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In this study, we investigated the microstructural evolution, surface hardening and general corrosion properties of a precipitation-strengthened Inconel 718 Ni-superalloy after triode-plasma nitriding (TPN) at low treatment temperatures of 400–450 °C (i.e. thermodynamic paraequilibrium conditions) and a high treatment temperature of 700 °C. At low treatment temperatures, apart from the formation of nitrogen-expanded austenite (γN) from the high-Cr γ matrix, the pre-existing γ′ and γ″ intermetallic nano-precipitates appear to exhibit different nitriding responses. The spheroidal N-modified γ′ (or γ′N) precipitates were ‘slightly-expanded’, leading to slightly shifted XRD peaks, i.e. 2-theta angles of ~0.2° from γsubstrate(111) and ~0.5° from γsubstrate(200). In contrast, N-modified γ″ (or γ″N) could experience substantial lattice expansion close to that of the γN matrix. With increasing treatment temperature, nitride formation started as additional nano-sized precipitates (e.g. ~3–6 nm diameter as observed at 450 °C) and grew into laths (e.g. ~5–10 nm thick and ~15–30 nm wide as observed at 700 °C). Without changing core microstructure/properties, surface nitrogen modification and hardening were obtained on alloy 718 after TPN (e.g. from ~486 HV0.025 to ~1212 HV0.025 after TPN at 400 °C). No degradation of corrosion performance was observed for the nitrogen-supersaturated surface after TPN at 400 °C. However, the 450 °C TPN-treated surface showed a slightly increased current density in the anodic region, which can be associated with early-stage nitride formation. The significantly deteriorated corrosion performance after TPN treatment at 700 °C is due to pronounced nitride formation and segregation of substitutional alloying elements.

Objectives: To determine if radiological response to pre-operative radiotherapy is related to oncologic outcome in patients with extremity soft tissue sarcomas (STSs). Methods: 309 patients with extremity STS who underwent pre-operative radiation and wide resection were identified from a prospective database. Pre- and post-radiation MRI scans were retrospectively reviewed. Radiological response was defined by the modified Response Evaluation Criteria in Solid Tumours. Local recurrence-free, metastasis-free (MFS) and overall survival (OS) were compared across response groups. Results: Tumour volume decreased in 106 patients (34.3%; PR - partial responders), remained stable in 97 (31.4%; SD - stable disease), increased in 106 (34.3%; PD - progressive disease). The PD group were older (p = 0.007), had more upper extremity (p = 0.03) and high-grade tumours (p < 0.001). 81% of myxoid liposarcomas showed substantial decrease in size. There was no difference in initial tumour diameter (p = 0.5), type of surgery (p = 0.5), margin status (p = 0.4), or complications (p = 0.8) between the three groups. There were 10 (3.2%) local recurrences with no differences between the three response groups (p = 0.06). 5-year MFS was 52.1% for the PD group vs 73.8 and 78.5% for the PR and SD groups, respectively (p < 0.001). OS was similar (p < 0.001). Following multivariable analysis, worse MFS and OS were associated with higher grade, larger tumour size at diagnosis and tumour growth following pre-operative radiation. Older age was also associated with worse OS. Conclusion: STS that enlarge according to Response Evaluation Criteria in Solid Tumour criteria following pre-operative radiotherapy identify a high risk group of patients with worse systemic outcomes but equivalent local control. Advances in knowledge: Post-radiation therapy, STS enlargement may identify patients with potential for worse systemic outcomes but equivalent local control. Therefore, adjunct therapeutic approaches could be considered in these patients.

