : Employee, Carestream Health, Inc , Scott Boerner MD, FRCR : Nothing toDisclose , Narinder S. Paul MD : Research funded, Toshiba Corporation

PURPOSE

To discriminate bloody from non-bloody pleural effusions using multi-spectral portable digital radiography (DR).


Thirty seven (13 bloody and 24 non-bloody) pleural aspirates were classified by an experienced cytopathologistas bloody or non-bloody and the classification was blinded to the research team. The samples were imaged witha portable DR unit (Carestream Health DRX-1C retrofit with GE AMX4) at 5 x-ray energies (60, 70, 80, 110 and120 kVp) - with adjusted mAs to ensure fixed entrance surface dose (50 uGy). The mean signal attenuation(μx) for each pleural sample was calculated across kVp by selecting a corresponding ROI of the sample in theimage and computing the mean-log signal. Values of μx were plotted vs. kVp and the behaviour of the curvesfor a sub-sample of 5 pleural samples was analyzed from which a set of classifying metrics (K) were derivedbased on the ratio of the signal attenuations at different energies. Metric K1 was the ratio of the difference of μxat (120, 60) kVp and (70, 60) kVp - namely [(μ120x-μ60x)/(μ70x-μ60x)=(μ120-μ60)/(μ70-μ60) - independentof sample thickness x], similarly for K2=(μ110-μ60)/(μ70-μ60) and K3=(μ120-μ80)/(μ70-μ60). The 37 pleuralsamples were analyzed to determine the accuracy of using the metrics to discriminate between bloody ornon-bloody fluids and the false positive rate (FPR) and true positive rate (TPR) were calculated for variousthresholds to yield the receiver operating characteristic curves ROC.

RESULTS

The ROC was plotted for the 37 blinded pleural samples. The area under the operating curve (AUC) was 0.66,0.67, and 0.56 for K1, K2, and K3, respectively. Based on these results, K2 was found to be most suitable fordifferentiating between bloody and non-bloody effusions. This was mainly due to the greater difference in x-rayenergies used for the measurements.

CONCLUSION

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In this work, a novel metric based on the multispectral x-ray signal was defined and tested on 37 pleuraleffusion samples. This metric may provide a reasonable differentiation between bloody and non-bloody pleuraleffusions. Further work is required to evaluate clinical feasibility.


We report initial results of a novel multi-spectral portable DR system, which may have the potential fordiscriminating between pleural effusions types (i.e., bloody from a non- bloody effusion).

Computed Tomography Volumetry for Subtyping Chronic Lung Allograft Dysfunction

Tomohito Saito MD, PhD (Presenter): Nothing to Disclose , Miho Horie MSc : Research Grant, ToshibaCorporation , Daisuke Nakajima : Nothing to Disclose , Masaaki Sato : Nothing to Disclose , Narinder S. Paul MD : Research funded, Toshiba Corporation , Shafique Keshavjee MD : Nothing to Disclose

PURPOSE

The long-term success of lung transplantation is challenged by the development of chronic lung allograftdysfunction (CLAD) and its distinct subtypes: bronchiolitis obliterans syndrome (BOS) and restrictive allograftsyndrome (RAS). However, the current diagnostic criteria for subtyping CLAD subtypes that relies on total lungcapacity (TLC) which is not always measured during routine post-transplant assessment. Our aim is toinvestigate the utility of 3D computed tomography (CT) lung volumetry for differentiating RAS from BOS.


Retrospective evaluation of 103 patients following bilateral lung or heart-lung transplantation; including 44patients without CLAD and 59 patients who developed CLAD of whom 41 had BOS and 18 RAS. All patients hadcomplete PFT and CT data. Median duration of post-transplabr follow-up was 47 months in BOS and 27 monthsin RAS. Median Interval of CT volumetry timepoints was 11 months in both BOS and RAS. The changes in CTlung volume over time and the diagnostic accuracy of CT lung volume (measured as % of baseline) fordifferentiating RAS from BOS were investigated.

RESULTS

The CT lung volumes varied over time; patients without CLAD experienced increase in lung volume (p= 0.001);patients with BOS had no significant post-transplant change, whereas patients with RAS showed a significantdecrease at disease onset compared to baseline (p< 0.0001) . The area under the receiver operatingcharacteristic curve of CT lung volume for differentiating RAS from BOS was 0.958 (95% confidence interval,0.908 to 1.00, p< 0.0001) and the calculated accuracy was 0.932 at a threshold of 85%.

CONCLUSION

In patients with chronic lung allograft dysfunction, a decrease in CT lung volume to 85% of baselinedifferentiates lung transplant recipients who develop RAS from those who develop BOS.


Computed tomography volumetry is useful tool for subtyping chronic lung allograft dysfunction. Restrictiveallograft syncrome shows significant decrease in lung volume after lung transplantation.

Trouble-shooting of Artifacts Related to Placement of Arms by the Side of the Chest during DualEnergy CT

Alexi Otrakji MD (Presenter): Nothing to Disclose , Efren Jesus Flores MD : Nothing to Disclose , Roberto Lo Gullo MD : Nothing to Disclose , Subba Rao Digumarthy MD : Nothing to Disclose , Jo-Anne O. Shepard MD : Consultant, Agfa-Gevaert Group , Mannudeep K. S. Kalra MD : Nothing to Disclose , Matthew David Gilman MD : Nothing to Disclose

PURPOSE

To evaluate the ability of single source dual energy (SS-DECT) to decrease the artifacts related to placing one orboth arms by the side of chest using monenergetic 75 Kev images and iterative reconstruction technique.


Our IRB approved study included 52 adult patients who underwent contrast enhanced chest CT. Twenty-sixpatients underwent chest DECT (13 patients (M:F 7:6, mean age 66± 17years,mean weight 81±21kg) with onearm or both by the side of chest; 13 patients (M:F 7:6,mean age 61±12years,mean weight 81±21kg) with botharms placed up) and 26 weight-matched patients who underwent contrast enhanced chest with single energyCT (SECT) (13 patients (M:F 8:5,mean age 57± 22years,mean weight 81±11kg) with one arm or both byside;13 patients (M:F 7:6,mean age 68±16years,mean weight 82±13kg) with both arms placed up). All chestCT exams were performed on a single source 64-row multidetector CT (GE 750HD Discovery). Additional 75 kevimages at adaptive statistical iterative reconstruction (ASIR 70% strength) were generated for 13 patients withone arm or both by their side. All image series were assessed qualitatively for image quality, level ofenhancement, and artifacts. CT numbers and noise was measured in main pulmonary artery (MPA) for allseries. CTDIvol and DLP were recorded as well.

RESULTS

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Radiation dose for DECT chest (CTDI:8±0.6mGy,DLP: 288±32mGy.cm). The vascular enhancement in (Mono75 Kev ASIR70%) was rated as optimal or better in all patients (100%) for MPA and its lobar branches and in69% (9/13 patients) for segmental and sub-segmental branches compared to just 85% and 54% for 60 kevimages and 69% and 8% for 100 kev images. There was significant reduction in image noise and artifacts atthe level of the tracheal carina and diaphragm with 75 kev images compared to the 60 and 100 kev images.There was a significant improvement in diagnostic quality with 75 kev compared to 60 and 75 kev images aswell as SECT.

CONCLUSION

Conventional monoenergetic (60 and 100 kev) DECT images and SECT are substantially impaired whenscanning is performed with one or both arms by the side. Monoenergetic 75 Kev images with ASIR70% helpincrease the diagnostic quality, and decrease artifacts without compromising vascular enhancement.


Appropriate modification to DECT of the chest can improve image quality in patients who can not place theirarms above the shoulders

Comparison of Filtered Back Projection (FBP), Adaptive Statistical Iterative Reconstruction (ASIR)and Model Based (MBIR) Iterative Reconstruction Techniques for Post Mortem Chest CT Acquired atEight Different Dose Levels

Atul Padole MD (Presenter): Nothing to Disclose , Sarabjeet Singh MD : Research Grant, Siemens AGResearch Grant, Toshiba Corporation Research Grant, General Electric Company Research Grant, KoninklijkePhilips NV , Diego Alfonso Lira MD : Nothing to Disclose , Sarvenaz Pourjabbar MD : Nothing to Disclose , Ranish Deedar Ali Khawaja MD : Nothing to Disclose , Mannudeep K. S. Kalra MD : Nothing to Disclose , Alexi Otrakji MD : Nothing to Disclose , Roberto Lo Gullo MD : Nothing to Disclose

PURPOSE

To assess diagnostic image quality in post mortem chest CT acquired at eight different dose levels andreconstructed with FBP, ASIR and MBIR techniques.


In an IRB approved, post mortem chest CT was performed in 40 human cadavers (57±13years, body massindex 26±6, F:M 13:27) at eight different dose levels with mean CTDIvol of 3.7-15 mGy at 100-120 kV and10-40 noise index (NI) on a 64 channel MDCT (GE Discovery CT750 HD). The remaining scan parameters wereheld constant at pitch of 0.984:1, rotation time of 0.5 second. Sinogram data at each dose level werereconstructed with FBP, ASIR (SS50, GE Healthcare) and MBIR (Veo, GE Healthcare) (n= 8*3*40= 960 series).Radiologist performed independent and blinded comparison of one image series at a time for lesions detection,lesions conspicuity, and visibility of small structures. In addition, subjective image noise and artifacts were alsoassessed. Objective image noise was measured at each dose levels.

RESULTS

There were total 256 lesions detected on 15 mGy. In mediastinal window, at CTDIvol of 5.7 mGy lesionsconspicuity was acceptable for 40/71 with FBP, 59/71 with ASIR, and 67/71 with MBIR. Similary, visibility ofsmall structures was acceptable in 8/40 with FBP, 23/40 with ASIR and 40/40 with MBIR. At CTDI vol of 3.7mGy, lesion conspicuity was acceptable for 21/71 with FBP, 27/71 with ASIR, and 57/71 with MBIR. Visibility ofsmall structures was acceptable in 1/40 with FBP, 1/40 with ASIR and 20/40 with MBIR. In lung window, at alldose levels, lesion conspicuity and visibility of small structures were equally seen on FBP, ASIR, and MBIR. AtCTDIvol of 3.7 mGy, lesions conspicuity was acceptable for 50/57 with FBP, 49/57 with ASIR, and 50/57 withMBIR. Similary, visibility of small structures was acceptable in 38/40 with FBP, 39/40 with ASIR and 39/40 withMBIR. For all dose levels, subjective image noise and artifact were lower with MBIR compared to FBP and ASIR.In addition, for all dose level, objective image noise was significantly lower for MBIR compared to FBP and ASIR(p<0.001).

CONCLUSION

MBIR improves the mediastinal lesion conspicuity and visibility of small structures in post mortem chest CTperformed at CTDIvol down to 3.7 mGy when compared to ASIR and FBP.


Mediastinal structures can be better seen with iterative reconstruction techniques at CTDIvol of 3.7 mGy, whereFBP technique is suboptimal.

Dual Energy CT: What Is the Optimal Energy Level for Monochromatic Imaging of Lung Parenchyma?A Qualitative Study on 50 Patients

Mickael Ohana MD, MSc (Presenter): Nothing to Disclose , Aissam Labani MD : Nothing to Disclose , Aina Venkatasamy : Nothing to Disclose , Mi-Young Jeung MD : Nothing to Disclose , Catherine Roy MD : Nothing to Disclose

PURPOSE

To determine the optimal energy level for lung parenchyma analysis in spectral CT imaging.

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50 dual energy CT pulmonary angiography (DE-CTPA) from a previously published prospective study were usedafter Institutional Review Board approvement. All patients (58% men, 64.8yo ±16) underwent a single sourceDE-CTPA with the following acquisition parameters: 80/140 kV, 0.6s rotation time, 275mA fixed tube current,50% ASIR, automatic injection of 50mL of Iohexol 350mgI/mL. Monochromatic images in lung windowreconstructed every 5keV from 40 to 140keV were independently assessed by two chest radiologists, based onoverall image quality and the depiction of potential parenchymal lesions. Each reader had to eventuallydesignate for every patient which keV provided the best diagnostic and image quality. A correlation betweenthe preferred keV and the body mass index (BMI) of the patients was searched using a Pearson'sproduct-moment correlation.

RESULTS

Mean radiation dose was 243mGy.cm ±33 and mean BMI of the participants was 25.6 ±4.5. Regarding the lungparenchyma, 28% of the examinations were normal, while the remaining 72% showed various lesions: nodulegreater than 5mm (n=6), mass (n=3), alveolar consolidation (n=10), ground glass opacities (n=6), diffuseseptal thickening (n=4), fibrosis (n=7), bronchiectasis (n=3) and emphysema (n=15). Reader 1 picked the55keV monochromatic reconstruction in 52% of cases, the 50keV in 30% and the 60keV in the remaining 18%.For reader 2, the 50keV monochromatic reconstruction was preferred in 52% cases, the 55keV in 40%, the60keV in 6% and the 40keV in 2%. The 55keV monochromatic reconstruction was chosen by at least onereader in 76% of patients, and the 50keV was preferred by at least one reader in 64% of all cases. Therewasn't any correlation between the preferred keV and the BMI for both readers (ρ<0.05 with p>0.05).

CONCLUSION

The best image quality for lung parenchyma in spectral CT is obtained with 50-55keV monochromaticreconstructions.


In dual energy chest CT, lung parenchyma is better analyzed using a 50-55keV monochromatic reconstruction.

Feasibility of Respiratory Gating in High-Pitch Spiral CT of the Chest

Matthias Stefan May (Presenter): Speakers Bureau, Siemens AG , Wolfgang Wust MD : Nothing to Disclose , Achim Eller MD : Nothing to Disclose , Michael Uder MD : Speakers Bureau, Bracco Group SpeakersBureau, Siemens AG Research Grant, Siemens AG , Michael Marcus Lell MD : Research Grant, Siemens AGSpeakers Bureau, Siemens AG Research Grant, Bayer AG Speakers Bureau, Bayer AG Research Consultant,Bracco Group

PURPOSE

Artifact free imaging of the chest remains difficult in non-compliant patients for breath-hold undergoing chestCT. Our aim was to establish a respiratory gated High-Pitch protocol using Dual-Source CT.


21 patients were examined on a second generation Dual Source CT with a high-pitch scan mode (pitch = 3.4,128 x 0.6 mm collimation, 0.28 s gantry rotation time, 150 ref.mAs per tube at 120kV) without breathingcommands. Measurements from a respiratory gating system were used as trigger to obtain images ininspiration. Previous examinations on a single source CT system with regular breathing instructions were usedas reference. Motion artifacts, delineation of pathologic findings and lung volumina were assessed for both,free-breathing and reference exams.

RESULTS

Delineation of the pathologic findings was good with both protocols. Significantly less motion artifacts wererecorded with the high pitch mode compared to the reference (p=0.021). Main location of artifacts was theperipheral parts of the lower lobes in the study group and the central part of the left lower lobe in thereference. Average total lung volume was 4.5 ± 1.5 l in respiratory gated examinations and 5.8 ± 0.9 l inexaminations with breath hold in inspiration.

CONCLUSION

High Pitch CT of the chest in inspiration is feasible by respiratory gating and minimizes motion artifacts in freebreathing patients.


Chest CT in patients that are unable to breath-hold should be performed using a High Pitch protocol with arespiratory gating device.

