Thoracic Imaging 2003 - Society of Thoracic Radiology

More documents

Recommendations

Info

TABLE: CLASSIFICATION OF PLEURAL NEOPLAMS OTHER THEN MALIGNANT MESOTHELIOMA PRIMARY Neoplastic Localised fibrous tumour of the pleura Multiple benign fibromas Calcifying fibrous pseudotumour Adenomatoid tumour Desmoplastic small round cell tumour Pleural lymphoma (pyothorax-associated /bodycavity based lymphoma) Non-neoplastic Thoracic splenosis Endometriosis Fibrin body Amyloid SECONDARY Metastatic adenocarcinoma (breast, lung, ovary, stomach, large bowel, kidney) Malignant thymoma Lymphoma Melonoma Sarcomas REFERENCES (1) Stout AP, Murray MR. Localized pleural mesothelioma: investigation of its characteristics and histogenesis by the method of tissue culture. Arch Pathol 1942; 34:951-964. (2) Leung AN, Müller NL, Miller RR. CT in differential diagnosis of diffuse pleural disease. AJR 1990; 154:487-492. (3) Boutin C, Rey F. Thoracoscopy in pleural malignant mesothelioma: a prospective study of 188 consecutive patients. Part 1: diagnosis. Cancer 1993; 72:389-393. (4) Menzies R, Charbonneau M. Thoracoscopy for the diagnosis of pleural disease. Ann Intern Med 1991; 114:271-276. (5) Mathur P, Martin WJII. Clinical utility of thoracoscopy. Chest 1992; 102(1):2-4. FURTHER READING: Desai SR, Wilson AG. Pleural and Pleural Disorders. In: Imaging of Diseases of the Chest. Armstrong P, Wilson AG, Dee P, Hansell DM eds. 3rd Edn. Mosby, St Louis Corrin B. Pleura and Chest Wall. In: Pathology of the Lung. Churchill Livingston, London 85 SUNDAY
SUNDAY 86 Image-Guided Therapy of Malignant Pleural Effusions H. Page McAdams, M.D. Learning Objectives: At completion of this lecture, the attendee will be able to: 1. Describe indications for image-guided treatment of malignant pleural effusions. 2. Explain image-guided treatment of malignant pleural effusions. 3. Discuss the use of fibrinolytic and sclerosing agents for management of malignant pleural effusions. Definition: Malignant pleural effusions are common in cancer patients with advanced disease. Approximately 50% of patients with breast carcinoma, 25% of patients with lung carcinoma and 35% of patients with lymphoma develop a malignant effusion during the course of their disease. Patients with malignant effusions present with progressive dyspnea, cough, and chest pain that compromises their quality of life. Treatment Options: Treatment options depend on the extent of disease, effectiveness of systemic therapy, and patient performance status. Pleural effusions in patients with lymphoma, small cell lung cancer or germ cell malignancies may be controlled by systemic treatment alone. Patients with pleural metastatic disease refractory to systemic therapy may require palliative treatment to improve their quality of life. Therapeutic options include thoracentesis, large bore tube thoracostomy and sclerotherapy, and thoracoscopic instillation of sclerosing agents such as talc. Numerous studies have now shown that malignant effusions can be effectively managed by image-guided small bore catheter drainage and sclerotherapy. Imaging guidance is particularly useful in these patients both for localizing pleural abnormalities and for avoiding unnecessary procedures in patients with central obstructing masses, a thick pleural peel, or multiple loculated fluid pockets. Tube Placement: We typically place our catheters in the mid-axillary line at the sixth or seventh interspace using either US or fluoroscopic guidance and adequate conscious sedation. The skin entrance site is marked and prepped using aseptic technique. The skin is anesthetized with 1% topical lidocaine and an 18 gauge trocar needle is placed directly into the pleural space. Fluid is aspirated to confirm the intrapleural location of the needle. A 0.38, 100 cm floppy-tip guidewire is then fed through the needle to guide tube placement and to mechanically break up pleural adhesions. With the guidewire in position, progressive dilation of the drainage tract is performed and a 14 French pig tail catheter is inserted. The chest tube is then secured by a catheter retention device and up to 1 liter of fluid is immediately aspirated. If the patient begins to cough or complain of increased shortness of breath during aspiration, we discontinue further aspiration. A post tube placement radiograph is obtained to assure proper placement of the tube. Up to 30% of patients will have a pneumothorax on the post tube placement films. This is usually due to an ‘ex vacuo’ phenomenon and will resolve over the next few days. When the patient is returned to the ward, the tube is connected to a Pleur-evac with continuous wall suction at 20 to 25 cm H 2 O. Daily tube outputs are recorded and tubes are flushed with 10 cc of normal saline every 8 -12 hours. Patients are seen each day to assure that the tube is functioning properly. Daily chest radiographs are not obtained when drainage continues without difficulty. When drainage decreases to 150-200 cc in a 24-hour period, a chest radiograph is performed to exclude loculated fluid and to assure complete lung re-expansion. It is important that the pleural fluid is completely drained and that the lung is completely re-expanded prior to instillation of the sclerosing agent. Sclerotherapy: Once the pleural space has been drained (usually 2 to 5 days), a sclerosing agent is infused. The most common agents are doxycycline, bleomycin or a sterile talc slurry. The dosage for doxycycline is 500 mg in 100 cc of normal saline. The dosage for Bleomycin is 60 units