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Background In critically ill patients, auscultation might be challenging as dorsal lung fields are difficult to reach in supine-positioned patients, and the environment is often noisy. In recent years, clinicians have started to consider lung ultrasound as a useful diagnostic tool for a variety of pulmonary pathologies, including pulmonary edema. The aim of this study was to compare lung ultrasound and pulmonary auscultation for detecting pulmonary edema in critically ill patients. Methods This study was a planned sub-study of the Simple Intensive Care Studies-I, a single-center, prospective observational study. All acutely admitted patients who were 18 years and older with an expected ICU stay of at least 24 h were eligible for inclusion. All patients underwent clinical examination combined with lung ultrasound, conducted by researchers not involved in patient care. Clinical examination included auscultation of the bilateral regions for crepitations and rhonchi. Lung ultrasound was conducted according to the Bedside Lung Ultrasound in Emergency protocol. Pulmonary edema was defined as three or more B lines in at least two (bilateral) scan sites. An agreement was described by using the Cohen κ coefficient, sensitivity, specificity, negative predictive value, positive predictive value, and overall accuracy. Subgroup analysis were performed in patients who were not mechanically ventilated. Results The Simple Intensive Care Studies-I cohort included 1075 patients, of whom 926 (86%) were eligible for inclusion in this analysis. Three hundred seven of the 926 patients (33%) fulfilled the criteria for pulmonary edema on lung ultrasound. In 156 (51%) of these patients, auscultation was normal. A total of 302 patients (32%) had audible crepitations or rhonchi upon auscultation. From 130 patients with crepitations, 86 patients (66%) had pulmonary edema on lung ultrasound, and from 209 patients with rhonchi, 96 patients (46%) had pulmonary edema on lung ultrasound. The agreement between auscultation findings and lung ultrasound diagnosis was poor (κ statistic 0.25). Subgroup analysis showed that the diagnostic accuracy of auscultation was better in non-ventilated than in ventilated patients. Conclusion The agreement between lung ultrasound and auscultation is poor. Trial registration NCT02912624. Registered on September 23, 2016.

Malignant lymphomas are a heterogenous group of malignancies, belonging to the ten most frequent types of cancers worldwide. Once a malignant lymphoma has been diagnosed, it is important to assess disease extent (staging), because this has prognostic and therapeutic implications. Computed tomography (CT) and 18F-fluoro-2-deoxyglucose positron emission tomography (FDG-PET)/CT are commonly used imaging methods for the staging of malignant lymphoma. An important disadvantage of CT and FDG-PET/CT, however, is the use of ionizing radiation, which may lead to the development of cancers in later life. Although this risk is relatively low, it cannot be ignored, especially in children. Magnetic resonance (MR) imaging does not have this disadvantage, and may be an alternative to CT and perhaps FDG-PET/CT for the evaluation of lymphoma. The aim of this thesis was to introduce and assess the value of whole-body magnetic resonance (MR) imaging, including diffusion-weighted imaging (DWI), for the staging of patients with newly diagnosed malignant lymphoma. Of interest, DWI is an advanced MR technique that may improve the detection and functional evaluation of lymphomatous tissue. In this thesis, new concepts were introduced to perform whole-body MR imaging studies, including whole-body DWI. It was shown that noninvasive measurement of diffusivity in lymph nodes by means of DWI is challenging in terms of observer agreement, but it could potentially aid in the discrimination between normal and lymphomatous lymph nodes. Unfortunately, whole-body MR imaging with DWI was found insufficiently reliable to replace bone marrow biopsy (BMB) for the assessment of the bone marrow for lymphomatous involvement. Nevertheless, it may increase the diagnostic yield of BMB alone, although this hypothesis requires further investigation. Head-to-head comparisons of whole-body MR imaging/DWI to CT and whole-body MR imaging/DWI to FDG-PET/CT in patients with newly diagnosed malignant lymphoma showed that these techniques are mostly in agreement with regard to Ann Arbor staging. However, disagreements in staging between the different imaging methods occurred; future studies are required to determine the rates at which whole-body MR imaging/DWI provides correct up- or downstaging in these cases. In addition, although DWI correctly changed Ann Arbor stage in several cases, further research is warranted to determine its additional diagnostic value. Finally, it was shown that future MR imaging studies may be limited to the head/neck and trunk, because in a series of 100 patients, whole-body MR imaging did not detect any clinically relevant lesions (i.e. lesions that change Ann Arbor stage) outside the head/neck and trunk. In conclusion, whole-body MR imaging, including DWI, is a feasible technique for staging newly diagnosed malignant lymphoma, and may be readily applied in those populations in which CT radiation is a major issue and in patients at risk for (severe) adverse reactions to CT contrast agents. However, further technical developments and prospective large-scale studies on staging performance are required before whole-body MR imaging will become a widespread accepted alternative to CT and FDG-PET/CT

Diffusion-weighted magnetic resonance imaging (DWI) provides functional information and can be used for the detection and characterization of pathologic processes, including malignant tumors. The recently introduced concept of “diffusion-weighted whole-body imaging with background body signal suppression” (DWIBS) now allows acquisition of volumetric diffusionweighted images of the entire body. This new concept has unique features different from conventional DWI and may play an important role in wholebody oncological imaging. This review describes and illustrates the basics of DWI, the features of DWIBS, and its potential applications in oncology.

The lymphomas comprise approximately 5.0% of all malignancies and are the sixth most frequently occurring type of cancer in the Western world. The World Health Organization International Classification of Tumors recognizes more than 50 subtypes of lymphoma, based on histopathologic, immunohistochemical, cytogenetic, and molecular analyses. However, the three most common subtypes diffuse large B-cell lymphoma (DLBCL), follicular lymphoma, and Hodgkin lymphoma account for more than 60% of all cases. Computed tomography (CT), 18F-fluoro-2-deoxyglucose positron emission tomography (FDG-PET) and whole-body magnetic resonance imaging (MRI) are imaging techniques that may be used for several purposes in lymphoma management. The aim of this thesis was to explore the role of imaging in lymphoma in five different domains: the role of imaging in the evaluation of the bone marrow, the role of imaging in pretreatment risk assessment, the role of imaging in therapy response assessment, the role of imaging in lymphoma grading, and the role of imaging from the patient's perspective. The results show that FDG-PET is reasonably sensitive for the detection of bone marrow involvement in Hodgkin lymphoma. However, the role of FDG-PET in the evaluation of the bone marrow in DLBCL and follicular lymphoma is limited. Initial results show whole-body MRI to be comparable to FDG-PET for bone marrow assessment, but more research is needed to define its exact role. In DLBCL, tumor necrosis at baseline appears to be an independent risk factor of the NCCN-IPI score. Interim FDG-PET has some prognostic value in advanced-stage Hodgkin lymphoma, but it has no role in early-stage Hodgkin lymphoma, DLBCL and follicular lymphoma. End-of-treatment FDG-PET fails to identify a large proportion of patients with Hodgkin lymphoma and DLBCL who will experience treatment failure, which emphasizes that its role in this setting should be reconsidered, if not abandoned. Moreover, there is no evidence-based role for FDG-PET in the end-of-treatment evaluation of follicular lymphoma. FDG-PET performed at baseline is reasonably accurate in differentiating aggressive non-Hodgkin lymphoma from indolent non-Hodgkin lymphoma and Hodgkin lymphoma, but appears to be not reliable in differentiating indolent non-Hodgkin from Hodgkin lymphoma. Finally, patients with newly diagnosed lymphoma regard whole-body MRI as a more patient-friendly technique than CT.