Thoracic Virtual Non-enhanced CT with Spectral CT: A Preliminary Study

He Taiping MMed (Presenter): Nothing to Disclose , Yu Yong MMed : Nothing to Disclose , Chen Xiaoxia MMed : Nothing to Disclose , Ma Guangming MMed : Nothing to Disclose , Jia Yongjun MMed : Nothing to

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Disclose , Yang Chuangbo MMed : Nothing to Disclose

PURPOSE

To compare the virtual non-enhanced chest CT (VNCT) generated from spectral CT with conventionalnon-enhanced chest CT in patients with lung disease in terms of CT number accuracy and image quality.


A total of 30 patients with lung disease proved by pathology underwent the conventional non-enhanced thoracicCT and contrast enhanced CT with spectral imaging mode in arterial phase (AP) and venous phase (VP). TheVNCT images were reconstructed based on the enhanced spectral CT imaging data. The mean CT number,signal to noise ratio (SNR) for the lesions and image quality score were obtained and compared between thetrue non-contrast CT (TNCT) and the VNCT (including AP and VP) with paired t test.

RESULTS

The mean ± standard deviation for CT Number were 38.74±5.17HU, 39.08±5.07HU and 38.96± 5.18HU forTNCT, VNCT at AP and VNCT at VP, respectively, with no statistical difference (p>0.05). All 3 sets of imagesdemonstrated acceptable image quality, even though there were statistically significant differences in the SNRvalue and image quality score. The mean ± standard deviation values for SNR were 4.74±0.42 withTNCT(figure 1#2), 3.79 ± 0.51 with VNCT at AP (figure 3)and 3.77 ± 0.39 with VNCT at VP(figure 4) (P<0.05),and the image quality scores were 5.00±0.00 with TNCT, 4.17±0.65 with VNCT at AP and 4.17±0.53 withVNCT at VP (p<0.05).

CONCLUSION

In patients with lung disease, the virtual non-enhanced CT images generated from spectral CT provide accurateCT numbers for lesions and acceptable image quality compared with the true non-contrast CT. VNCT may beused to replace TNCT to improve work flow and reduce radiation dose.


Virtual non-enhanced images generated from spectral CT may be used to replace the true non-contrast CT forlung patients to improve work flow and reduce radiation dose.

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ISP: Pediatrics (Chest) Scientific PapersPD MR CT CH AMA PRA Category 1 Credits ™: 1.50


Thu, Dec 4 10:30 AM - 12:00 PM Location: S102C

ParticipantsModeratorRobert Joseph Fleck MD : Nothing to Disclose ModeratorScott K. Nagle MD, PhD : Stockholder, General Electric Company Research Consultant, Vertex Pharmaceuticals Incorporated

Sub-Events Pediatrics Keynote Speaker: Imaging of Cystic Fibrosis—State of the Art

Scott K. Nagle MD, PhD (Presenter): Stockholder, General Electric Company Research Consultant, VertexPharmaceuticals Incorporated

Morphological and Functional MR Imaging of the Lung in CF Patients with Exacerbations

Giovanni Morana MD (Presenter): Nothing to Disclose , Silvia Bertolo : Nothing to Disclose , Federica DeLeo : Nothing to Disclose , Mirco Ros MD : Nothing to Disclose , Francesca Lucca : Nothing to Disclose , Pierluigi Ciet MD : Nothing to Disclose , Valentina Tavano : Nothing to Disclose

PURPOSE

Analysis of the information obtained in Patients with cystic fibrosis (CF) evaluated during exacerbation with MR,both with morphological and funtional (DWI) imaging.


50 patients with CF were enrolled: 26 with pulmonary exacerbations. Another group of 24 patients, matched forage and pulmonary function but without pulmonary exacerbations, to obtain comparative data. Each patientsperformed two RM examinations: pre and post antibiotic treatment for the case group, after and before 2weeks for the control group. MR examinations were performed on a 1.5-T Siemens Avanto 1. Breath holdHASTE sequences in the axial and in the coronal plane 2. DP Propeller (BLADE) sequences in the axial and in

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the coronal orientations, with navigator 3. EPI sequence with respiratory triggering for diffusion imaging withmultiple b-values (0, 10, 20, 30, 50, 70, 100, 150, 200, 400, 800 sec/ mm2) BLADE images were scored with aBrody Score adapted to MRI . Qualitative analysis of DWI imaged were conducted on high values of b -value (b500 and b800 ). The areas of high signal intensity (hot spots) were compared with the signal produced by thespinal cord, used as a reference . Qualitative analysis of DWI images were conducted with Mathlab, withcalculation of IVIM parameters. Statistical analysis was conducted using the following software: SPSS 13.0,Matlab2010 and Microsoft Excel 14.0 .

RESULTS

The independent samples t-test (p < 0.05 ) shows a statistically significant difference between the averages ofBRODY score between the exacerbation group and the stable group both at the first and second examination.Instead for the DWI score, the independent samples t-test (p < 0.05 ) show a statistically significant differencebetween the averages of DWI score between the exacerbation group and the stable group at the firstexamination but not at the second examination. The paired t-test (p < 0.05 ) show a statistically significantdifference between the averages of IVIM coefficients between the first and second examination in the"exacerbation"group while not show a statistically significant difference in the "stable" group.

CONCLUSION

MR is a feasible tool to follow CF patients with exacerbation


MR is able to distinguish reversible lung changes from irreversible with DWI. It can enhance the management ofCF patients with exacerbation

Lung-MRI in Children with Cystic Fibrosis (CF): Evaluation of Two Diagnostic-scores ConcerningInterobserver Reliability and Valuation of Clinical Impact

Matthias Teufel : Nothing to Disclose , Katharina Schmidt : Nothing to Disclose , Ines Ketelsen : Nothingto Disclose , Ute Graepler-Mainka : Nothing to Disclose , Joachim Riethmuller MD : Nothing to Disclose , Juergen F. Schaefer MD (Presenter): Nothing to Disclose , Ilias Tsiflikas MD : Nothing to Disclose , Konstantin Nikolaou MD : Speakers Bureau, Siemens AG Speakers Bureau, Bracco Group Speakers Bureau,Bayer AG

PURPOSE

The aim of this retrospective analysis was the evaluation of the Helbich-BallaScore (HBS) - already reviewed incomparison to CT - and a self-developed MRI-Score (MRS) in reference to the interobserver reliability and thevaluation of the clinical impact.


A standardized lung MRI at 1.5 T and a pulmonary function test were performed in 51 patients (mean 11.4 y,SD 3.1 y) on the same day. The MRI was independently and blinded scored by three radiologists with differentexperience (1 highest, 3 lowest) using the non modified HBS system. Additionally the examinations wereanalyzed by the same readers with the MRS system that was adapted from the Crispin Norman Score (CNS). Indifference to the CNS the MRS points were given on the basis of lung lobes, and the category "centrilobularnodules" was added. To evaluate interobserver reliability Pearson's correlation coefficient (R) was calculated.Scores were also correlated with forced expiratory volume in one second (FEV1). The possible prognostic valueof the scores was estimated using ROC analysis for significant decrease of FEV1 (> 3%/year) over period of 2years.

RESULTS

Both scores were reproducible (R = 0.85 to 0.88 for HBS and 0.85 to 0.90 for MRS). The scores correlatedsignificantly with FEV1 (HBS: R= - 0.50 to -0.58 and MRS: -0.51 to -0.63, P<0.001). The highest value in bothscores was achieved by reader 1. With a baseline FEV1 of 50% to 100% 7/30 patients showed a decrease>3%/year. In this group the mean AUC for centrilobular nodules and bronchiectases of the MRS was 0.96 and0.87, and 0.84 for bronchiectases of the HBS.

CONCLUSION

The results indicate that both scores are reproducible and clinical useful. The MRS may have the higherprognostic performance.


Application on thoracic/pulmonal MRI in patient suffering from cystic fibrosis for follow up and therapymonitoring. Detection and evaluation of the severity of pulmonal findings in cystic fibrosis and other pulmonarydiseases.

Humidifier Disinfectant-associated Children’s Interstitial Lung Disease: CT Features, HistopathologicCorrelation and Comparison between Survivor and Non-survivor

Hee Mang Yoon MD (Presenter): Nothing to Disclose , Eun Lee : Nothing to Disclose , Jin Seong Lee MD : Nothing to Disclose , Kyung-Hyun Do MD : Nothing to Disclose , Se Jin Jang : Nothing to Disclose , Soo-Jong Hong : Nothing to Disclose , Young Ah Cho : Nothing to Disclose

PURPOSE

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From 2006, epidemics of a fatal lung injury by inhalation of humidifier disinfectant (DI) in children wereobserved. The aim of this study was to report radiologic findings with pathologic correlation of the disease andto compare the CT findings between survivors and non-survivors.


Forty seven children were hospitalized with acute lung injury associated with DI inhalation (meanage=27.4±12.4 months) and divided into two groups: survivors (n=25) and non-survivors (n=22). CT findingsincluding the presence and extent of consolidation and centrilobular ground-glass opacity (cGGO) wereevaluated for hazard ratio (HR) in each group. Histopathologic correlation was performed in 25 patients.

RESULTS

CT scans showed the characteristic features according to the stage of disease progression. The early stage wascharacterized by patchy consolidation in bilateral basal lungs. In advanced stage, it evolved into cGGO involvingthe entire lung. In resolving stage, cGGO was resolved and slowly changed into the faint centrilobular nodules.Pathologic review revealed, in early stage, predominant denuded bronchiolar epithelium with bronchocentircfibroblast proliferation and intra-alveolar exudate. In advanced state, bronchial damage with fibroblasticproliferation was more profound. CT showing resolving stage does not exist in non-survivors. The time intervalbetween the presentation of initial symptom and CT scan showing early stage was significantly shorter innon-survivors than in survivors (9days and 14days respectively, p=0.021). Consolidation over 30% of lungvolume was the predictor of poor prognosis (p=0.014, HR=2.932) while cGGO over 30% of the lung was that ofgood prognosis (p<0.001, HR=0.124).

CONCLUSION

The distinctive CT feature was chronological changes from early consolidation to cGGO. In survivors, lesionseventually changed into the faint centrilobular nodules. It was correlated with histopathology. Wide area ofconsolidation in early stage results in the poor prognosis of disease.


This series of patients showed the inhalation injury caused by one kind of chemicals. Radiological understandingplays a pivotal role in management and prediction of outcome in chemical pneumonitis.

Pulmonary MRI in the NICU: Initial Experience Imaging BPD and CDH with a Small-Footprint Scanner

Laura Walkup PhD (Presenter): Nothing to Disclose , Jean A. Tkach PhD : Nothing to Disclose , Robert Thomen : Nothing to Disclose , Stephanie Merhar : Nothing to Disclose , Raouf S. Amin MD : Nothing toDisclose , Paul Kingma : Nothing to Disclose , Jason C. Woods PhD : Nothing to Disclose

PURPOSE

Neonatal pulmonary imaging poses difficulties because of small size, respiratory motion, and the delicatenature of moving infants to and from the NICU. While CT is the current clinical gold standard for diagnosticpulmonary imaging, it is not routine for the longitudinal evaluation of most neonatal pulmonary abnormalitieswithin the NICU. Our goal was to use our institution's one-of-a-kind NICU MRI scanner to investigate thefeasibility of performing pulmonary MRI in conditions that are present in our NICU (bronchopulmonary dysplasia[BPD] and congenital diaphragmatic hernia [CDH]), since they are poorly understood both physiologically andradiologically.


Pulmonary MRI was performed on a small-footprint 1.5T MRI scanner developed for orthopedic use (marketedas GE Optima MR430s) that was modified and adapted for use in our institution's NICU. Free-breathing FrFSE(TE/TR 3000/11.8, ETL=5 or 11) and FGRE (TE/TR 1.9/6.8, 7-10° FA) images were obtained for a small groupof non-sedated NICU patients (1 BPD, 2 CDH, 3 control). Images were evaluated qualitatively and aquantitative assessment of approximate lung density obtained by normalizing the lung signal to nearby softtissues.

RESULTS

Both FrFSE and GRE images were generally of high (diagnostic) quality and demonstrated very few motionartifacts for quietly-breathing babies, with parenchymal SNR of around 5. Pulmonary abnormalities werevisually apparent in many cases: pleural effusion, multiple local areas of atelectasis, alveolar simplification, andparenchymal opacities were all observed, with quantitative results that matched visual inspection. MR imagesfor one CDH patient revealed regions of air-trapping undetected in chest x-ray.

CONCLUSION

We have demonstrated that free-breathing pulmonary MRI in the NICU is feasible and can producediagnostic-quality images that may be used in detection and longitudinal assessment of various pulmonaryabnormalities, including BPD and CDH. The MR images obtained were of diagnostic-quality, compared well to CTin the opinion of our clinical radiologist, and did not require sedation.


Pulmonary MRI in the NICU provides diagnostic-quality images for the assessment of neonatal pathologies andwill add to our knowledge of normal and aberrant lung development.

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MR Lung Perfusion in 2-year old Children After Congenital Diaphragmatic Hernia — Comparison ofChildren after ECMO-therapy and Children without ECMO-requirement

Meike Weidner (Presenter): Nothing to Disclose , Frank G. Zoellner : Nothing to Disclose , Claudia Hagelstein MD : Nothing to Disclose , Stefan Oswald Schoenberg MD, PhD : Institutional researchagreement, Siemens AG , Katrin Zahn : Nothing to Disclose , Thomas Schaible : Nothing to Disclose , Wolfgang Neff MD, PhD : Nothing to Disclose

PURPOSE

In severe cases of congenital diaphragmatic hernia (CDH), extracorporeal membrane oxygenation (ECMO)therapy is required. Later on, lung morbidity defines development. Lung function measurement is thereforecrucial but limited in 2-year old children. With MRI, lung perfusion can be measured and is known to be reducedon the ipsilateral side after CDH. In this study we investigated if 2-year old children after ECMO-therapy showreduced MR-perfusion values as a sign of more severe lung hypoplasia in comparison to children withoutECMO-requirement.


DCE-MRI was performed in 38 children (24.3±1.8 month; 15 with ECMO-therapy; 23 without ECMO-therapy)after CDH repair using a 3D TWIST sequence (temporal resolution 1.5 sec ; voxel size: 2x2x2 mmCubed). 0.05mmol/kg body weight of contrast agent (Dotarem, Guerbet, France) was administered. Pulmonary blood flow(PBF), pulmonary blood volume (PBV) and mean transit time (MTT) were calculated for both lung sides byplacing 6 cylindrical regions of interest (ROI) in the apical, middle and basal lung respectively. Additionally, theratio of contralateral to ipsilateral lung was calculated for all parameters.

RESULTS

15 of 38 children (39%) required ECMO-therapy as neonates. In all children, PBF and PBV were significantlyreduced on the ipsilateral side in comparison to the contralateral side (p always

CONCLUSION

2-year old children after ECMO-requirement as neonates show significantly reduced MR perfusion values on theipsilateral lung in comparison to children without ECMO-requirement. Perfusion values of the contralateral lungare not significantly different. MR perfusion measurements therefore reflect the severity of lung hypoplasia andare helpful in follow-up investigations.


MR-perfusion values reflect the severity of lung hypoplasia after CDH as children after ECMO-therapy showmore reduced values. Therefore, MR-perfusion measurements are advisable for follow-up.

Validation of a Novel Parameter for the Evaluation of Pectus Excavatum: The Correction Index

Javier Vallejos MD, MBA (Presenter): Nothing to Disclose , Maria Eugenia Maccarone MD : Nothing toDisclose , Carlos Capunay MD : Nothing to Disclose , Marcelo Martinez Ferro : Nothing to Disclose , Patricia M. Carrascosa MD : Research Consultant, General Electric Company

PURPOSE

To validate the new correction index (CI) to determine severity in patients with pectus excavatum anddiscriminate from normal patients.


