Thoracic Imaging 2003 - Society of Thoracic Radiology

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MONDAY 118 AJRCCM Prospective CTA Validation, 2002 Fortunately, there are some well-constructed and logical studies that confirm the clinical role of CTA- even single slice CTA- and document the accuracy of a negative CTA during follow-up intervals. Lorut et al. reported results in a prospective (n=247) cohort of patients suspected of PE and studied with CTA, V/Q, and d-dimer levels all within 24 hours [18]. Gold standars for diagnosis included: Positive PE: CTA positive or DVT US positive (US was performed only if the if CTA was negative or inconclusive and the VQ was nondiagnostic) Negative PE: CTA negative and one of other stated criteria met The prevalence PE in the cohort was 42%; CT diagnosed 73% of these cases; US 23%; VQ 4% (VQ diagnoses were only in patients who did not undergo CT, US diagnosed DVT, not PE). The mortality rates in patients with (treated) and without (not treated) PE were comparable; recurrent PE /DVT rate was 1-2% in each group. The authors conclude that CTA positive diagnoses are reliable, negative CTA results were never overturned unless by leg ultrasound showing DVT, and that the VQ is superfluous. Outcomes After Negative CTA: European Journal of Radiology, 2001 Several outcomes studies are also now available documenting negligible PE or DVT rates in patients 3-6 months after negative CTA. Gottsater et al. reported 3-month outcomes in 305 patients studied with CTA for possible PE; 61 (20%) had a CTA diagnosis of PE, and 215 of the negative CTA group were followed and not treated. Three (1.4%) of these patients developed DVT or PE; 2 had underlying advanced malignancy and one had COPD [19]. The authors conclude that patient outcomes after negative CTA are no different than outcomes reported after normal VQ or conventional angiography. Outcomes After Negative CTA in High risk Patients, 2001 Ost et al. studied 103 patients who had intermediate or low probability VQ scans and a high clinical suspicion for PE with CTA: 22 were positive, 71 negative, and 10 indeterminate. Only 3 of the 71 patients with negative CTA had a PE in a 6 month follow-up period [20]. Thus, even in these symptomatic patients with non-normal scintigraphy, negative CTA appears to be safe. This has been our clinical experience as well. CONCLUSIONS • CTA has all the desired attributes of a test for PE/DVT • Multi-channel CTA is an angiogram- but better • The accuracy, particularly of multi-channel CTA, exceeds 100% for PE • Multi-channel CTA is the best test for subsegmental (and smaller) clot • CTA allows rapid estimate of clot age and extent • CTA facilitates other diagnoses in the chest and allows leg vein assessment • Perfusion analysis and color volumetric images possible in the near future • Not all CTA is the same: beware simplistic accuracy quotes and meta-analyses • Be suspect of the literature: especially if no radiologist is involved • New research directions: redo all aspects of PE from physiology to treatment REFERENCES 1. Siddique RM, Siddique MI, Rimm AA. Trends in pulmonary embolism mortality in the US elderly population: 1984 through 1991. Am J Public Health 1998; 88(3):478-480. 2. Goldhaber SZ, Hennekens CH, Evans DA, et al. Factors associated with the correct antemortem diagnosis of major pulmonary embolism. Am J Med 1982; 73:822-826. 3. Proctor MC, Greenfield LJ. Pulmonary embolism: diagnosis, incidence, and implications. Cardiovasc Surg 1997; 5(1):77-81. 4. Monreal M, Ruiz J, Olazabal A, Arias A, Roca J. Deep venous thrombosis and the risk of pulmonary embolism: a systematic study. Chest 1992; 102:667-681. 5. Decousus H, Leizorovicz A, Parent F, et al. A clinical trial of vena cava filters in the prevention of pulmonary embolism in patients with proximal deep venous thrombosis. N Engl J Med 1998; 338:409-415. 6. The PIOPED investigators. Value of the ventilation/perfusion scan in acute pulmonary embolism: results of the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED). JAMA 1990; 263:2753-2759. 7. Remy-Jardin M, Remy J, Deschildre F. Diagnosis of pulmonary embolism with spiral CT: comparison with pulmonary angiography and scintigraphy. Radiology 1996; 200:699-706. 8. Quinn MF, Lundell CJ, Klotz TA, et al. Reliability of selective pulmonary arteriography in the diagnosis of pulmonary embolism. AJR 1987; 149:469-471. 9. Stein PD, Henry JW, Relyea B. Untreated patients with pulmonary embolism: outcome, clinical, and laboratory assessment. Chest 1995; 107:931-935. 10. Breslaw BH, Dorfman GS. Ventilation/perfusion scanning for prediction of the location of pulmonary emboli: correlation with pulmonary angiographic findings. Radiology 1992; 185:180-185. 11. Stein PD, Henry JW. Prevalence of acute pulmonary embolism in central and subsegmental pulmonary arteries and relation to probability interpretation of ventilation/perfusion lung scans. Chest 1997; 111:1246-1248. 12. Cross JJL, Kemp PM, Walsh CG, Flower CDR, Dixon AK. A randomized trial of spiral CT and ventilation perfusion scintigraphy for the diagnosis of pulmonary embolism. Clin Radiol 1998; 53:177-182. 13. van Rossum AB, Pattynama PMT, Mallens WMC, Hermans J, Heijerman HGM. Can helical CT replace scintigraphy in the diagnostic process in suspected pulmonary embolism? A retrolective-prolective cohort study focusing on total diagnostic yield. Eur Radiol 1998; 8:90-96. 14. ACCP Consensus Committee on Pulmonary Embolism. Opinions regarding the diagnosis and management of venous thromboembolic disease. Chest 1998; 113:499-504. 