We hypothesize that the incidence of screen-detected lung cancer (LC), in participants with previously negative scans, will be highest in the cohort with the highest baseline risk score.Individuals with negative baseline screening results from the Princess Margaret International Early Lung Cancer Action Program before 2009 underwent low-dose computed tomography rescreening from 2015 to 2018. Individuals were contacted in order of descending risk, as determined by the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial's PLCOOf the 1261 participants we attempted to re-contact, 359 participants returned for a rescreening scan (mean of 7.6 years between scans). Participants were divided into low (2%), moderate (≥2% to3.5%), and high baseline risk (≥3.5%) cohorts. On average, those in the high-risk cohort compared to the moderate- and low-risk cohorts were older (66 years versus 62 and 59 years) and had a greater smoking history (54 pack-years versus 47 and 29 pack-years). The incidence of cancer in the high-risk cohort was significantly higher than in the moderate-risk cohort (11% versus 1.7%, p = 0.002).There was a significantly higher incidence of LC in the high-risk cohort than in the moderate-risk cohort. The cut-point between the high- and moderate-risk was determined to be greater than or equal to 3.5% of the 6-year baseline risk.

This study identifies participants ineligible for lung cancer screening with the greatest likelihood of future eligibility. Lung cancer risk in participants enrolled in longitudinal lung screening was assessed using the Prostate, Lung, Colorectal and Ovarian lung cancer risk calculator (PLCOm2012) at two timepoints: baseline (T1) and follow-up (T2). Separate analyses were performed on four PLCOm2012 eligibility thresholds (3.25%, 2.00%, 1.50%, and 1.00%); only participants with a T1 risk less than the threshold were included in that analysis. Cox-models identified T1 risk factors associated with screen-eligibility at T2. Three models, applying differing assumptions of participant behavior, predicted future eligibility and were benchmarked against the observed cohort. Nine hundred and fifty-six participants had a T1 risk 30 years, current smokers, less educated participants, and those with chronic obstructive pulmonary disease (COPD) at T1 were significantly more likely to become screen-eligible. New diagnoses of COPD and/or non-lung cancers between T1 and T2 precipitated eligibility in a subset of participants. The prediction model that assumed health behaviors observed at T1 continued to T2 reasonably predicted changes in lung cancer risk. This prediction model and the identified baseline risk factors can identify screen-ineligible participants who should be closely followed for future eligibility.

Background Radiological assessment of patients with chronic thromboembolic pulmonary hypertension (CTEPH) is critical to decide whether patients should be treated with pulmonary endarterectomy (PEA). Although computed tomography pulmonary angiography (CTPA) is increasingly used for decision making in CTEPH, the value of CTPA to predict surgical findings and outcome has never been explored. Methods We retrospectively reviewed 100 consecutive patients with high-quality CTPA undergoing PEA for CTEPH between May 2015 and December 2017. The most proximal level of disease in the pulmonary artery on CTPA was classified by two blinded radiologists as level 1 (main pulmonary artery), 2a (lobar pulmonary artery), 2b (origin of basal segmental pulmonary artery), 3 (segmental pulmonary artery) or 4 (predominantly subsegmental pulmonary artery). Results CTPA demonstrated level 1 in 20%, level 2a in 43%, level 2b in 11%, level 3 in 23% and level 4 in 3%. A majority of males presented with level 1 (55%) and level 2 (57%), and a majority of females (83%) with level 3 (p=0.01). Levels 3 and 4 were associated with longer duration of circulatory arrest (p=0.03) and higher frequency of Jamieson type III disease at surgery (p, High-quality CTPA provides accurate evaluation of CTEPH patients. The level of disease on CTPA can predict surgical difficulty and the need for targeted PH therapy after PEA. https://bit.ly/317ZBSu