Retrospective analysis of prospectively collected chest computed tomographic data in PE (N=87) and controls(N=24). We calculated HI in a standard fashion. For the CI, we drew a horizontal line across the anterior spineand measured two distances: the minimum distance between the posterior sternum and the anterior spine (D1)and the maximum distance between the line placed on the anterior spine and, the inner margin of the mostanterior portion of the chest (D2). The difference between these two lines (D1 and D2) is the amount of defectthe patient has in their chest. KCI formula was as follows: D2-D1/D2*100.

RESULTS

The mean age did not vary between both groups (19.5±9.3 years for PE and 22±2.9 for controls, p=0.92). Inthe table, we illustrate the HI and CI values from our study and St. Peters et al. In our study, 10/87 (11.4%)patients with PE had overlapped with controls (area under the ROC curve 0.48, p=0.67) compared to 47% inSt. Peters et al. Using the CI, only 2/87 (2.3%) patients overlapped (area under ROC curve 0.99, p<0.001),while no overlap was reported.

CONCLUSION

The use of CI resulted in less overlap than with HI in both studies; however, overlap between PE and controlswith HI depended on the baseline severity of the PE population.


The Haller index (HI) is the most commonly used parameter to determine surgical candidacy in patients withpectus excavatum (PE). However, the use of the HI cannot discriminate between PE and normal patients. Thisnew correction index expresses the percentage of thoracic depression represented by the sternal defect,demonstrating optimum discrimination between PE and controls.

High Resolution, Contrast Enhanced MR Angiography as the Sole Test for Evaluation ofBroncho-Vascular Anatomy in Pediatric Patients with Suspected Vascular Rings

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Elena Karavaeva MD (Presenter): Nothing to Disclose , M. Ines Boechat MD : Nothing to Disclose , Simon Gabriel MD : Nothing to Disclose , J. Paul Finn MD : Research Grant, Siemens AG Research Grant, BraccoGroup

PURPOSE

to assess the feasibility of high resolution, 3D contrast enhanced MR Angiography (CEMRA) as a single test forcomplete evaluation of detailed vascular and proximal 3-dimensional airway anatomy in pediatric patients withsuspected vascular rings.


Forty-two consecutive pediatric patients (25 male, 17 female; mean age, 6.14 +/- 4.07 years, range 1m to 13y) with a clinical suspicion of vascular rings underwent multiphase, high spatial resolution CEMRA at 3.0T (31patients) or 1.5T (15 patients) with gadolinium-based contrast medium (Multihance, Bracco Diagnostics, N=38,0.2 mmol /kg, or Ablavar, Lantheus Medical, N=3, 0.06 mmol /kg). Using a standardized scoring system 2independent, board certified radiologists scored the studies for image quality, artifacts, the visibility of upperairways that were divided into 5 segments: trachea, right main stem bronchus, left main stem bronchus, rightupper lobe bronchus and bronchus intermedius. Additionally, all studies were evaluated for the presence ofpathology, including vascular rings and trachea-bronchial compression, by the same two radiologists and a thirdindependent board certified radiologist. Correlation with chest X-ray findings was available in all patients andwith chest CT in 12 patients.

RESULTS

All scans were scored as highly diagnostic with good or excellent image quality. Visualization of the trachea andbronchi was assessed as confident and very confident, the interobserver agreement was considered as 'good'and 'excellent' (Cohen's kappa ranged from 0.607 to 0.846 depending on scored segment). A total of 10vascular rings with tracheobronchial compression were detected with excellent interobserver agreement (Fleiss'kappa = 1). The mean difference between MR and CT measurements of trachea diameter at 3 different levelswas 0.45 +/- 0.3 mm.

CONCLUSION

High resolution CE MRA allowed for confident assessment of both vascular anatomy and relevant 3-dimensionaltrachea-bronchial anatomy in pediatric patients with suspected vascular rings. The complementary 3-Dvisualization of vascular and airway anatomy with CEMRA may make supplemental CT imaging unnecessary inappropriate patient groups.


High resolution CEMRA can evaluate 3D vascular anatomy and relevant 3D airway anatomy in childrensuspected of tracheobronchial compression, obviating the need for CT scanning and radiation exposure

Is It Worth Improving Temporal Resolution (TR) in Paediatric Chest CT?

Alexandre Bridoux : Nothing to Disclose , Jean-Baptiste Faivre MD : Nothing to Disclose , Julien Pagniez : Nothing to Disclose , Antoine Hutt MD (Presenter): Nothing to Disclose , Jacques Remy MD : ResearchConsultant, Siemens AG , Martine J. Remy-Jardin MD, PhD : Research Grant, Siemens AG

PURPOSE

To evaluate the influence of optimized temporal resolution (TR) in pediatric standard chest CT imaging.


93 consecutive children less than 4 years of age (mean age: 1 yr, mean weight: 7.73 kg) underwent a chest CTangiographic examination for non-cardiac indications on a dual-source CT system. No sedation was performedand no β-blocker used. The examinations were obtained with a non-ECG-gated dual-source, single-energymode using the following parameters: collimation: 64x2x0.6 mm; rotation time: 0.28 s; 70 kVp and 80 mAs;pitch: 2.0. From each dataset, two series of images were systematically reconstructed on a prototypeworkstation: images with a TR of 140 ms (i.e., standard TR) (Group 1) and images with a TR of 75 ms (i.e.,optimized TR) (Group 2). Using a 5-point scale, two radiologists independently analyzed the detection andsharpness of proximal and mid segments of the right (RCA) and left (LCA) coronary arteries (total number ofcoronary segments examined: n= 651). These anatomical structures, highly sensitive to motion artifacts inotherwise uncooperative patients, were chosen to analyze the impact of an optimized TR.

RESULTS

Interobserver agreement for coronary artery analyzability was excellent (Group 1: kappa=0.86 [95% CI:0.82-0.89]) (Group 2: kappa=0.86 [95% CI: 0.83-0.90]). The mean rate of detection and grade of analyzabilityof all coronary segments were significantly higher in Group 2 than in Group 1 (p<0.001). The rate of detectionof the proximal RCA (26/93; 28% versus 18/93; 19.35%; p=0.0114) and left main (LM) artery (60/93; 64,52%versus 54/93 ;58,06% p=0,0339) were significantly higher in Group 2 than in Group 1. Group 2 imagesprovided the best image quality for 64,52% of LM (60/93) and 35,48% of proximal RCA (33/93) whereas Group1 images were found to be the best reconstruction for only 5,38% of LM (5/93) and 1,08% (1/93) proximalRCA.

CONCLUSION

Optimized TR improves image quality in standard paediatric chest CT, still perfectible at 75 ms.


Optimization of TR improves image quality of standard chest examinations in children.

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ASRT@RSNA 2014: Advanced Radiographic Practice in Adult Chest Imaging Multisession CoursesCH CH CH AMA PRA Category 1 Credits ™: 1.00


Thu, Dec 4 11:45 AM - 12:45 PM Location: N230AB

ParticipantsNick Woznitza BSC (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) Consider the role of the advanced radiographer practitioner in the United Kingdom.

2) Recognise the contribution that advanced radiographer practitioners make to patients, clinicians and radiologists, usinganonymised real case scenarios.

3) Review the current evidence base which supports advanced radiographer practice, including radiographer reporting of adultchest x-rays

ABSTRACT

Increasing cost and activity pressures on health systems worldwide has led to advanced radiographer practice modelsdeveloping internationally. In the United Kingdom, radiographer reporting has evolved from the reporting of trauma skeletalx-rays by trained radiographers to include the interpretation of adult chest x-rays, CT head, MRI knee and lumbar spine,mammography, ultrasound and gastrointestinal examinations.

Advanced radiographer practice encompasses the entire spectrum of imaging, from justification of the referral, obtaining highquality images, initial image review and the provision of a definitive clinical report. The contribution that advanced practitionerradiographers make at patient, departmental and hospital levels will be highlighted. The positive influence on improved patientcare and the service provided to referring clinicians will be illustrated through real case scenarios. Departmental and hospitalbenefits of radiographer role extension will be explored through presentation of a service review.

The Royal College of Radiologists and the College of Radiographers are united in their position that all radiographers whoexpand their scope of practice must perform at a level comparable to a consultant radiologist. The growing body of evidencesupporting adult chest x-ray interpretation by trained radiographers will be explored, including performance at the end ofaccredited postgraduate training, audit of radiographer chest x-ray reporting in clinical practice and agreement between expertconsultant chest radiologists and clinical reports; both radiologist and radiographer.

URL's

http://create.canterbury.ac.uk/12642/

Handout:Nick Woznitzahttp://media.rsna.org/media/abstract/2014/14000945/Advanced Radiographic Practice in Adult Chest Imaging.pdf

CHS-THA

Chest Thursday Poster Discussions Scientific PostersCH AMA PRA Category 1 Credits ™: .50

Thu, Dec 4 12:15 PM - 12:45 PM Location: CH Community, Learning Center

ParticipantsModeratorYoshiharu Ohno MD, PhD : Research Grant, Toshiba Corporation Research Grant, Koninklijke Philips NV Research Grant,Bayer AG Research Grant, DAIICHI SANKYO Group Research Grant, Eisai Co, Ltd Research Grant, Terumo CorporationResearch Grant, Fuji Yakuhin Co, Ltd Research Grant, FUJIFILM Holdings Corporation Research Grant, Guerbet SA

Sub-Events Normal Right Hemidiaphragmatic Motion Measured with M-Mode Ultrasonography in a Large HealthyPopulation (Station #1)

June-Sik Cho MD : Nothing to Disclose , Jeong Eun Lee : Nothing to Disclose , Kyung-Sook Shin MD : Nothing to Disclose , Borahm Lee (Presenter): Nothing to Disclose , Won Hong Park MD : Nothing toDisclose

PURPOSE

To establish the reference value for normal right hemidiaphragmatic motion measured by M-modeultrasonography in a large healthy population.


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From May 2013 to January 2014, a total of 288 adult subjects(140 men and 148 women) who had regularcheckup liver ultrasound scans underwent M-mode ultrasonography for evaluation of right hemidiaphragmaticmotion. Examinations were performed three times: during quiet breathing, deep breathing, and voluntarysniffing. Diaphragmatic excursion was determined as median value of the three measurements during eachexamination. Relationships between diaphragmatic motion and different variables [sex, age groups(≤30, 31-60,≥61), and BMI groups(<18.5, 18.5-23, >23)] were assessed.

RESULTS

Right hemidiaphragmatic motion was successfully evaluated in all 288 subjects during quiet breathing, deepbreathing, and voluntary sniffing. The median values of diaphragmatic excursions of quiet breathing, deepbreathing, and voluntary sniffing were 1.9 cm(range, 0.9-4.2; mean ±SD, 2.0±0.5), 4.9 cm(range, 1.8-8.6;mean ±SD, 4.9 ± 1.2), and 2.6 cm(range, 1.2-5.5; mean ±SD, 2.7±0.8). There was no significant difference indiaphragmatic motion between sex and age groups, respectively, during quiet breathing, deep breathing, andvoluntary sniffing(p> .05 in all examinations). In BMI groups, there was no significant difference indiaphragmatic motion during quiet breathing and voluntary sniffing(p=0.626 and 0.137, respectively);however, there was significant difference during deep breathing(P< .05).

CONCLUSION

The results of this study suggest a reference value of normal right hemidiaphragmatic motion.


The reference value of normal right hemidiaphragmatic motion can be used in study of diaphragmaticmovement disorders such as diaphragmatic paralysis.

Clinical Value of Spectral CT Imaging for the Assessment of Interface between Atelectasis and LungTumor (Station #2)


PURPOSE

To evaluate the utility of spectral CT images for the visualization of the interface between atelectasis and lungtumor.


The study consist of 24 patients pathologically confirmed of lung cancer with atelectasis underwent spectral CTimaging in artery and venous phase.The optimal monochromatic and iodine-based material decompositionimages were obtained.Images were assessed by two radiologists for the display of interface between atelectasisand lung tumor.The iodine concentrations between tumour and atelectasis was compared by paired t test. Thegrades of the interfaces were evaluated by using a 4-point scale (0-poor to 3- excellent) and comparedbetween artery phase and venous phase.

RESULTS

The optimal energy level was in the range of 50-65keV (median 54.99 keV) for displaying tumour-atelectasisinterface at venous phase. CNR and image score of interface between tumour and atelectasis in venous phasewas significant higher than that of in artery phase( p<0.05).Interface could be defined in 2(8%)and21(87.5%)patients in artery phase and venous phase,respectively.The iodine concentrations of atelectasis wasstatistical higher than that of tumor in venous phase, (p < 0.05), but there was no statistical difference in arteryphase( P>0.05).

CONCLUSION

Spectral CT imaging could improve contrast between atelectasis and tumor in central lung cancer with theoptimized CNR. Monochromatic images from spectral CT enable better visualization of the interface betweentumor and atelectasis.


Spectral CT characteristic measurements is promising for differentiating benign and malignant findings.

Differentiating Lung Cancer from Inflammatory Lesions Using Spectral CT Imaging (Station #3)

Yun Liu MD (Presenter): Nothing to Disclose , Xuemei Wang : Nothing to Disclose , Xingjuan Wang : Nothing to Disclose , Xiaolu Ren : Nothing to Disclose , Hua I. Shi MD : Nothing to Disclose , Lulu Yang MD : Nothing to Disclose , Shaoning Yan : Nothing to Disclose

PURPOSE

To investigate the feasibility of differentiating lung cancer from inflammatory lesions by using spectral CTimaging.

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82 patients with pulmonary focal lesions (57 patients with lung cancer and 25 patients with inflammatorylesions) underwent plain and enhanced CT scans with spectral imaging mode. Spectral CT imaging relatedparameters for lesions such as calcium concentration in the plain CT phase and normalized iodine concentration(NIC, to that of aorta) and spectral HU curve in the enhanced CT phase were obtained. The slope k of thespectral HU curve was calculated as k=[HU(40keV)-HU(90keV)]/50. All results were analyzed with independentsamples t test. Receiver operating characteristic (ROC) curves were generated to determine thresholdparameters for optimizing sensitivity and specificity in differentiating lung cancer and inflammatory lesions.

RESULTS

(1) In the plain CT: The calcium concentrations of lung cancer and inflammatory lesions were(3.41±1.48mg/ml) and (4.59±2.65mg/ml), respectively with significant differences between the two groups(t=-2.09, p=0.045). (2) In the enhanced CT: The slope k and NIC were (1.60±0.35, 0.12±0.02) and(1.94±0.62, 0.15±0.04) for lung cancer and inflammatory lesions, respectively, with statistical differencesbetween the two groups (all p<0.05). (3) With value of 1.80, the slope in the enhanced CT provided relativelyhigh sensitivity (72%) and specificity (76%) in differentiating lung cancer from inflammatory lesions, and thearea under curve was 0.75.

CONCLUSION

Spectral CT imaging provides additional parameters (slope of spectral curve and NIC) than conventional CT toprovide relatively high sensitivity and specificity for differentiating lung cancer from inflammatory lesions.


With additional information, Spectral CT may provide better solution for differentiating lung cancer frominflammatory lesions than conventional CT.