15. Rathbun SW, Raskob GE, Whitsett TL. Sensitivity and specificity of helical computed tomography in the diagnosis of pulmonary embolism: a systematic review. Ann Intern Med 2000; 132:227-232. 16. Perrier A, Howarth N, Didier D, Loubeyre P, Unger PF, de Moerloose P, Slosman D, Junod A, Bounameaux H. Performance of helical computed tomography in unselected outpatients with suspected pulmonary embolism. Ann Intern Med 2001; 135(17):88-97. 17. Velmahos GC, Vassiliu P, Wilcox A, Hanks SE, Salim A, Harrel D, Palmer S, Demetriades D. Spiral computed tomography for the diagnosis of pulmonary embolism in critically ill surgical patients: a comparison with pulmonary angiography. Arch Surg 2001; 136(5):505-11. 18. Lorut C, Ghossains M, Horellou MH, Achkar A, Fretault J, Laaban JP. A noninvasive diagnostic strategy including spiral computed tomography in patients with suspected pulmonary embolism. Am J Respir Crit Care Med 2000 Oct;162:1413-8. 19. Gottsater A, Berg A, Centergard J, Frennby B, Nirhov N, Nyman U. Clinically suspected pulmonary embolism: is it safe to withhold anticoagulation after a negative spiral CT? Eur Radiol 2001;11(1):65-72. 20. Ost D, Rozenshtein A, Saffran L, Snider A. The negative predictive value of spiral computed tomography for the diagnosis of pulmonary embolism in patients with nondiagnostic ventilation-perfusion scans. Am J Med 2001;110(1):16-21.
CT Strucural and Functional Imaging of PE U. Joseph Schoepf, M.D. Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School CT Imaging of Pulmonary Embolism: General Considerations Although increasingly sophisticated clinical algorithms for “bed-side” exclusion of Pulmonary Embolism (PE) are being developed, mainly based on a negative d-dimer test 1-4 there is a high and seemingly increasing demand for imaging tests for suspected PE. Some still regard invasive pulmonary angiography as the “gold standard” technique for PE diagnosis, but in reality it is infrequently performed 5-8 . It is perceived as an invasive procedure, although the incidence of complications with contemporary technique is low 9, 10 . More importantly there is accumulating evidence describing the limitations of this technique for the unequivocal diagnosis of isolated peripheral pulmonary emboli: Two recent analyses of the inter-observer agreement rates for detection of subsegmental emboli by selective pulmonary angiography ranged between only 45% and 66% 11, 12 . Given such limitations, use of this test as an objective and readily reproducible tool for the verification of findings at competing imaging modalities as to the presence or absence of PE seems questionable and the status of pulmonary angiography as the standard of reference for diagnosis of PE is in doubt 11, 12 . Use of nuclear medicine imaging, once the first study in the diagnostic algorithm of PE, is in decline 13, 14 due to the high percentage of indeterminate studies (73% of all performed 15 ) and poor inter-observer correlation 16 . Revised criteria for the interpretation of ventilation-perfusion scans 17, 18 and novel technologies in nuclear medicine such as single photon emission tomography (SPECT) 19, 20 can decrease the ratio of indeterminate scintigraphic studies, but cannot offset the limitations inherent to a functional imaging test 21 . Contrast enhanced magnetic resonance (MR) angiography has been evaluated for the diagnosis of acute PE 22-23 . However, the acquisition protocols that are currently available for MR pulmonary angiography lack sufficient spatial resolution for reliable evaluation of peripheral pulmonary arteries 23, 24 . More importantly, this modality has not seen widespread use in the acutely ill patient with suspected PE due to lack of general availability, relatively long examination times and difficulties in patient monitoring. This leaves us with computed tomography (CT), which for most practical purposes has become the first line imaging test after lower extremity ultrasound for the assessment of patients with suspected PE in daily clinical routine. The most important advantage of CT over other imaging modalities is that both mediastinal and parenchymal structures are evaluated, and thrombus is directly visualized 25, 26 . Studies have shown that up to two thirds of patients with an initial suspicion of PE receive another diagnosis 27 , some with potentially life-threatening diseases, such as aortic dissection, pneumonia, lung cancer, and pneumothorax 28 . Most of these diagnoses are amenable to CT visualization, so that in many cases a specific etiology for the patients’ symptoms and important additional diagnoses can be established 21 . The inter-observer agreement for CT is better than for scintigraphy 29 ; in a recent study the inter-observer agreement for the diagnosis of PE was excellent for spiral CT angiography (k= 0.72) and only moderate for ventilation–perfusion lung scanning (k= 0.22) 16 . CT also appears to be the most cost-effective modality in the diagnostic algorithm of PE compared to algorithms that do not include CT, but are based on other imaging modalities (ultrasound, scintigraphy, pulmonary angiography) 30 . Additionally, there are some indications that CT may not only be used for evaluating thoracic anatomy in suspected PE but could also to some degree allow derivation of physiologic parameters on lung perfusion at single-slice, electron-beam and multidetector-row CT 31-33 . The main impediment for the unanimous acceptance of computed tomography as the new modality of choice for the diagnosis of acute PE have been limitations of this modality for the accurate detection of small peripheral emboli. Early studies comparing single-slice CT to selective pulmonary angiography demonstrated CT’s high accuracy