To compare a novel thick-slab projection technique for ultra-low dose computed tomography (CT; thoracic tomogram) with conventional chest x ray with respect to 13 diagnostic categories.With the approval of the institutional ethics board, a dataset was retrospectively collected of 22 consecutive patients who had undergone a clinically requested emergency room conventional chest x ray (CXR) and a same-day standard-of-care non-contrast CT. Scanner specific noise was added to the CT images to simulate a target dose of 0.18 mSv. A novel algorithm was used to post-process CT images as coronal isotropic reformats by applying a voxel-based, locally normalized weighted-intensity projection to generate 2 cm thick slabs with 1 cm overlap. Three chest radiologists with no prior training for the study reviewed the CXR and thoracic tomogram for each case and assessed each diagnostic category (pneumonic infiltrates, pulmonary edema, interstitial lung disease, nodules 5 mm, nodules 5 mm, pleural effusion, pericardial effusion, heart size, acute bone fractures, foreign bodies, pneumothorax, mediastinal vessel diameter, free abdominal air) on a Likert scale from -4 (definitely absent/normal) to +4 (definitely present/abnormal). MRMC ROC curves were generated for each category. Time for interpretation and subjective image quality score (0-10) were also assessed.For focal lung disease (pneumonic infiltrates, nodules 5 mm, nodules 5mm), the area under the ROC curve (AUC) was significantly higher for thoracic tomograms than CXR (0.803 vs 0.648, respectively, P = 0.02). For non-focal lung disease (pulmonary edema, interstitial lung disease) and effusions (pulmonary, pericardial), the AUC was larger for thoracic tomograms than CXR but the difference did not reach significance (0.870 vs 0.833, P = 0.141; and 0.823 vs 0.752, P = 0.296, respectively). For acute bone fractures and foreign bodies, the AUC was smaller for thoracic tomograms than CXR, the difference was however not significant (0.491 vs 0.532, P = 0.42; and 0.871 vs 0.971, P = 0.39, respectively). Other diagnostic categories had no true positive cases in the dataset. The mean time for interpretation for each was 36.9 and 24.0 s with standard deviations of 0.857 and 5.977. The image quality score for each was 8.2 and 7.8 with standard deviations of 0.970 and 1.614.Thoracic tomograms were found to be diagnostically superior to CXR for focal lung disease, at no increased radiation dose. The thoracic tomogram presents an opportunity to improve the standard-of-care for patients who would otherwise receive a conventional CXR.

Background Supine or prone positioning of the patient on the gantry table is the current standard of care for CT-guided lung biopsy; positioning biopsy side down was hypothesized to be associated with lower pneumothorax rate. Purpose To assess the effect of positioning patients biopsy side down during CT-guided lung biopsy on the incidence of pneumothorax, chest drain placement, and hemoptysis. Materials and Methods This retrospective study was performed between January 2013 and December 2016 in a tertiary referral oncology center. Patients undergoing CT-guided lung biopsy were either positioned in (a) the standard prone or supine position or (b) the lateral decubitus position with the biopsy side down. The relationship between patient position and pneumothorax, drain placement, and hemoptysis was assessed by using multivariable logistic regression models. Results A total of 373 consecutive patients (mean age ± standard deviation, 68 years ± 10), including 196 women and 177 men, were included in the study. Among these patients, 184 were positioned either prone or supine depending on the most direct path to the lesion and 189 were positioned biopsy side down. Pneumothorax occurred in 50 of 184 (27.2%) patients who were positioned either prone or supine and in 20 of 189 (10.6%) patients who were positioned biopsy side down (P < .001). Drain placement was required in 10 of 184 (5.4%) patients who were positioned either prone or supine and in eight of 189 (4.2%) patients who were positioned biopsy side down (P = .54). Hemoptysis occurred in 19 of 184 (10.3%) patients who were positioned prone or supine and in 10 of 189 (5.3%) patients who were positioned biopsy side down (P = .07). Prone or supine patient position (P = .001, odds ratio [OR] = 2.7 [95% confidence interval {CI}: 1.4, 4.9]), emphysema along the needle path (P = .02, OR = 2.1 [95% CI: 1.1, 4.0]), and lesion size (P = .02, OR = 1.0 [95% CI: 0.9, 1.0]) were independent risk factors for developing pneumothorax. Conclusion Positioning a patient biopsy side down for percutaneous CT-guided lung biopsy reduced the incidence of pneumothorax compared with the supine or prone position. © RSNA, 2019.