Drug-related Pneumonitis during mTOR Inhibitor Therapy in Patients with WaldenstromMacroglobulinemia (Station #4)

Mizuki Nishino MD (Presenter): Consultant, Bristol-Myers Squibb Company , Erica N. Boswell : Nothing toDisclose , Hiroto Hatabu MD, PhD : Research Grant, Toshiba Corporation Research Grant, AZE, Ltd ResearchGrant, Canon Inc , Irene M. Ghobrial MD : Nothing to Disclose , Nikhil H. Ramaiya MD : Nothing to Disclose

PURPOSE

To determine the frequency of drug-related pneumonitis during mTOR inhibitor therapy in Waldenstrommacroglobulinemia (WM) patients, and investigate the imaging characteristics and patterns of pneumonitis.


Forty patients (23 males and 17 females, age:43-84) with WM treated in 2 trials of mTOR inhibitor, everolimus,who had baseline and at least one follow-up chest CT available for review were retrospectively studied. All chestCT scans were reviewed for abnormalities suspicious for drug-related pneumonitis by consensus of 3radiologists, evaluating 1) extent in upper, middle and lower lungs (none, <5%, 5-25%,25-50%, >50%), 2)distributions (peripheral, diffuse, central or mixed; and upper, lower, diffuse, multifocal or focal), and 3)specific CT findings. The cases with definite or probable drug-related pneumonitis were classified using ATS/ERSclassification of interstitial pneumonia based on CT features.

RESULTS

Drug-related pneumonitis was noted in 23 patients (58%)(definite in 19; probable in 4). Median time betweentherapy initiation and the onset of pneumonitis was 5.5 months. Lower lungs were involved in all 23 patients,with higher extent than other zones (median extent: upper:<5%; middle:5-25%; lower:25-50%; p<0.001).The distribution was most commonly peripheral and lower in 11 (48%), and mixed and multifocal in 10 patients(44%). Findings were bilateral in 20 (87%). GGOs and reticular opacities were present in all 23 patients, withconsolidation in 12, traction bronchiectasis in 2 and centrilobular nodularity in 1 patient. The pattern ofpneumonitis was classified as COP in 16 and NSIP in 7, while overlapping features of COP and NSIP were notedin 7 patients (5 in COP group and 2 in NSIP group). No significant differences were noted in clinicalcharacteristics between patients with and without pneumonitis (p>0.34).

CONCLUSION

Drug-related pneumonitis was noted on CT in 58% of WM patients treated with mTOR inhibitor. Most commonfindings were bilateral GGOs and reticular opacities, with or without consolidation, in peripheral and lower lungs.Patterns of CT findings simulate COP and NSIP.


Awareness of the high incidence and characteristic imaging features of drug-related pneumonitis during mTORinhibitor therapy contribute to accurate radiologic interpretation and patient management.

Female Asthmatics Show a BMI Dependent Change in their Deltalumen: SARP Cohort Data Showsthat Females are More at Risk than Males for Bronchial Collapse with an Increase in Weight (Station#6)

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Sung Shine Shim (Presenter): Nothing to Disclose , Sean B. Fain PhD : Research Grant, General ElectricCompany Research Consultant, Marvel Medtech, LLC , Ronald L. Sorkness : Nothing to Disclose , Nizar Jarjour : Nothing to Disclose , Loren Denlinger MD : Nothing to Disclose , Mark L. Schiebler MD : Shareholder, Cellectar Biosciences, Inc

PURPOSE

The aim of this study was to assess airway luminal change found on post processing of HRCT images in asthmapatients and to determine if there was any correlation with their respective clinical indices and BMI.


We prospectively enrolled a total of 152 severe asthma research program (SARP) subjects. The airwaydeltalumen was defined as the ratio of difference between airway lumen area found at HRCT during total lungcapacity (TLC) and functional residual capacity (FRC) / airway lumen area at TLC. Deltalumen of all 1st -6thgeneration airways was measured using VIDATM software, and the mean values for each subject werecalculated. Correlations were made between mean value of deltalumen and age, sex, duration of asthma,severity, spirometry parameters including baseline FEV 1 percentage predicted (PP), baseline FEF 25-75% PP,and body mass index (BMI). SPSS package was used to test for any statistical significance for each of thevariables measured in the asthmatics (Spearman rank correlation coefficient and multivariate regression).

RESULTS

We found that deltalumen showed the positive correlation with BMI (r=0.274, p=0.001), baseline FEV1pp.(r=0.163, p=0.045) and FEF 25-75 pp. (r=0.182, p=0.028) and multivariate regression analysis ofdeltalumen in asthmatics was independently determined by BMI (P<0.001). By gender, BMI in females was alsofound to be positively correlated with deltalumen (r=0.391, p<0.001) but, this was not found for male subejcts(r=0.023, p=0.860). This association was also different in non-severe and severe asthma groups. BMI wasfound to be significantly correlated with deltalumen for the non-severe asthmatics (r= 0.417, p=0.001), but notfor severe asthmatics (r=0.180, p=0.095).

CONCLUSION

Deltalumen was found to be positively associated with lung function and BMI. BMI was most highly correlatedwith deltalumen in the female non-severe asthmatic group.


Weight control in female non-severe asthmatics may prove to be important for their lung function. As this groupgains weight they are more likely to have collapse of their airways.

CHS-THB

Chest Thursday Poster Discussions Scientific PostersCH AMA PRA Category 1 Credits ™: .50

Thu, Dec 4 12:45 PM - 1:15 PM Location: CH Community, Learning Center

Sub-Events Quantification of Lung Perfusion Blood Volume (Lung PBV) by Dual-energy CT in Patients with andwithout Pulmonary Hypertension (Station #1)

Hirofumi Koike (Presenter): Nothing to Disclose , Eijun Sueyoshi MD : Nothing to Disclose , Ichiro Sakamoto : Nothing to Disclose , Masataka Uetani MD : Nothing to Disclose

PURPOSE

Recently, software programs that quantify and objectively evaluate lung perfusion blood volume (PBV) usingdual-energy CT have been developed. The present study evaluates the quantification of lung PBV using Syngosoftware in patients with and without pulmonary hypertension.


Two hundred sixty three patients who underwent echocardiography in the previous month underwentdual-energy CT angiography. The population consisted of 2 patient groups with and without pulmonaryhyperension (n=52 and n=211). We evaluated lung PBV quantified with using Syngo software, associationsbetween lung PBV and pulmonary artery pressure, and the impact of lung PBV on pulmonary hypertensionpathogenesis.

RESULTS

Early phase lung PBV values were 24.7±1.3 and 29.0±0.6 in patients with and without pulmonaryhypertension, with a significance difference observed between the two study group (p<0.0032). Late phasevalues were13.9±0.6 and 14.6±0.4, with no significant difference observed between patiens with and withoutpulmonary hypertesion (p=0.47). In the early phase, a negative correlation between lung PBV value andpulmonary artery pressure was observed (R=-0.41, p<0.0001). In patients with pulmonary hypertensionsecondary to pulmonary disease and embolism, lung PBV values were 19.3±2.0 and 24.7±2.2. they were lowerin comparison with those in patients without pulmonary hypertension.

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in comparison with those in patients without pulmonary hypertension.

CONCLUSION

Quantification of lung PBV reflects reduced pulmonary perfusion in patients with pulmonary hypertension. Thistechnique may prove useful for objective evaluation of pulmonary blood flow in patients with pulmonaryhypertension.


This method objectively showed the reduced pulmonary perfusion in patients with pulmonary hypertension. Thismethod may be a new diagnostic tool for the evaluation of pulmonary hypertension.

Diagnostic Value of Spectral CT Imaging for differentiating Pulmonary Adenocarcinoma fromTuberculosis (Station #2)


PURPOSE

To investigate the feasibility of spectral imaging for differentiating pulmonary adenocarcinoma from tuberculosisby comparing spectral curve and material decomposition measurements.


63 isolated lung nodules of diameter between 1cm and 3cm with pathology proven and follow-up confirmedwere evaluated. All enhanced CT examinations were performed on Discovery CT750 HD scanner .Monochromatic and material decomposition images were reconstructed. (ROI) was placed on the highestenhanced region of nodules, The slope of spectral curve (defined by the formula: K= (CT40keV -CT140keV)/100),iodine concentration,water concentration and effective Z value in ROIs were recorded andstatistically compared.

RESULTS

Pathological results and follow-up information confirmed that 50 cases were pulmonary adenocarcinoma while13 cases were tuberculosis. Slope of spectral curve of pulmonary adenocarcinoma was significantly higher thanthat of tuberculosis( (1.43±0.35 vs 1.03±0.29, t=-3.745,p< 0.05). Iodine concentration and effective Z valueof pulmonary adenocarcinoma were also significantly higher than that of tuberculosis(18.54±4.54 100μg/L, vs13.35±3.84 100μg/L,8.70±0.24 vs 8.41±0.22,t=-3.783, t=-3.922,p< 0.05). Water concentration of pulmonaryadenocarcinoma and tuberculosis were1022.57±8.83mg/ml and 1017.23±13.78 mg/ml respectively, there wasno significant difference between them.

CONCLUSION

Spectral imaging is demonstrated as an efficient approach to differentiate between pulmonary adenocarcinomafrom tuberculosis, suggesting its potential applications in further application in complex lung nodule diagnosis.


The spectral CT characteristic measurements is promising for differentiating benign and malignant findings.

CT Scoring Systems in Sarcoidosis: Comparison with Cardiopulmonary Exercise Testing Parameters(Station #4)

Yeon Joo Jeong MD (Presenter): Nothing to Disclose , David Augustine Lynch MBBCh : Research support,Siemens AG Scientific Advisor, PAREXEL International Corporation Consultant, Boehringer Ingelheim GmbHConsultant, InterMune, Inc Consultant, Gilead Sciences, Inc Consultant, F. Hoffmann-La Roche Ltd Consultant,Veracyte, Inc Research support, Johnson & Johnson Research support, AstraZeneca PLC , Seungbaek Hong MD : Nothing to Disclose , Ji Young Rho : Nothing to Disclose , Ji Won Lee MD : Nothing to Disclose

PURPOSE

To correlate CT scoring systems for pulmonary sarcoidosis with cardiopulmonary exercise testing and toevaluate which scoring system provides the most reliable information to assess disease severity and predictimpairment of gas exchange during exercise.


Institutional review board approved this retrospective study and the requirement for patient informed consentwas waived. All 62 patients (31 male and 31 female; mean age, 50.8 years) with sarcoidosis underwent CT,pulmonary function tests, and cardiopulmonary exercise test. Two independent observers scored CT patternsand extent according to scoring systems published by Remy-Jardin et al, Oberstein et al, and Leung et al.Weighted kappa and intraclass correlation coefficient were used to assess the reliability of CT scoring systems.Spearman's rank correlation coefficients were calculated between CT patterns and pulmonary functionalimpairment parameters and multiple regression analyses were performed to evaluate which CT abnormalitieswere significantly associated with pulmonary functional impairment parameters.

RESULTS

Interobserver agreement for CT scoring was excellent or good for the Remy-Jardin scoring system whereas fairor good for the Oberstein and the Leung scoring systems. All CT abnormalities scored with the Remy-Jardin

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scoring system showed moderate to fair correlation with DLCO% (Spearman's rho = -0.270~-0.426), SaO2max (Spearman's rho = -0.265~-0.534), PaO2 max (Spearman's rho = -0.328~-0.551), and Vd/Vt max(Spearman's rho = 0.279~0.495). Regardless of scoring system, PaO2 max was significantly associated withthe subscores of ground glass opacity, linear opacity and total CT scores. Multiple regression analyses showedthat subscores of ground glass and linear opacity in the Leung scoring system and subscores of consolidationand septal and nonseptal lines and total CT scores of the Oberstein scoring system appeared to explain asignificant amount of variance in functional parameters at rest and at maximal exercise.

CONCLUSION

CT findings, particularly ground glass linear opacities can explain a significant amount of variance incardiopulmonary exercise parameters. This suggests that CT-based scoring systems are valid measures ofdisease severity in sarcoidosis.


Although current CT scoring systems are quite complicated and subjective, CT-based scoring systems are validmeasures of disease severity in sarcoidosis.

The Use of Contrast-enhanced Post Mortem CT in the Detection of Cardiovascular Deaths (Station#5)

Jonas Christoph Apitzsch MD (Presenter): Nothing to Disclose , Saskia Westphal : Nothing to Disclose , Tobias Penzkofer MD : Nothing to Disclose , Christiane Katharina Kuhl MD : Nothing to Disclose , Ruth Knuchel-Clarke PhD : Nothing to Disclose , Andreas Horst Mahnken MD : Nothing to Disclose

PURPOSE

To evaluate the diagnostic value of contrast enhanced post mortem computed tomography in comparison tonon-enhanced post mortem CT in the detection of cardiovascular causes of death


In a prospective study, 20 corpses were examined using a 64-row multisclice CT before and after intraarterialperfusion with a newly developed, barium-bearing contrast agent and ventilation of the lungs. The cause ofdeath was determined in enhanced and unenhanced scans and a level of confidence was given by threeexperienced radiologists on a scale between 0 and 4. Results were compared to autopsy results as goldstandard. Autopsy was performed blinded to PMCT-findings

RESULTS

The method allowed visualization of different types of cause of death. There was a significant improvement inLevel Of Confidence in enhanced scans compared to unenhanced scans as well as an improvement in thedetection of cause of death. The cause of death could be determined in 19 out of 20 patients

CONCLUSION

PMCT is feasible and appears to be robust for diagnosing cardiovascular causes of death. When compared withunenhanced post-mortem CT intraarterial perfusion and pulmonary ventilation significantly improvevisualization and diagnostic accuracy.


PMCT is on its way to close the gap between virtual and conventional autopsy. Until now, both methods shouldbe seen as complementary, each one adding valuable information to the other.

Oxygen-enhanced Pulmonary MRI in Patients with Chronic Thromboembolic PulmonaryHypertension (CTEPH) Pre and Post Pulmonary Endarterectomy (PEA) Compared to Healthy Controls(Station #6)

Julius Renne MD (Presenter): Nothing to Disclose , Reemt Nieland : Nothing to Disclose , Jan Hinrichs MD : Nothing to Disclose , Christian Olaf Schoenfeld MD : Nothing to Disclose , Marcel Gutberlet DiplPhys : Nothing to Disclose , Andreas Voskrebenzev : Nothing to Disclose , Marius Hoeper : Nothing to Disclose , Tobias Welte MD : Nothing to Disclose , Serghei Cebotari MD : Nothing to Disclose , Axel Haverich : Nothing to Disclose , Peter Michael Jakob PhD : Nothing to Disclose , Frank K. Wacker MD : ResearchGrant, Siemens AG Research Grant, Pro Medicus Limited , Jens Vogel-Claussen MD : Nothing to Disclose

PURPOSE

This study aims to explore pulmonary oxygen-enhanced MRI in patients with CTEPH to detect changes inregional blood oxygenation after PEA compared to healthy controls.


After approval of the institutional review board 16 patients with CTEPH and 12 healthy controls were included.MRI was performed at 1.5T using an inversion recovery snapshot fast low-angle shot (FLASH) sequence for T1mapping at room air and 100% oxygen. CTEPH patients underwent MRI pre and 7-24 days post PEA. Controls

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mapping at room air and 100% oxygen. CTEPH patients underwent MRI pre and 7-24 days post PEA. Controlsreceived two MRI 7 days apart. A minimum of six coronal slices (15mm slice thickness, 5mm gap) wereacquired. Mean T1 value, coefficient of variation under room air and 100% oxygen, and a previously establishedmarker for ventilation, oxygen diffusivity and blood oxygenation -the oxygen transfer function (OTF)- werecalculated for the lungs. OTF=((1/T1100%O2)-(1/T121%O2))/(C100%O2-C21%O2) Mean±SD, t-test.