for the detection of PE to the segmental arterial level 34-37 but suggested that subsegmental pulmonary emboli may be overlooked by CT scanning. The degree of accuracy that can be achieved for the visualization of subsegmental pulmonary arteries and for the detection of emboli in these vessels with single-slice, dual-slice and electron-beam CT scanners was found to range between 61% and 79% 36, 38- 40 , limitations that are overcome by novel developments in CT technology. Advantages of Multidetector-Row CT for PE Imaging In the last few years CT has seen decisive dynamic developments, mainly brought about by the advent of multidetector-row CT technology 41, 42 . The current generation of 4-slice, 8-slice and16-slice CT scanners now allows for acquisition of the entire chest with 1-mm or sub-millimeter resolution within a short single breath-hold of now less than 10 seconds in the case of 16slice CT. The ability to cover substantial anatomic volumes with high in-plane and through-plane spatial resolution has brought with it a number of clear advantages. Shorter breath-hold times were shown to benefit imaging of patients with suspected PE and underlying lung disease reducing the percentage of nondiagnostic CT pulmonary angiography investigations 43 . The near isotropic nature of high-resolution multidetector-row CT data lends itself to 2-D and 3-D visualization. This may, in some instances, improve PE diagnosis 44 but is generally of greater importance for conveying information on localization and extent of embolic disease to referring clinicians in a more intuitive display format. Probably the most important advantage is improved diagnosis of small peripheral emboli. Single-slice CT has shown that superior visualization of segmental and subsegmental pulmonary arteries can be accomplished with thinner slice widths (e.g. 2-mm versus 3-mm) 38 . However, with single-slice CT the range of coverage with thin slice widths within one breath-hold was limited 38, 40 . The high spatial resolution of 1-mm or submillimeter collimation data sets now allows evaluation of pulmonary vessels down to 6 th order branches 45 and significantly increases the detection rate of segmental and subsegmental pulmonary emboli 46 . This improved detection rate is likely due to reduced volume averaging and the accurate analysis of progressively smaller vessels by use of thinner sections. These results are most striking in peripheral arteries with an anatomic course parallel to the scan plane; such vessels tend to be most affected by volume averaging when thicker slices are used 46 . The high spatial resolution along the scan axis of a thin-collimation multidetector-row CT data set, however, allows an accurate evaluation of the full course of such vessels. The inter-observer correlation for confident diagnosis of subsegmental emboli with high-resolution multidetector-row CT by far exceeds the reproducibility of selective pulmonary angiography 11, 12,46 . 119 MONDAY
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The Society of Thoracic Radiology T
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Dear Friends, Welcome to Miami Beac
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Continuing Medical Education Credit
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Warren B. Gefter, MD University of
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Ernest M. Scalzetti, MD SUNY Upstat
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Registration Hours Saturday, March
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Program Committee Ella A. Kazerooni
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Small Airway Disease Americana 3 Mo
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Benjamin Felson Memorial Lecture Am
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Session 2-B Concurrent Session Clin
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Workshops (choose 1) 1:00 - 1:45 D1
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Sunday
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March 2, 2003 General Session Sunda
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SUNDAY 46 One type of direct-readou
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CT-PET Imaging Suzanne Aquino, M.D.
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SUNDAY 58 an accompanying decreased
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SUNDAY 60 Radiofrequency Ablation i
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Page 37 and 38: SUNDAY 64 cal ventilation will be r
Page 39 and 40: SUNDAY 66 radiologic, and histopath
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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 and 58: SUNDAY 84 Other Pleural Neoplasms S
Page 59 and 60: SUNDAY 86 Image-Guided Therapy of M
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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
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Page 83 and 84: Multi-channel Pulmonary CTA: New Te
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Page 99 and 100: REFERENCES Bergin CJ, Rios G, King
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Page 103 and 104: March 4, 2003 General Session 7:00
Page 105 and 106: Adult Manifestations of Congenital
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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
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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
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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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