Thoracic Imaging 2003 - Society of Thoracic Radiology

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CT, ultrasound and MRI are highly sensitive for detecting pleural fluid. Ultrasound is particularly useful in demonstrating septations within loculated collections. SUGGESTED READING Fridlender ZG, Gotsman I. Pleural Effusion. N Engl J Med 2002; 347:1286-1287. Fraser RG, Muller NL, Colman N, Pare PD. Diagnosis of diseases of the chest, 4th ed. Philadelphia: WB Saunders Co., 1999:2739-2779. Light RW. Pleural diseases. 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2001. Petersen JA. Recognition of infrapulmonary pleural infusion. Radiology 1960; 74:34-41. Sahn, SA. The pleura. Am Rev Respir Dis 1988; 138:184-234. Vix VA. Roentgenographic manifestations of pleural disease. Semin Roentgenol 1977; 12:277-286. 81 SUNDAY
SUNDAY 82 Asbestos Related Pleural Disease and Mesothelioma Francine L. Jacobson, M.D., MPH Learning Objectives: Understand sources of exposure to asbestos. Recognize asbestos exposure on radiographs and CT. Review current practice for diagnosis, staging and treatment of malignant pleural mesothelioma (MPM). Exposure to Asbestos Asbestos is a fibrous silicate that had been widely used in commercial applications for its unique combination of attributes. It is strong, flexible, and will not burn. It resists corrosion and is an effective insulator. The three most common varieties are chrysotile, amosite, and crocidolite. Chrysotile fibers, widely used in commerce, are pliable and most often arranged in bundles of cylinders. Asbestos fibers can be combined with binding materials and used in a variety of construction applications. It is estimated that 3000 commercial products, ranging from older plastics and paper products to brake linings, floor tiles, cement pipe, and insulation, have contained asbestos. Asbestos containing materials were used most extensively for fireproofing, insulation, soundproofing and decorating in the United States for thirty years following World War II. Amosite and crocidolite fibers (collectively called amphibole fibers) are like tiny needles. When crushed, asbestos fibers are too small to be seen by the human eye and do not become dust particles. Small and light, the fibers can remain in the air, available to be inhaled, for a long time. The EPA estimates asbestos was included in most of the approximately 107,000 primary and secondary schools and 733,000 public and commercial buildings in the United States. It is estimated that between 1940 and 1980, 27 million Americans had occupational exposure to asbestos. Occupational exposure is greatest among those who work in asbestos mines, mills, factories, shipyards that use asbestos, and those who manufacture and install asbestos insulation. Proximity to such facilities and exposure to the laundry of those occupationally exposed to asbestos also provide significant sources of exposure. Two to six million people in the United States are estimated to currently have significant occupational levels of exposure. Evidence of Exposure to Asbestos Pleural effusion, the earliest radiographic finding, may not be attributed to asbestos exposure, if a chest radiograph is even obtained when it is present. It generally occurs within ten years of exposure and may or may not be present years later when pleural plaques have developed. Upon testing, the effusion is exudative with non-specific findings. It can be hemorrhagic and therefore resolves with diffuse pleural thickening. Further complications include calcification and development of rounded atelectasis. Pleural plaques occur after a latent period of 20-40 years. In approximately 80% of cases, asbestos exposure is known. The plaques consist of acellular collagen bundles primarily involving the parietal pleura and may contain asbestos fibers. For many years it was felt that the fibers reached the parietal pleural by penetrating the visceral pleura, however, they may also reach it via the lymphatics where they incite an inflammatory response. Plaques grow slowly and continue to grow in the absence of continued exposure and without malignant potential. Calcification may occur after 10-20 years. Pleural plaques tend to occur without other stigma of asbestos exposure, such as asbestosis. Pleural plaques may be calcified or not, but