RESULTS

All healthy controls (29y ±7y) and 14 of the 16 CTEPH patients (53y ±15y) completed MRI scans. Mean T1values under room air and 100% O2 were significantly lower in CTEPH patients compared to controls (room air:1250±51ms vs. 1097±63ms, p=0.0001; O2: 1093±38ms vs. 974±53ms, p=0.0001). The coeff. of variationwas significantly higher in patients with CTEPH (room air: 4.9±0.9 vs. 12.2±3.2, p=0.0001; O2: 5.9±2 vs12.6±3.8, p=0.0001). OTF was not significantly different between patients and controls (p=0.55), and did notchange at the 2nd MRI for controls (p=0.47) nor after PEA (p=0.14) in the CTEPH group, despite a significantdecrease in mPAP after PEA (mean difference -18.7±15mmHg (-44%), p=0.008) and improvement ofparenchymal perfusion (mean difference +18.5±17ml/min/100ml (+51%), p=0.0025).

CONCLUSION

Oxygen-enhanced MRI shows significantly decreased and more heterogeneous T1-values of the lungs inpatients with CTEPH compared to normal controls, which reflects the mosaic perfusion pattern in CTEPH.However, OTF was not significantly different between controls and CTEPH patients nor after PEA, indicating thatOTF reflects predominantly regional ventilation and oxygen diffusion into the alveolar interstitium rather thanimprovement in regional blood oxygenation after PEA.


The current study shows that T1 mapping MRI-derived OTF predominantly reflects changes of oxygen withinthe lung parenchyma and is not applicable for monitoring regional blood oxygenation changes in patients withCTEPH after PEA.

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Interventional Oncology Series: Lung and Bone Series CoursesRO OI IR MK CH AMA PRA Category 1 Credits ™: 4.25


Thu, Dec 4 1:30 PM - 6:00 PM Location: S405AB

ParticipantsModeratorMatthew Raymond Callstrom MD, PhD : Research Grant, Thermedical, Inc Research Grant, General Electric CompanyResearch Grant, Siemens AG Research Grant, Galil Medical Ltd

Sub-Events MW vs RFA vs Cryo for Lung Mass Ablation—Which/When/Where?

Damian E. Dupuy MD (Presenter): Research Grant, NeuWave Medical Inc Board of Directors, BSD MedicalCorporation Stockholder, BSD Medical Corporation Speaker, Educational Symposia

LEARNING OBJECTIVES

1) Understand differences between the various thermal technologies as applied to lung tumors. 2) Reviewcurrent clinical thermal ablation data with regard to the treatment of lung tumors. 3) Comprehend the usage ofthe various thermal modalities with clinical examples of lung tumor treatment.

Latest Advances in Lung Surgery for Metastic Disease

Francis C. Nichols MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) Identify appropriate patients who are felt to benefit from pulmonary metastasectomy. 2) Discuss the prosand cons of pulmonary metastasectomy done via a traditional open thoracotomy versus minimally invasiveVideo-Assisted Thoracic Surgery (VATS). 3) Describe a localization technique for the small difficult to locatepulmonary metastasis(es). 4) Discuss the rationale for mediastinal lymphadenectomy during pulmonarymetastasectomy and its prognostic implications.

Quantitative Validation of Thermal Ablation: An Improved Image Fusion Algorithm to ReflectTreatment Coverage

David Thomas Glidden BS (Presenter): Nothing to Disclose , Grayson L. Baird MS : Nothing to Disclose ,

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Derek Merck : Nothing to Disclose , Damian E. Dupuy MD : Research Grant, NeuWave Medical Inc Board ofDirectors, BSD Medical Corporation Stockholder, BSD Medical Corporation Speaker, Educational Symposia

PURPOSE

To propose the foundation of a quantitative method for validation of thermal ablations.


24 patients (M:F= 10:14) with solitary lung tumors underwent microwave ablation under CT-guidance. Eachtumor was treated with one of four MW applicators (BSD Medical, Salt Lake City, UT, Neuwave Medical,Madison, WI) for 5-15 minutes according to the manufacturers' specifications. Each case included a CT scanpre- intra- and post-procedure. Tumor volumes were manually segmented from pre-scans and ablation volumesfrom post-scans using the ground glass halo surrounding the tumor. Pre-scans were fused onto post-scansusing two algorithms-a rigid registration, and a rigid plus deformable registration. Volume overlap resultingfrom both algorithms were calculated. Bland-Altman plots and Deming regression were used to identify possibledifferences in these image fusion techniques.

RESULTS

The volume overlap between tumors and ablation zones increased proportional to tumor size when deformableregistration was applied (p < 0.001). Deming regression showed a significant deviation from perfectconcordance between rigid and deformable registration (95 % CI: [1.13, 1.39]) in which more volume overlapwas attributable to deformable registration.

CONCLUSION

Quantitative validation of thermal ablation margin analysis remains challenging due to inherent tumor positionand morphology changes after ablation. Rigid registration techniques rarely reflect how an ablation zone coversthe tumor and margin because of movement (e.g. respiratory, tumor displacement, patient position). Theaddition of deformable registration may more accurately reflect how the tumor and ablation zone overlap, thusimproving local control outcomes.


Improved fusion between pre- and post-scans using deformable registration will provide a basis for quantitativevalidation of thermal ablations by correcting for anatomical movement.

Lung Mass SBRT Current Results and Ongoing Trials

Kenneth Richard Olivier MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) Review definitions of SBRT. 2) Discuss results of SBRT for pulmonary nodules. 3) Review current andproposed clinical trials for pulmonary nodules. 4) Review currently accepted indications for SBRT.

ABSTRACT

Stereotactic Body Radiotherapy (SBRT), also known as Stereotactic Ablative Radiotherapy (SABR) has becomean important new tool for oncologists looking to treat patients with primary lung cancers or pulmonarymetastases. In this talk we will discuss some of the fundamentals of SBRT, review relevant literature, andcurrent indications of SBRT for either primary lung cancers or metastases.

Percutaneous Microwave Ablation of Pulmonary Malignancies: Survival, Imaging Follow-up, andComplications

Mark William Little MBBS, MSc (Presenter): Nothing to Disclose , Daniel Yiu Fai Chung MBBS, FRCR : Nothing to Disclose , Eoghan John Patrick McCarthy MBBCh : Nothing to Disclose , James Henry Briggs MBChB, FRCR : Nothing to Disclose , Philip Boardman MBChB : Nothing to Disclose , Fergus Vincent Gleeson MBBS : Alliance Medical Ltd Consultant , Ewan Mark Anderson MBBCh : Nothing to Disclose

PURPOSE

Survival analysis, technical success, safety and imaging follow-up of malignant pulmonary nodules treated witha novel high power microwave ablation system.


Over a three year period, 55 patients, 33 male, mean age 64 years (31-88) with 92 unresectable pulmonarymalignancies of mean diameter 18mm (6-59mm) underwent computed tomography (CT)-guided percutaneousmicrowave ablation in 72 ablation sessions. Primary non-small cell bronchogenic carcinoma was treated in 28lesions, whilst metastatic tumors were ablated in the remainder (colorectal=28, renal=9, sarcoma=17,adrenal=3, esophageal=2, melanoma=3, breast=1, tcc=1). Tumors were diagnosed by biopsy, or PET avidity(median SUV max = 9.5) and interval growth. Technical success was defined as needle placement in theintended lesion without death or serious injury. Adequacy of ablation was assessed at 24 hours oncontrast-enhanced CT, for a circumferential solid or ground glass margin > 4mm. Patients were followed withcontrast-enhanced CT 3-monthly until death, or local tumor progression (LTP), or for at least 12 months postprocedure. LTP was defined as contiguous enlargement or a change in the shape of the ablation zone or thedevelopment of contrast enhancement in part of the zone. Survival rate was evaluated by Kaplan-Meieranalysis.

RESULTS

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Microwave ablation was technically successful in n=88 (96%) of lesions. Mean ablation duration was 4 minutes(1-22 minutes). 21(29%) pneumothoracies were diagnosed on chest x-ray after 72 ablation sessions; chestdrain was required in 8 (11%) sessions. 30-day mortality rate was 0%. The mean hospital stay was 1.1 days(1-11 days). Local tumor progression was present in 6 tumors; for tumors under 4cm (n=88), LTP wasidentified in 3 (3%) at a median follow up of 13months. The mean diameter of lesions with LTP weresignificantly larger than those without (mean diameter 41mm vs 17mm; p=0.009). The cancer-specific survivalwas 79% (95%CI 0.68-0.9) at 1 year, and 66% (95% CI 0.51-0.83) at 2-years.

CONCLUSION

Microwave ablation of pulmonary malignancies is a safe, successful technique. Local control rates and survivalanalysis are encouraging, with rapid treatment times


Primary and metastatic lung tumors are extremely common; surgical options are often limited due to advanceddisease and or poor respiratory function. Microwave ablation offers a robust method of local disease control

Ablation for Primary Lung Cancer What Does the Data Support

Robert D. Suh MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) Discuss long term outcomes of image-guided ablation for early stage lung cancer. 2) Discuss local controlrates of image-guided ablation for early stage lung cancer. 3) Understand the factors in image-guided ablationinfluencing survival and local control. 4) Understand treatment options and relative outcomes of image-guidedablation compared to alternative therapies for early stage lung cancer.

ABSTRACT

Although the literature on thermal ablation demonstrates heterogeneous, sometimes markedly so, reporting,thermal ablation confers increasingly improved local control and survival benefits in carefully selected patients:RF ablation with long-term results comparable to competitive therapies, particularly in the high-risk patientpopulation. Despite advances in thermal energy devices, specifically microwave and cryoablation, delivery andcombination therapy leading to improved local control, gains in survival will be limited for this high-riskpopulation, given the limitations of radiographic staging and presence of already microscopic lymph nodal anddistant disease at the time of image-guided ablation, a risk inherently present with all local therapies. Thus far,thermal ablation remains a safe therapeutic and effective option to treat 1° lung malignancies.

Ablation for Metastatic Lung Cancer Is Ablation Competitive with Surgery or SBRT?

Thierry Debaere (Presenter): Consultant, Terumo Corporation Speaker, Terumo Corporation Consultant,Guerbet SA Speaker, Guerbet SA Consultant, General Electric Company Speaker, General Electric CompanyProctor, Galil Medical Ltd

LEARNING OBJECTIVES

1) To know results of percutaneous ablation of lung metastases in term of local efficacy and survival. 2) Toknow predictive factors of RFA for lung metastases. 3) To know results of surgery and stereotaxic radiationtherapy for lung metastases.

ABSTRACT

Since first report of RFA in lung tumor in year 2000, RFA has been demonstrated to provide 80 to 90% completeablation for tumors less than 2 cm, with decrease in efficacy for larger tumors. Percutaneous ablation is today avalid option for lung metastases in non surgical candidates with overall survival reported after RFA is inbetween 56 to 67% at 3 years. Such survival reported is comparable to what reported in large surgical serieseven if no comparative data exists. Age, disease free interval, tumor size and tumor numbers are independentpredictor of survival after RFA of lung metastatses. The same predictive factors have been reported as predictiveof survival after surgical metastasectomy. One of the advanteg of RFA over other technique such as surgery andSBRT is that it can be easily repeated in case of occurrence of new metastases which is difficult with surgerydue to the aggressively of the procedure. Subsequent surgical resection are limited by pulmonary reserve. Thesame applies to stereotaxic radiation therapy where multiple irradiation results in toxicity lo lung parenchyma,skin or mediastinum. Consequently, RFA is today part of routine practice armentarium against lung metastases.However, better determination of the role of RFA relative to other therapies are needed. In addition, the needand benefit from combining local ablation and systemic therapy must be evaluated. Future trends in treatmentof pulmonary metastases will favor minimal aggressive treatments and percutaneous ablation have a role toplay. Evidence based medicine supporting the use of lung RFA metastatic disease and defining what is the bestpopulation to target with ablation or SBRT. For today the ideal candidate has less than 3 tumors less than 3 cm.

Lung Tumor Board

Moderator Matthew Raymond Callstrom MD, PhD : Research Grant, Thermedical, Inc Research Grant, GeneralElectric Company Research Grant, Siemens AG Research Grant, Galil Medical Ltd

LEARNING OBJECTIVES

1) Describe the characteristics of lung and bone tumors amenable to interventional oncologic treatment. 2)Describe new techniques for the percutaneous treatment of lung tumors and bone metastases. 3) Describe therole of percutaneous ablation for lung tumors and bone metastases in the context of other treatments includingsurgery and radiation oncology.

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surgery and radiation oncology.

Treatment of Complex Benign Skeletal Disease

Afshin Gangi MD, PhD (Presenter): Proctor, Galil Medical Ltd

LEARNING OBJECTIVES

1) Identify the best indications of percutaneous technique and list them. 2) Describe the methods used intreatment of benign skeletal tumors and the advantages and limits of each of them. 3) Identify the risks of thepercutaneous procedures and their limits. 4) Explain the measures used to protect the surrounding tissues toavoid major complications. 5) Learn how to follow up the patients and analyze the results.

URL's

http://www.openradiology.org

Pain Palliation of Bone Metastases and Local Tumor Control with Magnetic Resonance GuidedFocused Ultrasound Surgery (MRgFUS) Treatment

Brachetti Giulia MD : Nothing to Disclose , Valeria De Soccio : Nothing to Disclose , Fabrizio Andrani : Nothing to Disclose , Gianluca Caliolo : Nothing to Disclose , Fulvio Zaccagna MD : Nothing to Disclose , Alessandro Napoli MD (Presenter): Nothing to Disclose

PURPOSE

to evaluate the efficacy of MRgFUS for treatment of painful bone metastases and its potential for local tumorcontrol.


after IRB approval 42 patients were scheduled for treatment using the Exablate system (InSightec). Before and1, 2 and 3 months after MRgFUS treatment, pain scores were assessed according to Brief PainInventory-Quality of Life (BPI-QoL) criteria. Imaging (CT and ceMR: Bracco) follow-up was obtained at 1 and 3months; in survivals, follow-up was extended at 6 and 12 months. For local tumor control, imaging changeswere evaluated with the MD Anderson (MDA) criteria. Patients were classified in responder and non-responders.The extent of necrosis within the ablated metastasis was evaluated using non-perfused volume (NPV).

RESULTS

All 42 patients underwent MRgFUS (20 recurrence post-RT; 22 primary treatment). Statistically significantdifference between baseline and follow-up values for both pain severity and pain interference scores wasobserved (p<0.05; no statistical difference between the post-RT and primary treatment group). Stable painscore (VAS<2) was observed in survival group at 6 (15 patients) and 12 (9 patients) month control. Increasedbone density was observed in 10 (23,8%) patients. Complete response was found in 20 (47,6%) patients;partial response was found in 22 (52,3%) patients (pain recurrence in 3 patients), according to both the MDAand clinical criteria. NPV values ranged between 23% and 94%. There was no difference in non-perfusedvolume between responders and non-responders (p=0.7). No adverse events were recorded

CONCLUSION

MRgFUS is an effective and durable treatment for pain palliation of bone metastasis; moreover, a positive rolein local tumor control and bone restoration was demonstrated.


MRgFUS can be safely and effectively used as treatment for pain palliation of bone metastasis in patients whohad exhausted EBRT and also in patients not previously treated with EBRT. The treatment creates bonemetastasis necrosis and so might have a positive role in local tumor control and bone restoration.The majoradvantages of the technique include its non-invasive nature. The treatment can be performed in a singlesession, does not use ionizing radiation and utilizes MR guidance for precise targeting and thermal control.