in 100 cc of D5W. The dosage for talc is 5 grams in 100 cc saline. Although no single sclerosant has been shown to have a clear advantage over the others, we are currently using talc because it is both effective and inexpensive. We usually add 10 cc of a one percent lidocaine solution to the talc slurry for pain control. Most patients require some degree of pain control and sedation during instillation of either talc or doxycycline. Pain is the most common complication of sclerotherapy. A small percentage of patients develop systemic complaints such as fever after bleomycin or talc instillation. There are rare reports of serious reactions, including ARDS and death, following instillation of large amounts of talc, usually 10 grams or greater. After the sclerosing agent is instilled, the tube is closed to suction and the patient is instructed to change positions every 15 minutes for 2 hours in order to evenly distribute the sclerosant throughout the pleural space. The tube is then reopened to suction until the following day when the tube is removed if overnight drainage is less than 200 cc. Repeat sclerosis is recommended if the overnight drainage is greater than 200 cc. Complications: Complications are unusual and include tube malfunction (e.g., clotting or kinking) or malposition, infection, loculation, pneumothorax and re-expansion pulmonary edema (see below). Tubes with decreased drainage are flushed with saline, heparin or streptokinase to determine patency; guide wire insertion is occasionally required to re-establish tube patency. If the tube is severely kinked or clotted, it may have to be replaced. If the pleural fluid is loculated, multiple drainage catheters may be required. We have also found that fibrinolytic agents such as streptokinase are quite useful for managing complex or loculated collections. We typically instill 250,000 U of streptokinase mixed in 100 cc of normal saline directly into the pleural space. The tube is then closed for 2 hours to allow the fibrinolytic agent to distribute throughout the pleural space and is thereafter reopened to continuous suction. We repeat instillation on a daily basis as needed. The choice of fibrinolytic agent is controversial. While streptokinase is less expensive than either urokinase or tPA, it is antigenic and can cause fever in up to 28% of treated patients. Urokinase is non-antigenic, does not cause fever, and may be slightly more effective than streptokinase. The dosage for Urokinase is 100,000 units in 100 cc of normal saline. Unfortunately, Urokinase is not currently available for intrapleural injection in the United States. Experience with tPA in the pleural space is limited.
Page 1 and 2:
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 and 54: SUNDAY 80 Pleural Effusions Gerald
Page 55 and 56: SUNDAY 82 Asbestos Related Pleural
Page 57: SUNDAY 84 Other Pleural Neoplasms S
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
Page 105 and 106: Adult Manifestations of Congenital
Page 107 and 108: will usually display the limbs of t
Page 109 and 110:
Imaging of the Pericardium Paul L.
Page 111 and 112:
Cardiomyopathy Martin J. Lipton, M.
Page 113 and 114:
TUESDAY 150 Nuclear Cardiology Upda
Page 115 and 116:
TUESDAY 152 ties. The predominant 1
Page 117 and 118:
TUESDAY 154 Imaging protocols: Util
Page 119 and 120:
Manpower Shortage in Radiology: Sol
Page 121 and 122:
159 TUESDAY
Page 123 and 124:
161 TUESDAY
Page 125 and 126:
163 TUESDAY
Page 127 and 128:
NIBIB Update for Thoracic Radiology
Page 129 and 130:
vertically along the right atrium t
Page 131 and 132:
Multidetector Pediatric Chest CT: P
Page 133 and 134:
The Spectrum of Pulmonary Infection
Page 135 and 136:
Immune deficiency occurs frequently
Page 137 and 138:
TUESDAY 180 The Internet and the Pr
Page 139 and 140:
TUESDAY 182 Workshop A1: Lymphoma:
Page 141 and 142:
TUESDAY 184 Digital Images: Camera
Page 143 and 144:
TUESDAY 186 Analysis of Mediastinal
Page 145 and 146:
Unusual Manifestations of Lung Canc
Page 147 and 148:
Wednesday
Page 149 and 150:
March 5, 2003 General Session Wedne
Page 151 and 152:
WEDNESDAY 208 principle is that “
Page 153 and 154:
WEDNESDAY 210 years and a current o
Page 155 and 156:
WEDNESDAY 212 lesions generally mim
Page 157 and 158:
WEDNESDAY 214 capable of studying t
Page 159 and 160:
WEDNESDAY 216 Small T1 Lung Cancer:
Page 161 and 162:
WEDNESDAY 218 REFERENCES Seely JM,
Page 163 and 164:
WEDNESDAY 220 Therefore, radiologis
Page 165 and 166:
WEDNESDAY 222 sectional area varies
Page 167 and 168:
WEDNESDAY 224 Lung Cancer Staging A
Page 169 and 170:
Metastatic Disease to Lung Gordon L
Page 171 and 172:
Thoracic Metastates from Osteosarco
Page 173 and 174:
STR tutorial: Use of MD CT reconstr
Page 175 and 176:
ogenic edema, fat embolism, heroin
Page 177 and 178:
WEDNESDAY 236 Pulmonary Arterial Hy
Page 179 and 180:
WEDNESDAY 238 pathological process,
Page 181 and 182:
Thursday
Page 183 and 184:
THURSDAY 250 Pulmonary Tuberculosis
Page 185 and 186:
THURSDAY 252 1. Clinical criteria:
Page 187 and 188:
THURSDAY 254 AIDS patients are also
Page 189 and 190:
THURSDAY 256 Viral Infection on HRC
Page 191 and 192:
THURSDAY 258 Imaging of Coccidioido
Page 193 and 194:
THURSDAY 260 from the laryngeal sur
Page 195 and 196:
THURSDAY 262 Inflammatory Diseases
Page 197 and 198:
Virtual Endoscopy in the Thorax: Pr
Page 199 and 200:
Notes 269 THURSDAY
Page 201:
SECOND LEVEL THIRD LEVEL
show all

Thoracic Imaging 2003 - Society of Thoracic Radiology

Create successful ePaper yourself

Delete template?

Save as template?