chest radiographic criterion of bilateral hemidiaphragmatic calcification remains the radiographic criterion for the diagnosis of asbestos exposure. Pleural plaques may also be seen following middle ribs, and along the spine. These finding are more apparent on CT scans. Malignant Pleural Mesothelioma (MPM) Due to the long latency period, the incidence of MPM has continued to increase in the United States despite the removal of asbestos from commercial use. Two to three thousand cases are now seen per year; MPM is not limited to those with occupational exposure but 6-10% of asbestos workers will develop the disease based on tumorogesesis of amphibole fibers after 35-40 years. The peak years in which patients present are the 6 th to 8 th decades of life, particularly when due to occupational exposure. The occupations involved have been male dominated resulting in 3-6:1 ratio of men to women patients. The onset of symptoms is usually insidious characterized by dyspnea, chest pain, cough and weight loss. Right-sided disease is more common and SVC syndrome and Horner syndrome may also be seen. Hypertrophic osteoarthropathy, clubbing and hypoglycemia may complicate the differentiation of this disease from metastatic adenocarcinoma. Pathologically, this differentiation remains difficult. VATS is recommended for diagnosis (98% sensitivity) with special histochemical stains or ultrastructural analysis. Due to the tendency of the tumor to seed the incision, incisions are planned with an eye to be resected at the time of more definitive treatment. Early in its course, the tumor burden may be relatively small with pleural effusion dominant. While the pleural effusion can be large enough to cause shift of the mediastinum to the contralateral side, decreased volume of the affected hemithorax is far more common. Asbestos pleural plaques are present in approximately 20% of patients. Over time, tumor involving both the parietal and visceral pleural surfaces will progress to encase the lung with reduction in lung volume and fixation of the mediastinum. It will eventually lead to lobulation of pleural masses and invade the contiguous structures including the lung, mediastinum, and chest wall. Distant metastases are a very late phenomenon and very uncommon at initial presentation. The prognosis has improved, particularly for patients with epithelial cell type disease who undergo aggressive multimodality therapy, including extra-pleural pneumonectomy with intra-operative chemotherapy. MPM presenting as a pleural effusion may present for imaging that is routine but not specific to MPM. Once the diagnosis is established, the primary role of imaging is to help select the course of treatment. The decision to perform a procedure such as an extra-pleural pneumonectomy requires confidence that the entire burden of disease can be removed. If the disease cannot be entirely resected, only palliative therapy, such as pleurectomy, will be offered. Sagittal and coronal image planes are most helpful to assess extent of disease, particularly regarding potential invasion of chest wall, mediastinum, diaphragm and abdomen. The modality of the imaging may actually be less important although MRI has been used to provide this multi-planar imaging for several years. MR easily differentiates the separate solid components of disease from pleural effusion. MR does remain limited
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The Society of Thoracic Radiology T
Page 3 and 4: Dear Friends, Welcome to Miami Beac
Page 5 and 6: Continuing Medical Education Credit
Page 7 and 8: Warren B. Gefter, MD University of
Page 9 and 10: Ernest M. Scalzetti, MD SUNY Upstat
Page 11 and 12: Registration Hours Saturday, March
Page 13 and 14: Program Committee Ella A. Kazerooni
Page 15 and 16: Small Airway Disease Americana 3 Mo
Page 17 and 18: Benjamin Felson Memorial Lecture Am
Page 19 and 20: Session 2-B Concurrent Session Clin
Page 21 and 22: Workshops (choose 1) 1:00 - 1:45 D1
Page 23 and 24: Sunday
Page 25 and 26: March 2, 2003 General Session Sunda
Page 27 and 28: SUNDAY 46 One type of direct-readou
Page 29 and 30: CT-PET Imaging Suzanne Aquino, M.D.
Page 31 and 32: SUNDAY 58 an accompanying decreased
Page 33 and 34: SUNDAY 60 Radiofrequency Ablation i
Page 35 and 36: SUNDAY 62 17. Sewell PE, Vance RB.