Radiofrequency Ablation of Spinal Disease

Jack William Jennings MD (Presenter): Speakers Bureau, DFINE, Inc Consultant, DFINE, Inc

LEARNING OBJECTIVES

1) Metastatic spine overview 2) Patient selection and treatment evaluation 3) Current guidelines for treatmentof metastatic spine lesions 4) Imaging of lesions 5) Role of vertebral augmentation in metastatic disease 6)Targeted Radiofrequency ablation (RFA) 7) RFA and radiotherapy (RT) 8) Multi-disciplinary treatment algorithm

ABSTRACT

Bone metastases are a major cause of morbidity in patients with cancer and represent a common occurrence inthese patients. The vertebral column is the most common site for bone metastases with an incidence of 30-70%in patients with metastatic cancer and is likely related to the high hematopoietic activity and vascularization ofthe spine. Management of these patients is challenging and traditionally involves a combination of radiation andchemotherapy in adjunct with analgesics. Surgery has remained a mainstay of treatment in patients with

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chemotherapy in adjunct with analgesics. Surgery has remained a mainstay of treatment in patients withneurologic deficit, instability requiring stabilization, or with a longer life expectancy. Surgical options in thesepatients with decreased life expectancy are often morbid and present a therapeutic dilemma. Minimally invasiveprocedures, including thermal ablation, are safe and effective treatments of painful osseous metastatic lesionsin patients who are not surgical candidates or have exhausted or are unable to have radiation therapy.Radiofrequency ablation (RFA) has been increasingly utilized in management of osseous metastases. In thespine, this treatment has traditionally been limited to lesions within the anterior vertebral body since thislocation is more accessible and further away from sensitive neural elements. Many spinal tumors will continue togrow and cause pain after radiation therapy. Posterior vertebral body lesions will often progress and extendthrough the posterior cortex into the spinal canal making therapeutic options very limited. The development ofan articulating bipolar electrode has allowed for targeted RFA and the ability to treat posterior spinal lesions viaa transpedicular approach. Review of the existing literature and current treatment guidelines demonstrates theneed for future prospective studies of spine tumor ablation and for the development of a treatment algorithmdefining its role with the current accepted treatment options.

Sequential Interventional Treatment of Pelvic/Sacral Tumors via Angiographic Embolization,Cryoablation, and Stabilization Plasty Combinational Therapy

Sri Hari Sundararajan MD (Presenter): Nothing to Disclose , Marisa Giglio : Nothing to Disclose , Sudipta Roychowdhury MD : Consultant, Johnson & Johnson , Vyacheslav Gendel MD : Nothing to Disclose , Gaurav Gupta MD : Nothing to Disclose , John L. Nosher MD : Nothing to Disclose

PURPOSE

The purpose of the study is to review the treatment experiences of patients treated at our institution withcombination angiographic embolization, cryoablation or thermal ablation, and stabilization plasty for theirpelvic/sacral tumor burden. This study hopes to assess if such combinational interventional therapy has thepotential to become a mainstay treatment option in managing pelvic and sacral neoplasms.


A combined interventional paradigm was employed in 8 patients thus far over the last year: Phase I:Angiographic embolization of neoplasm Phase II: Cryoablation of solid tumor, followed by supportive sacroplastyPhase III: Image-guided drainage/TPA flush, followed by sclerosis of residual bed Procedures were performedunder general anesthesia. Phase I was within 1 day to 1-2 weeks prior to Phase II and III dependent on lesionlocation and patient tolerance. Neurological monitoring were utilized in Phases 2 and 3 to assess integrity ofsacral nerve function during procedures. Each patient underwent pretreatment CT and/or MRI examination priorto therapy. All patients have undergone post-therapy follow-up imaging within 1-3 months. Medical recordsand imaging portfolios for these patients will be reviewed. A reassessment of pre and post procedure lesionmeasurements and quality of life outcomes will be performed. Linear regression will be performed to correlateresults of imaging and quality of life assessment.

RESULTS

It is hypothesized that patients undergoing sequential combinational therapy will demonstrate significantdecrease in lesion growth, as well as improved pain control and quality of life. It is unclear if survival will beaffected by such measures, as patients with terminal disease pursued such procedures more so forsymptomatic relief.

CONCLUSION

An interventional paradigm consisting of combinational implementation of angiography-mediated embolization,thermal/radiofrequency ablation, and mechanical drainage followed by cavity sclerosis is expected to become amainstay treatment option of pelvic and sacral neoplasms. The results of our review is expected to provideinsight into its use in patients needing physical and symptomatic reduction of their pelvic/sacral tumor burden.


Sequential incorportation of several effective interventional treatments may play a role in the treatmentparadigm of pelvic and sacral neoplasms.

Avoiding Complications with Bone and Soft Tissue Ablation

Anil Nicholas Kurup MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) Identify critical anatomic structures to be avoided during bone and soft tissue tumor ablation. 2) Applydisplacement techniques to minimize risk of collateral damage during bone and soft tissue ablation. 3)Understand radiographic and neurophysiologic monitoring techniques that may be employed during bone andsoft tissue ablation. 4) Recognize the role of bone consolidation as an adjunct to bone ablation.

Treatment of Oligometastatic Disease: What Is the Role of Ablation?

Peter John Littrup MD (Presenter): Founder, CryoMedix, LLC Research Grant, Galil Medical Ltd ResearchGrant, Endo Health Solutions Inc Officer, Delphinus Medical Technologies, Inc

LEARNING OBJECTIVES

1) Understand how ablation of limited, or oligo-, metastases could produce a major impact on numerous cancer

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types. 2) Describe the major anatomic locations that are considered common oligometastatic sites. 3) Describethe outcomes for procedure complication and recurrence rates for the major anatomic sites. 4) Describe thepotential economic impacts of ablation as part of palliative care for major cancer types (e.g., renal, lung,colorectal, ovarian).

Preoperative Embolization in Surgical Treatment of Spinal Metastases: Single-Blind, RandomizedControlled Clinical Trial of Efficacy in Decreasing Intraoperative Blood Loss

Caroline Clausen MD (Presenter): Nothing to Disclose , Benny Dahl MD, PhD : Nothing to Disclose , Susanne Christiansen Frevert MD : Nothing to Disclose , Lars Valentin MD : Nothing to Disclose , Michael Bachmann Nielsen MD, PhD : Nothing to Disclose , Lars Lonn MD, PhD : Nothing to Disclose

PURPOSE

To assess whether preoperative embolization reduces intraoperative blood loss, the need for blood transfusion,and operative time in the surgical treatment of symptomatic metastatic spinal cord compression.


A single-blind, randomized (balanced 1:1), controlled, parallel-group trial conducted as a single-center study;48 participants were included from May 2011 until March 2013. Participants scheduled for decompression andposterior thoracic/lumbar instrumented spinal instrumentation because of symptomatic metastatic spinal cordcompression were randomly assigned to either preoperative arteriography and embolization - the interventiongroup or preoperative arteriography - the control group. Primary outcome: intraoperative blood loss. Secondaryoutcomes: Intra- plus postoperative blood loss, blood transfusion and duration of surgery. Outcomes werereported as intention-to-treat analyses (ITT) including all randomized patients with a standing consent toparticipate and meeting the inclusion criteria.

RESULTS

Of the 48 randomized patients, 45 (23:22) were available for the ITT after exclusion of patients violatinginclusion criteria. Mean intraoperative blood loss did not differ significantly between the embolization group(618 ml; SD 282 ml) and the control group (735 ml; SD 415 ml). This was also the case for intra- pluspostoperative blood loss and the need for blood transfusion. The duration of surgery was shorter in theembolization group compared to the control group (p=0.031); median 90 minutes (range 54-252) vs. 124minutes (range 80-183).

CONCLUSION

Preoperative embolization does not result in a reduction of intraoperative blood loss and blood transfusion, butreduces the duration of surgery. The general routine use of preoperative embolization cannot be recommendedin decompression and posterior instrumented spinal instrumentation for symptomatic metastatic spinal cordcompression.


This randomized controlled clinical trial displays that preoperative embolization has the advantage of reducingthe duration of surgery for symptomatic metastatic spinal cord compression.

Bone Metastases Tumor Board

Moderator Matthew Raymond Callstrom MD, PhD : Research Grant, Thermedical, Inc Research Grant, GeneralElectric Company Research Grant, Siemens AG Research Grant, Galil Medical Ltd

LEARNING OBJECTIVES

1) Describe the characteristics of lung and bone tumors amenable to interventional oncologic treatment. 2)Describe new techniques for the percutaneous treatment of lung tumors and bone metastases. 3) Describe therole of percutaneous ablation for lung tumors and bone metastases in the context of other treatments includingsurgery and radiation oncology.

SPSH52

Hot Topic Session: Lung Cancer Screening: Update on Policies and Procedures Special Courses

HP CH HP CH HP CH



Thu, Dec 4 3:00 PM - 4:00 PM Location: S406B

ParticipantsModeratorReginald F. Munden MD, DMD : Nothing to Disclose

VSIO51-16

VSIO51-17

Reginald F. Munden MD, DMD : Nothing to Disclose

LEARNING OBJECTIVES1) Describe the ACR perspective on lung cancer screening in regards to policy and practice guidelines. 2) Appraise governmentaldecisions and policies on lung cancer screening, and their economic impact. 3) Recognize the patient's perspective of our lungcancer screening activities, and how it can impact screening.

ABSTRACT

The success of the NLST in reducing lung cancer specific mortality has generated great interest in the medical communityregarding deployment of CT for lung cancer screening. While guidelines for who should be screened have been developed bymany organizations, policies and procedures for performing lung cancer screens have not been fully developed. The radiologycommunity, governmental officials, and patient advocacy groups have been influential in affecting standards, policies andprocedures for lung cancer screening. This session will review and update radiologist of these actions.

Sub-Events Radiologist Perspective: LungRADS - Practice Guidelines, Accreditation and Oversight, Centers ofExcellence


LEARNING OBJECTIVES


ABSTRACT

see course abstract

Government Perspective: Economics of Screening, USPSTF Recommendation Impact, CMS and 3rdParty Coverage, Regulation/Concerns

Geraldine B. McGinty MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES


Patient Perspectives

Laurie Fenton Ambrose (Presenter): Nothing to Disclose

LEARNING OBJECTIVES


RC701

Practical Issues in Chest Imaging (An Interactive Session) Refresher/Informatics

CH



Thu, Dec 4 4:30 PM - 6:00 PM Location: E450A

ParticipantsModeratorEric J. Stern MD : Nothing to Disclose

Sub-Events Thoracic Emergencies

Amita Sharma MBBS (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) To identify specific disease processes that present with acute thoracic symptoms. 2) Recognize the radiologicfeatures that differentiate thoracic emergencies. 3) Understand the role of the Radiologist in management

Missed Lung Cancer: Hiding in Plain Sight!

SPSH52A

SPSH52B

SPSH52C

RC701A

RC701B

Eric J. Stern MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) Understand characteristics of missed lung cancers on CXR. 2) Understand how we visually search. 3) Beaware of common observer errors. 4) Know CXR hiding spots. 5) Be aware of some ancillary diagnostic tools.

Management of Sub-Solid Lung Nodules: How I do it...

Myrna Cobos Barco Godoy MD, PhD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) To comprehend the new IASLC/ATS/ERS classification of lung adenocarcinomas and its correlation withsubsolid nodules. 2) To review the current approach to diagnosis and management of subsolid pulmonarynodules.

Imaging of Thoracic Infections: What's New?

Rachna Madan MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) Discuss spectrum of immunocompromised hosts and infections associated with specific immune deficits. 2)To review clinical presentation, and imaging findings of pulmonary infections with emphasis onimmunocompromised hosts. 3) Review imaging signs in infections. 4) Review the role of percutaneous samplingespecially in tissue invasive infections where bronchoscopy and bronchial lavage may have low yield. 5) Discussrevised EORTC/MSG criteria for diagnosis of invasive fungal infections. 6) Emphasize diagnostic conundrumssuch as presence of multiple infectious processes, mimics of infection and immune reconstitution inflammatorysyndrome (IRIS). 7) Use case scenarios to illustrate formulation of differential diagnosis by combining clinical,serological data with imaging findings.

ABSTRACT

Infections are the most common pulmonary complications in immunocompromised patients and lung is themost frequently affected site of tissue invasive infection. It is imperative to adopt an aggressive approach togetting specific microbiologic diagnosis. Early cross sectional imaging with CT allows narrowing of differentialdiagnosis using radiological features and gives clues about the mechanism of spread, possible organism, burdenof disease and guides subsequent invasive procedures such as lung biopsy. Imaging signs must be applied withcaution and it is important to consider non-infectious etiologies. Pursuit of a unifying diagnosis is not alwayspossible. Multiple infections may co-exist in a single organ. The radiologist must take on the role of an imageguided clinician and combine clinical, serological and microbiological data with imaging features in making adiagnosis.

RC718

Radiogenomics of Lung Cancer—Changing Landscape and Challenges Refresher/InformaticsOI BQ CH AMA PRA Category 1 Credits ™: 1.50


Thu, Dec 4 4:30 PM - 6:00 PM Location: S404CD

Sub-Events Lung Cancer in the Radiogenomic Era—Implications for Imaging

Lawrence H. Schwartz MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) To understand the clinical needs for Radiogenomic Imaging in Lung Cancer. 2) To understand what imagingmodalities and quantification techniques can be used in Radiogenomic Imaging in Lung cancer. 3) To illustrateexamples of successes and failures in Radiogenomic Imaging approaches in Lung Cancer.

Qualitative Assessments of Lung Cancer for Radiogenomic Analysis

Hyun-Ju Lee MD, PhD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) To introduce the results of correlation between imaging features and genetic phenotypes of lung cancer. 2)

RC701B

RC701C

RC701D

RC718A

RC718B

To describe the implications of imaging traits on pathology, patient prognosis, and genetics. 3) To introduce therole of qualitative assessment for the next step high-throughput quantitative feature selection.

Quantitative Assessment in Lung Cancer Radiogenomics—Reproducibility and Reliability

Binsheng Zhao DSc (Presenter): License agreement, Varian Medical Systems, Inc License agreement, KeosysLicense agreement, Hinacom Software and Technology, Ltd License agreement, AG Mednet, Inc

LEARNING OBJECTIVES

1) Familiarize the audience with quantitative image features that can be computed to characterize tumors. 2)Discuss reproducibility and reliability of image features due to, repeat CT scans, CT acquisition andreconstruction techniques, tumor segmentations.

ABSTRACT

The way tumors look on radiological images may also reveal their underlying cancer gene expressions. Tumorimaging phenotypes can be characterized not only qualitatively by the radiologist's eyeballing, but alsoquantitatively by computer through image feature analysis. Radiogenomics promises the ability to assess cancergenotype though the tumor's imaging phenotype. However, to date, little attention has been paid to thesensitivity of image features to repeat scans, imaging acquisition techniques, reconstruction parameters andtumor segmentations. This refresher course will first familiarize the audience with quantitative image featuresthat can be computed to characterize tumor size, shape, edge and density texture statistics. Both phantom andin-vivo studies will be introduced to explain how repeat CT scans and CT imaging acquisition and reconstructiontechniques affect the assessment of quantitative image features in lung cancer Radiogenomics studies. Last butnot least, the effects of image segmentation on feature calculations will be addressed.

RC727

From Research to Reimbursement: Lung Cancer Screening and Healthcare Payment Policy (InConjunction with the American College of Radiology) Refresher/Informatics

HP OI CH HP OI CH



Thu, Dec 4 4:30 PM - 6:00 PM Location: S403B

ParticipantsModeratorPamela Kassing : Nothing to Disclose Geraldine B. McGinty MD (Presenter): Nothing to Disclose James Vincent Rawson MD (Presenter): Nothing to Disclose Mark Otto Bernardy MD (Presenter): Nothing to Disclose Robert K. Zeman MD (Presenter): Stockholder, General Electric Company

LEARNING OBJECTIVES

1) Understand the current process of how reimbursement for new procedures and technology is obtained from CPT codedevelopment, valuation and coverage. 2) Using Lung Cancer Screening as an example, the participants will become familiarwith the specific processes for obtaining coverage for new screening programs in the public and private sectors and how amyriad of governmental agencies and other policymaking groups are involved in determining which new procedures arecovered. 3) Understand how obtaining coverage will bring this new technology to the mainstream. 4) Interactive techniques willbe used to engage the audience in the consideration of strategic partnerships between industry, clinical research, governmentalagencies and third party payors.

URL's

http://www.acr.org/

RC801

HRCT of Diffuse Lung Disease: Read Cases with the Experts (An Interactive Session) Refresher/Informatics

CT CH



Fri, Dec 5 8:30 AM - 10:00 AM Location: S406A

ParticipantsModeratorGeorgeann McGuinness MD : Nothing to Disclose

RC718C

Sub-Events Technique, Basic Anatomy and Patterns for Differential Diagnosis

Brett M. Elicker MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) Understand basic high-resolution CT anatomy and it's relationship to disease pathophysiology. 2) Describecommon protocols in high-resolution CT and their advantages/disadvantages. 3) Understand the role ofradiology in the multi-disciplinary diagnosis of patients with diffuse lung diseases.

Patterns: Lines and Cysts

Daria Manos MD, FRCPC (Presenter): Author, Springer Science+Business Media Deutschland GmbH

LEARNING OBJECTIVES

1) Use the terms intralobular septal thickening, interlobular septal thickening, irregular reticulation,parenchymal bands, traction bronchiectasis, lung cysts and honeycombing appropriately. 2) Understand thediagnostic significance of honeycombing, septal thickening and other forms of reticulation. 3) Use imagingfeatures to identify and distinguish causes of cystic air spaces including honeycombing, emphysema and cysticlung diseases such as lymphangioleiomyomatosis, langerhans cell histiocystosis, and lymphoid interstitialpneumonia.

Patterns: Nodules and Ground Glass Opacities

Sharyn Leigh Shirley MacDonald MBChB (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) Understand that nodules < 10 mm are seen in many conditions and that the differential diagnosis on HRCT isbased on the size of the nodules, their appearance, and their distribution. 2) Understand that ground glassopacity is a non-specific pattern that reflects the presence of abnormalities below the resolution of HRCT. 3)Understand that the differential diagnosis of ground glass opacity is based on the clinical history (in particularthe duration of symptoms), the distribution of the ground glass opacity, and the presence of associatedabnormalities.

Read Cases with the Experts

Georgeann McGuinness MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) Understand the applications and limitations of HRCT in detecting and characterizing diffuse lung diseasethrough the discussion of expert analysis of unknown cases. 2) Apply correct usage of the HRCT lexicon tospecific findings, to better elucidate pathophysiology and to refine differential considerations, by observingexperts in HRCT approach unknown cases. 3) Develop diagnosis and management algorithms by workingthrough problematic cases with the expert discussions.

SST04

Chest (Dual Energy: Spectral CT/Vascular) Scientific PapersCT BQ VA CH AMA PRA Category 1 Credits ™: 1.50


Fri, Dec 5 10:30 AM - 12:00 PM Location: E451B

ParticipantsModeratorMyrna Cobos Barco Godoy MD, PhD : Nothing to Disclose ModeratorJens Vogel-Claussen MD : Nothing to Disclose

Sub-Events Quantification of MRI Derived Regional Pulmonary Parenchymal Perfusion and Cardiac Function forAssessment of Hemodynamic Changes before and after Pulmonary Endarterectomy in Patients withChronic Thromboembolic Pulmonary Hypertension

Christian Olaf Schoenfeld MD (Presenter): Nothing to Disclose , Serghei Cebotari MD : Nothing to Disclose , Jan Hinrichs MD : Nothing to Disclose , Julius Renne MD : Nothing to Disclose , Marcel Gutberlet DiplPhys : Nothing to Disclose , Andreas Voskrebenzev : Nothing to Disclose , Tobias Welte MD : Nothingto Disclose , Marius Hoeper : Nothing to Disclose , Axel Haverich : Nothing to Disclose , Frank K. Wacker

RC801A

RC801B

RC801C

RC801D

SST04-01

MD : Research Grant, Siemens AG Research Grant, Pro Medicus Limited , Jens Vogel-Claussen MD : Nothingto Disclose

PURPOSE

An established method for treatment of patients with chronic thromboembolic pulmonary hypertension (CTEPH)is pulmonary endarterectomy (PEA). The aim of the study is to evaluate the surgical success after PEA bymeans of cardio-pulmonary MRI.


16 patients (53±17 years; 9 male) with CTEPH were examined with a 1.5T MRI before and 17±12 days afterPEA. After contrast medium bolus administration the lung was evaluated with a dynamic 3D FLASH sequence(TWIST) with an update rate of 1.2s per 3D data set and the pulmonary blood flow (PBF) was determined usinga deconvolution algorithm. Furthermore, the left (LV), right ventricular (RV) function and cardiac mass weredetermined. Mean pulmonary artery pressure (mPAP) was measured before and after PEA by right (r.) heartcatheterization. Means ± SD, paired t-test.

RESULTS

Regional PBF after PEA increased significantly in: total lung parenchyma by 48% (37.3±12.8 to55.1±19.4ml/min/100ml, p=0.001), r. upper lobe (UL) by 29% (p=0.048) (cardiac output (CO) adjusted: 2%(p=0.873), the middle lobe by 70% (p=0.003)(CO adjusted: 30%, p=0.079), the r. lower lobe (LL) to 74%(p=0.003) (CO adjusted: 36% (p=0.02,) lUL by 25% (p=0.01) (CO adjusted: 5% (p=0.653) and the lLL by59% (p<0.001) (CO adjusted: 25% (p=0.008). After PEA RV mass decreased by 17% (46.5 to 38.5g/m²,p=0.006). Ventricular mass index decreased by 19% (0.69 to 0.56, p=0.001) and RV function increased: RVend-diastolic volume by -14.6% (91.0 to 77.7ml/m², p=0.037), RV end-systolic volume by -38% (63.7 to39.5ml/m², p=0.0008), RV ejection fraction by +25% (40.2 to 50.2%, p=0.0004). Cardiac index increased by28% (2.8 to 3.3l/min/m², p=0.01) and LV systolic eccentricity index decreased by 19% (1.84 to 1.49, p=0.02)as a sign of improved pulmonary hemodynamics after PEA. Mean mPAP decreased significantly by 44% (45.4to 25.4 mmHg, p<0.0001) after PEA.

CONCLUSION

Improvement of PBF is observed predominantly in the lower lungs 2 weeks after PEA: Even after adjusting forCO regional PBF improved in bilateral lower lobes and ML. Increased flow after PEA in bilateral upper lobes wasproportional to increased CO in response to decreased pulmonary pressures in our patient cohort.


In patients with CTEPH quantitative cardio-pulmonary MRI is a novel noninvasive clinical tool for comprehensivepatient assessment pre and post PEA.

Evaluation of Monoenergetic Reconstruction on Pulmonary Angiography Using Spectral Detector CT

Andrew Sher MD : Research Grant, Koninklijke Philips NV , Abed Ghandour MD : Nothing to Disclose , Amar Dhanantwari : Employee, Koninklijke Philips NV , Luis Alberto Landeras MD : Institutional Grantsupport, Koninklijke Philips NV , Prabhakar Rajiah MD, FRCR (Presenter): Institutional Research Grant,Koninklijke Philips NV

PURPOSE

Utilize the novel Spectral Detector CT (SDCT) system to retrospectively augment pulmonary arteryenhancement on routine chest CT and assess whether resulting image sets enable diagnostic evaluation ofpulmonary vasculature.


29 patients underwent routine contrast-enhanced chest scans with SDCT (Philips Healthcare) following 70 ml IVcontrast. 21 studies not in ideal angiographic phase were chosen, defined as not achieving attenuation greaterthan 200 HU in the main pulmonary artery. Monoenergetic image sets from 40 to 180 keV were retrospectivelycreated. Images were assessed at fixed window level (30) and width (450). A 5-point scale measuredsubjective evaluation of central and peripheral arterial enhancement and image noise (1=Non-diagnostic,5=Excellent). An ideal image set was chosen, defined as the highest energy set with attenuation greater than200 HU in the main PA and a subjective image evaluation of diagnostically acceptable. At ideal energy, meanattenuation, noise, and signal-to-noise ratios of 9 ROIs throughout the pulmonary vasculature as well assubjective image quality were compared to the standard 120 kVp study. Paired t-test and Wilcoxon signed-ranktest were used for analysis.

RESULTS

The mean optimal monoenergetic level was 53 keV ± 7.3. Optimal reconstructions showed higher attenuationthan 120 kVp studies (241 ± 81 vs. 133 ±53 HU; p<.001). Image noise was significantly higher inmonoenergetic studies (47.7±86.4 vs. 22.6 ±23.7; p<.001), while overall SNR remained significantly higher(13.1 ± 9.5 vs. 10.3 ± 6.4; p <.05). Subjective vascular enhancement within monoenergetic images washigher than 120 kVp images (Central: 4.2 ± .4 vs. 1.9 ± .8; p<.001, Peripheral: 4.6 ±.5 vs. 1.6 ± .7, p<.001).Subjective image noise was higher on monoenergetic images (4.4 ± .7 vs. 4.9 ± .3, p<.05) however all studiesmaintained diagnostic acceptability.

CONCLUSION

Optimal monoenergetic energy reconstruction of routine chest CT obtained on SDCT significantly increasedpulmonary arterial enhancement and SNR, achieving attenuation levels comparable with pulmonaryangiographic exams and maintaining diagnostic acceptability.

SST04-02


SDCT enables creation of an optimal image set of the pulmonary vessels that can allow creation of CTPA from aroutine or low-dose chest CT.

Comparison of 35-second and 100-second Scan Delays for Contrast Enhanced Routine Dual EnergyCT of the Chest: Lesion and Vascular Enhancement

Alexi Otrakji MD (Presenter): Nothing to Disclose , Subba Rao Digumarthy MD : Nothing to Disclose , Roberto Lo Gullo MD : Nothing to Disclose , Jo-Anne O. Shepard MD : Consultant, Agfa-Gevaert Group , Cristy Savage RT : Nothing to Disclose , Mannudeep K. S. Kalra MD : Nothing to Disclose

PURPOSE

To compare performance of routine dual energy chest CT (DECT) for lesion and vascular enhancement at 35and 100 seconds scan delays following administration of intravenous iodinated contrast media.


Our study included 52 adult patients who underwent contrast enhanced routine DECT CT of the chest on dualsource MDCT(Somatom Definition Flash,Siemens)or single source 64-row MDCT(GE 750HD Discovery,GE).Ofthese 26 patients (mean age 64±11years,M:F12:14,mean weights75 ±19 kg)received 80 ml of 370mg%iodinated intravenous contrast(2-3 cc/seconds)and were scanned at 35 second fixed delay.The remaining sex-and gender-matched 26 patients(mean age 67±12years,M:F 12:14,mean weights74 ±19 Kg) were scanned at100 second delay following administration of the same contrast agent(370mg%,80 ml,44ml of contrast injectedat 0.6ml/second followed by 36ml contrast at 1.8ml/second) using the identical DECTtechnique.Blended,monoenergetic(60 kev),and material decomposition image (iodine/ pulmonary blood volumeand virtual non contrast (VNC)) were generated for all patients.HU (in main pulmonary artery (MPA)),CTDI voland DLP were recorded .

RESULTS

There was no significant difference between weights and radiation dose of the patients undergoing DECT at 35-or 100-second scan delay (p>0.1).DECT at 100 seconds demonstrated significantly better contrastenhancement compared to prior CT examinations (in 20/53 pulmonary abnormalities) as compared to DECT at35-second scan delay (better in 16/20).Optimal to excellent quality was noted in DECT at 100 seconds for allimage types (100% Mono60 Kev, iodine, and VNC images)With none to minimal contrast related artifacts inmost patients.There was superior iodine subtraction on VNC images on DECT performed with 100 secondsdelay compared to those at 35 seconds (p<0.0001). Vascular contrast enhancement in MPA at 100 second scandelay 333±137 HU.

CONCLUSION

DECT of the chest at 100 second scan delay allows better lesion enhancement,fewer artifacts and superiorquality of material decomposition images as compared to standard 35 second scan delay.Pulmonary arterialenhancement is not compromised due to split bolus contrast injection technique used for longer scan delays.


Fixed delay split bolus DECT gives enough time for lung lesions to enhance which improves the diagnosticcharacterization of these lesions,without compromising the vascular enhancement.

Spectral CT Characteristics of Iodine, Bismuth, and Tungsten Based Contrast Media with anEnergy-Resolving Photon-Counting Detector

Alex Justin Lewis MD (Presenter): Nothing to Disclose , Felix G. Meinel MD : Nothing to Disclose , Andrew Douglas McQuiston BS : Nothing to Disclose , Bernhard Schmidt PhD : Employee, Siemens AG , Steffen Kappler DIPLPHYS : Researcher, Siemens AG , U. Joseph Schoepf MD : Research Grant, BraccoGroup Research Grant, Bayer AG Research Grant, General Electric Company Research Grant, Siemens AG , Gregor Jost PhD : Employee, Bayer AG , Hubertus Pietsch PhD : Employee, Bayer AG , Christian Canstein: Employee, Siemens AG

PURPOSE

Recently developed energy resolved photon-counting detectors allow high Z materials to be effectivelyseparated based on their absorption characteristics in the energy range of interest. Importantly, this allowscontrast agents (CA) that contain different materials to be separated based on the incident X-ray spectrum.The aim of this study was to evaluate the characteristics and optimal combination of three different contrastagents by using a research prototype CT unit with small pixel counting photon detectors.


To demonstrate proof-of-principle, experimental bismuth, tungsten and iodine CA were introduced into a chestphantom utilizing a two-threshold energy resolved photon-counting detector. Standard tube voltage (120kV)and tube current (80mAs) were applied with a photon counting detector using energy thresholds of 25keV and65keV allowing reconstruction into three energy bins: 25keV to 120keV, 65keV to 120keV and 25keV to 65keV.Region of interest analysis was performed to assess attenuation patterns, contrast to noise ratios and identifyoptimal contrast agent combination for discrimination by the photon counting detector.

RESULTS

SST04-03

SST04-04

The CT acquisitions revealed strong contrast enhancement within the chest phantom with excellent contrast tonoise ratios and differentiation of photon energies for each contrast agent by the photon counting detectors.Contrast materials could be uniquely identified by their characteristic attenuation profile at each energythreshold. Based on attenuation characteristics and contrast to noise ratios, the optimal contrast agentcombination for scanning with photon counting detector CT technology appears to be iodine and tungsten withenergy bins corresponding to an average X-ray energy of 62.5keV and 73keV.

CONCLUSION

The separation of three simultaneously administered contrast agents is feasible with the use of an energyselective, photon counting detector in CT. Spectral CT has the potential to enable distinct characterization ofcontrast agents in a chest phantom with the optimal contrast agent pair being iodine and tungsten withdetector energy bins corresponding to an average X-ray energy of 62.5keV and 73keV.