Page 37 and 38: SUNDAY 64 cal ventilation will be r
Page 39 and 40: SUNDAY 66 radiologic, and histopath
Page 41 and 42: SUNDAY 68 application. The untreate
Page 43 and 44: SUNDAY 70 The Expanded Spectrum of
Page 45 and 46: SUNDAY 72 Hypersensitivity Pneumoni
Page 47 and 48: SUNDAY 74 Small Airway Diseases Mic
Page 49 and 50: SUNDAY 76 The “Head-cheese Sign
Page 51 and 52: SUNDAY 78 “Holes” in the Lung:
Page 53: SUNDAY 80 Pleural Effusions Gerald
Page 57 and 58: SUNDAY 84 Other Pleural Neoplasms S
Page 59 and 60: SUNDAY 86 Image-Guided Therapy of M
Page 61 and 62: Notes 88
Page 63 and 64: March 3, 2003 General Session 7:00
Page 65 and 66: Cardiac MRI: Established Indication
Page 67 and 68: Cardiac MRI: New Developments Gauth
Page 69 and 70: 5. The volume of contrast medium re
Page 71 and 72: Acute Aortic Syndrome Ernest M. Sca
Page 73 and 74: as well as separation of the cusps
Page 75 and 76: Pulmonary Veins: Imaging for Radiof
Page 77 and 78: Imaging of Cardiopulmonary Support
Page 79 and 80: plied to the hollow fibers by an ex
Page 81 and 82: swelling of the entire leg, calf sw
Page 83 and 84: Multi-channel Pulmonary CTA: New Te
Page 85 and 86: terminate scintigrams, CT correctly
Page 87 and 88: CT Strucural and Functional Imaging
Page 89 and 90: curves (TDCs) are generated by manu
Page 91 and 92: 7. Crawford T, Yoon C, Wolfson K, e
Page 93 and 94: 80. Fleischmann D, Rubin GD, Bankie
Page 95 and 96: 127 MONDAY
Page 97 and 98: 129 MONDAY
Page 99 and 100: REFERENCES Bergin CJ, Rios G, King
Page 101 and 102: Notes 134
Page 103 and 104: March 4, 2003 General Session 7:00
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Adult Manifestations of Congenital
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will usually display the limbs of t
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Imaging of the Pericardium Paul L.
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Cardiomyopathy Martin J. Lipton, M.
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TUESDAY 150 Nuclear Cardiology Upda
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TUESDAY 152 ties. The predominant 1
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TUESDAY 154 Imaging protocols: Util
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Manpower Shortage in Radiology: Sol
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159 TUESDAY
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161 TUESDAY
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163 TUESDAY
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NIBIB Update for Thoracic Radiology
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vertically along the right atrium t
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Multidetector Pediatric Chest CT: P
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The Spectrum of Pulmonary Infection
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Immune deficiency occurs frequently
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TUESDAY 180 The Internet and the Pr
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TUESDAY 182 Workshop A1: Lymphoma:
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TUESDAY 184 Digital Images: Camera
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TUESDAY 186 Analysis of Mediastinal
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Unusual Manifestations of Lung Canc
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Wednesday
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March 5, 2003 General Session Wedne
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WEDNESDAY 208 principle is that “
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WEDNESDAY 210 years and a current o
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WEDNESDAY 212 lesions generally mim
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WEDNESDAY 214 capable of studying t
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WEDNESDAY 216 Small T1 Lung Cancer:
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WEDNESDAY 218 REFERENCES Seely JM,
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WEDNESDAY 220 Therefore, radiologis
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WEDNESDAY 222 sectional area varies
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WEDNESDAY 224 Lung Cancer Staging A
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Metastatic Disease to Lung Gordon L
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Thoracic Metastates from Osteosarco
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STR tutorial: Use of MD CT reconstr
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ogenic edema, fat embolism, heroin
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WEDNESDAY 236 Pulmonary Arterial Hy
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WEDNESDAY 238 pathological process,
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Thursday
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THURSDAY 250 Pulmonary Tuberculosis
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THURSDAY 252 1. Clinical criteria:
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THURSDAY 254 AIDS patients are also
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THURSDAY 256 Viral Infection on HRC
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THURSDAY 258 Imaging of Coccidioido
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THURSDAY 260 from the laryngeal sur
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THURSDAY 262 Inflammatory Diseases
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Virtual Endoscopy in the Thorax: Pr
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Notes 269 THURSDAY
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SECOND LEVEL THIRD LEVEL
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