The separation of contrast agents with different pharmacokinetics utilizing photon counting technology maylend itself to a variety of beneficial applications in future contrast enhanced CT.

Diagnostic Quality and Limitations of Dual Energy CT of the Chest in Large Adult Patients

Alexi Otrakji MD (Presenter): Nothing to Disclose , Mannudeep K. S. Kalra MD : Nothing to Disclose , Efren Jesus Flores MD : Nothing to Disclose , Roberto Lo Gullo MD : Nothing to Disclose , Jo-Anne O. Shepard MD : Consultant, Agfa-Gevaert Group , Subba Rao Digumarthy MD : Nothing to Disclose

PURPOSE

There are little data to support use of DECT of chest in large patients. The purpose of our study was to evaluatethe performance of dual energy routine chest CT in large patients for providing required diagnostic informationand image quality


Our study included 45 patients(M:F 31:14, mean age 53± 13years,mean weight 130±14kg) who underwentcontrast enhanced chest CT using dual energy protocol on 128-slice dual source MDCT(Somatom DefinitionFlash, Siemens) or single source 64-row MDCT (GE 750HD Discovery) scanners. Inclusion criteria for the studyincluded consecutive patients over 114 Kg (>250 lbs) who underwent routine contrast enhanced CT of the chestwith DECT.Following DECT image series were generated for each patient - monoenergetic 60 kev, 100 Kev,pulmonary blood volume (PBV) and virtual non contrast (VNC). All image series were assessed qualitatively forthoracic abnormality, level of pulmonary arterial enhancement, diagnostic quality, image noise, and artifacts.The CTDIvol and DLP were recorded and compared to 60 weight matched patients who underwent routine chestCT with single energy on the same scanners.

RESULTS

Radiation dose for patients who underwent chest DECT(10 ±2.4mGy,350±67mGy.cm) was significantly lower ascompared to the weight matched single energy chest CT(15±2.6mGy, 576±147mGy.cm) (p<0.001).Pulmonaryarterial enhancement was optimal to excellent in 84% patients(38/45) up to lobar level and in 71%(32/45)patients in segmental branches. There was significant reduction in image noise and artifacts at the level of thetracheal carina and diaphragm on 100 Kev images compared to the 60 kev images (p<0.001).There was asignificant improvement in acceptable diagnostic quality with 100 Kev (93%) compared to 60 Kev images(76%).Excellent or optimal diagnostic quality was noted in 80% of patients on PBV and VNC images,but waslimited or suboptimal in other larger patients due to marked beam hardening artifacts

CONCLUSION

Routine chest CT with dual energy technique can provide optimal diagnostic information and diagnostic qualityin most large patients at lower radiation dose compared to the single energy chest CT. 100 kev images arehelpful in reducing noise and artifacts.


Routine chest CT with dual energy technique needs additional higher kev (100) images for obtaining optimaldiagnostic information in large patients.

Iodine Content Measurement with Spectral CT Imaging as a New Quantitative Tool? Assess theEsophageal Microcirculation in Patients with Liver Cirrhosis

Ruyi Bao MD (Presenter): Nothing to Disclose , Zhiyong Li : Nothing to Disclose , Ailian Liu MD : Nothingto Disclose

PURPOSE

To quantitatively investigate the blood flow of esophageal wall and its change induced by liver cirrhosis bymeasuring effective iodine content (eIC) in the lower esophagus with spectral CT imaging.

SST04-05

SST04-06


Thirty-five patients with liver cirrhosis (including 15 cases compensated cirrhosis and 20 cases decompensatedcirrhosis) and sixteen normal volunteers, who had no detectable intrinsic lung and heart disease, underwentGSI scanning to collect iodine-water concentrations with a standard injection protocol. We measured eIC valuesof the esophageal wall in the lower esophagus. The hepatic artery index(HAI)was then calculated by thechanges of the iodine-water concentrations in liver parenchyma from the artery to portal vein phase. Wequantitatively evaluated the difference of eIC values between normal volunteers and different type cirrhosis byT-test and the correlation between eIC values and HAI with pearson correlation test.

RESULTS

Mean eIC values of the esophageal wall in the lower esophagus in decompensated cirrhosis group, compensatedgroup, normal control group were 38.00±11.72, 15.64±9.60 and 11.18±4.62 mg/ml, respectively. Mean eICvalues in decompensated cirrhosis group was significantly higher than that in compensated group (t=5.13,p=0.00) and that in normal group (t=7.14, p=0.00), indicating more blood flow of the esophageal wall bydecompensated cirrhosis. Mean HAI in decompensated and compensated group was 0.28±0.20 and 0.15±0.90respectively. There was strong positive correlation between HAI and mean eIC values (r=0.43, P=0.04).

CONCLUSION

The findings of this study suggest that effective iodine content of the esophageal wall may reflect esophagealblood perfusion, which is useful to quantitatively evaluate esophagus blood flow change and esophageal varicesin patients with liver cirrhosis.


Esophageal varices have been recognized as an important complication in patients with cirrhosis. A betterquantitative evaluation of pathophysiological change underlying cirrhosis helps to guide its treatment. SpectralCT imaging may become a new quantitative tool.

Detection of Pulmonary Embolism on CT: Improvement Using a Model-based IterativeReconstruction Algorithm Compared to a Filtered Back Projection Algorithm

Seth Jay Kligerman MD (Presenter): Author, Reed Elsevier , Kian Lahiji MD : Nothing to Disclose , ChengTing Lin MD : Nothing to Disclose , Jean Jeudy MD : Nothing to Disclose , Robert Daniel Pugatch MD : Nothing to Disclose , Elizabeth Kristine Weihe MD : Author, Amirsys, Inc , Aletta Ann Frazier MD : Nothingto Disclose , Charles S. White MD : Nothing to Disclose , Jeffrey R. Galvin MD : Nothing to Disclose

PURPOSE

To determine if a model-based iterative reconstruction (MBIR) improves diagnostic confidence and detection ofpulmonary embolism (PE) compared to hybrid iterative reconstruction (HIR) and filtered back projection (FBP)reconstructions in patients undergoing CT pulmonary angiography (CTPA).


The study had IRB approval and was HIPPA compliant. 50 patients underwent CTPA at 100kV usingdepartmental protocol. 22/50 patients had studies positive for PE as determined by two radiologists notinvolved in the reader study. The 50 studies were reconstructed with FBP, HIR (iDoseL3, Philips), and MBIR(IMR, Philips). Noise, attenuation, and contrast-to-noise (CNR) were recorded. After image randomization, fivethoracic radiologists and two thoracic radiology fellows graded each study on a scale of 1 (very poor) to 5(ideal) in four categories: diagnostic confidence, noise, PA enhancement and plastic appearance. Readers alsomarked each study for the presence or absence of PE. Parametric and non-parametric data were analyzed witha repeated measures ANOVA and Friedman's ANOVA, respectively. After Bonferroni correction, significance ofpairwise comparisons was set at p<0.0167.

RESULTS

CNR of MBIR (19.7) was signficantly higher than CNR of FBP (7.1) and HIR (10.3, p<0.0001 for both). Pooledsensitivity for detection of PE was 76% (117/154), 78.6% (121.154) and 82.5% (127/154) using FBP, HIR, andMBIR, respectively. With MBIR, detection of PE significantly increased compared to FBP (p=0.016). Detection ofPE was not significantly higher with MBIR than HIR (p=0.045). Due to the non-significant increase in FP studiesusing HIR and MBIR (p=0.153), accuracy with MBIR (88.6%), HIR (87.1%), and FBP (87.7%) was similar.Compared to FBP, MBIR led to a significant subjective increase in diagnostic confidence, noise, andenhancement in 6/7, 6/7, and 7/7 readers, respectively. Compared to HIR, MBIR led to significant subjectiveincrease in diagnostic confidence, noise, and enhancement in 5/7, 5/7, and 5/7 readers, respectively. All sevenreaders graded MBIR as having a significantly increased plastic appearance compared to both FBP and HIR.

CONCLUSION

MBIR led to a significant increase in PE detection compared to FBP. MBIR led to qualitative improvements indiagnostic confidence compared to both FBP and HIR.


In CTPA, MBIR can be safely integrated into clinical practice and can increase detection of PE

Enhancement Characteristics of the CTPA Test Bolus Curve: Use in Predicting Right Ventricular

SST04-07

Enhancement Characteristics of the CTPA Test Bolus Curve: Use in Predicting Right VentricularDysfunction and Mortality in Patients with Acute Pulmonary Embolism

Li Caiying MD, PhD : Nothing to Disclose , Cheng Ting Lin MD : Nothing to Disclose , Seth Jay Kligerman MD : Author, Reed Elsevier , Susie N Hong : Nothing to Disclose , Charles S. White MD (Presenter): Nothing to Disclose

PURPOSE

To evaluate the value of CT pulmonary angiography (CTPA) test bolus curve data to predict mortality in patientswith pulmonary embolism (PE) in comparison with conventional methods of right ventricular (RV) dysfunction.


The study was approved by our IRB and is HIPAA-compliant. We consecutively evaluated each CTPA studyperformed with a test bolus technique in a 2-year period. Time-density curve was derived from each test bolus.For comparison, left and right ventricular dimensions (area, diameter) were measured using CT data. Acardiologist blinded to the clinical and other imaging data reviewed a subset of the correspondingechocardiographic images to assess for RV dysfunction. Demographic data, mode of treatment, and patientoutcome information were gathered using electronic medical records. Test bolus and anatomic data werecorrelated with PE-related mortality.

RESULTS

71 patients (34 men and 37 women, average age 54.4 years) who had a CTPA performed using a test bolustechnique were diagnosed with acute pulmonary embolism. Factors that were significantly correlated withPE-related mortality were: age > 60 years, RV/LV diameter > 1.5, RV/LV area > 1, bolus curve upslope time >6 seconds, and 50% downslope time > 6 seconds. Sensitivity/specificity for the last two parameters were100%/69% and 80%/86%, respectively.

CONCLUSION

Data from the CTPA timing bolus curve provides predictive power similar to that of conventional methods ofassessing right ventricular dysfunction for PE-related mortality.


To the best of our knowledge, scant attention has been paid to the characteristics of the test bolus curve andtheir implications in assessingthe severity of pulmonary embolism. Thus, the purpose of this study is todetermine whether test bolus parameters obtained in conjunction with CTPA have predictive value equal to orgreater than image-based anatomical parameters for predicting PE-relatedmortality.

Assessment of Regional Xenon-ventilation, Perfusion and Ventilation-perfusion Mismatch UsingDual-energy Computed Tomography in COPD Patients

Hye Jeon Hwang MD (Presenter): Nothing to Disclose , Joon Beom Seo MD, PhD : Nothing to Disclose , Sang Min Lee MD : Nothing to Disclose , Sang Young Oh MD : Nothing to Disclose , Namkug Kim PhD : Stockholder, Coreline Soft, Inc , Taekjin Jang : Nothing to Disclose , Jae Seung Lee : Nothing to Disclose , Sei Won Lee : Nothing to Disclose , Yeon-Mok Oh MD, PhD : Nothing to Disclose

PURPOSE

To assessthe feasibility of combined xenon-enhanced ventilation (V) and iodine-enhanced perfusion (Q)dual-energy CT (DECT) for the evaluation of regional V and Q status in COPD.


Fifty-two male patients with COPD (mean age 67.9) were prospectively enrolled. Combined V and Q DECTimaging was performed. Virtual noncontrast image, V map, and Q (pulmonary blood volume) map wereanatomically co-registered with deformable registration and evaluated with in-house software. After thenormalization of the V and Q values of each pixel, V/Qratio map and VQmin map, which is a map of smallervalue between V and Q in each pixel, were additionally generated. For visual analysis, regional V, Q, andV/Qratio pattern was determined as decreased, normal and increased, in combination of the regional diseasepatterns including emphysema, bronchial wall thickening and normal at each segment. Mean V, Q, V/Qratio,VQmin values and standard deviation of V/Qratio (V/Qsd) of each patient were quantified and compared withPFT parameters, such as FEV1, FEV1/FVC, and DLco with Pearson correlation test.

RESULTS

At visual analysis, while segments with normal parenchyma showed matched V/Qratio pattern, segment withbronchial wall thickening commonly showed mismatched pattern. There was no dominant V/Qratio pattern atemphysema area. At quantitative analysis, mean V, Q, V/Qratio, VQmin values showed significant positivecorrelation with PFT parameters (r = 0.290 ~ 0.815, p < 0.05). V/Qsd showed significant negative correlationwith PFT parameters (r = - 0.439 ~ - 0.736, p < 0.001). VQmin values showed the best correlation with PFT (r= 0.483 ~ 0.815, p < 0.001).

CONCLUSION

Visual and quantitative assessment of regional V, Q, V/Qratio, VQmin is feasible with combined V and Q DECTimaging, with significant correlation with PFT results in COPD patients. Assessment of disease pattern atconventional CT images may not represent regional V, Q and V-Q mismatch.

SST04-08

SST04-09

conventional CT images may not represent regional V, Q and V-Q mismatch.


Regional structural abnormities, ventilation and perfusion status can be assessed simultaneously with combinedxenon-enhanced ventilation and iodine-enhanced perfusion DECT.

SPFR61

Friday Imaging Symposium: A Guided Tour for Managing Incidental Findings: Adnexal,Thyroid, Pediatric, Adrenal and Chest Special Courses

PD HN GU CH



Fri, Dec 5 12:30 PM - 3:00 PM Location: E253CD

ParticipantsModeratorLincoln L. Berland MD : Consultant, Nuance Communications, Inc Stockholder, Nuance Communications, Inc

LEARNING OBJECTIVES

1) Appreciate the scope, variety and nature of the problem of incidental findings on imaging studies in multiple contexts and thespecial challenges each present. 2) Better apply a system for managing incidental adnexal lesions, including when to follow orfurther evaluate lesions based on their features, size and on patient factors. 3) Apply criteria for diagnosing and followingincidental adrenal lesions, including when and how to reference information from an ACR White Paper addressing this topic. 4)Assess how new knowledge and techniques developed since publication of the Fleischner criteria in 2005 will lead to changes formanaging incidental pulmonary lesions.

Sub-Events Chest

Reginald F. Munden MD, DMD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES


Adnexal

Susan M. Ascher MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES


Adrenal

William W. Mayo-Smith MD (Presenter): Author with royalties, Reed Elsevier Author with royalties, CambridgeUniversity Press

LEARNING OBJECTIVES


Thyroid Nodules

Edward G. Grant MD (Presenter): Research Grant, Bracco Group Research Grant, General Electric CompanyMedical Advisory Board, Nuance Communications, Inc

LEARNING OBJECTIVES


Pediatrics

R. Paul Guillerman MD (Presenter): Nothing to Disclose

SPFR61A

SPFR61B

SPFR61C

SPFR61D

SPFR61E

R. Paul Guillerman MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES

1) Recognize common or vexing incidental findings encountered in pediatric body imaging, such as lymphoidhyperplasia, brown fat, ectopic thymus, pulmonary nodules, small bowel intussusceptions, duodenal inversum,intraperitoneal free fluid, infantile ovarian cysts, urachal remnants, renal cysts, renal collecting system ectasia,neonatal adrenal masses, testicular microlithiasis, osteochondral irregularities, and hypercellular marrow. 2)Understand the clinical implications of these incidental findings to distinguish which of them can be dismissedand which of them warrant additional investigation or follow-up

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