Background CT-guided microcoil localization has been shown to reduce the need for thoracotomy or video-assisted thoracoscopic surgery (VATS) anatomic resection. However, only short-term follow-up after CT-guided microcoil localization and lung resection has been previously reported. Purpose To assess the diagnostic utility and recurrence-free survival over a minimum of 2 years following CT-guided microcoil localization and VATS. Materials and Methods Among 1950 VATS procedures performed in a single tertiary institution from October 2008 through April 2016, 124 consecutive patients with CT-guided microcoil localization were retrospectively evaluated. Patient demographics, nodule characteristics, and histopathologic findings were recorded. The primary end point was recurrence-free survival after 2 or more years of CT surveillance. Statistical analysis included Kaplan-Meier survival curves and Cox regression. Results In 124 patients (men, 35%; mean age, 65 years ± 12) with a nodule found at CT, microcoil localization and VATS resection were performed for a total of 126 nodules (mean size, 13 mm ± 6; mean distance to pleura, 20 mm ± 9). On presurgical CT evaluation, 42% (53 of 126) of nodules were solid, 33% (41 of 126) were ground glass, and 24% (30 of 126) were subsolid. VATS excisional biopsy altered cytopathologic diagnosis in 21% (five of 24) of patients with prior diagnostic premicrocoil CT-guided biopsy. At histopathologic examination, 17% (21 of 126) of the nodules were adenocarcinoma in situ, 17% (22 of 126) were minimally invasive adenocarcinoma, 30% (38 of 126) were invasive lung primary tumors, and 22% (28 of 126) were metastases. Among the 72 patients with malignancy at histopathologic examination and at least 2 years of CT surveillance, local recurrence occurred in 7% (five of 72), intrathoracic recurrence in 22% (16 of 72), and extrathoracic recurrence in 18% (13 of 72) after 2 or more years of CT surveillance. There was no recurrence for adenocarcinoma in situ, minimally invasive adenocarcinoma, or invasive lung tumors measuring less than 1 cm. After multivariable adjustment, nodule location at a distance greater than 10 mm from the pleura was an independent predictor of time to recurrence (hazard ratio, 2.9 [95% confidence interval: 1.1, 7.4]; P = .03). Conclusion CT-guided microcoil localization and video-assisted thoracoscopic surgical resection alter clinical management and were associated with excellent recurrence-free survival for superficial premalignant, minimally invasive, and small invasive lung tumors. © RSNA, 2019 Online supplemental material is available for this article.

BACKGROUND. Multimodality therapy with preoperative radiation (RT) followed by extrapleural pneumonectomy (EP) for patients with operable malignant pleural mesothelioma (MPM) has demonstrated encouraging results. At relapse, there are few data on the tolerance and efficacy of systemic therapies after prior multimodality therapy. MATERIALS AND METHODS. We conducted a retrospective analysis of patients with relapsed MPM after RT and EPP ± adjuvant chemotherapy to determine overall survival (OS; date of relapse to death) and the proportion of patients that received systemic therapy and associated response rate (RR). OS was estimated using Kaplan–Meier method and potential prognostic variables were examined. RESULTS. Fifty‐three patients were included (2008–2016). Median OS was 4.8 months (median follow‐up 4.4 months, range 0.03–34.8). Eastern Cooperative Oncology Group (ECOG) performance status (PS) ≥2, disease‐free interval (DFI)

Introduction HER2 mutations occur in 1–3% of lung adenocarcinomas. With increasing use of next-generation sequencing at diagnosis, more patients with HER2-mutant tumours present for treatment. Few data are available to describe the clinical course and outcomes of these patients when treated with afatinib, a pan-HER inhibitor. Methods We identified patients with metastatic or recurrent HER2-mutant lung adenocarcinomas treated with afatinib among seven institutions across Europe, Australia, and North America between 2009 and 2017. We determined the partial response rate to afatinib, types of HER2 mutations, duration of response, time on treatment, and survival. Results We collected information on 27 patients with stage IV or recurrent HER2-mutant lung adenocarcinomas treated with afatinib. Of 23 patients evaluable for response, three partial responses were noted (13%, 95% confidence interval [CI] 4–33%). In addition, 57% of patients (13/23) had stable disease, and 30% (7/23) had progressive disease. We documented partial responses in patients with HER2 exon 20 insertions, including two with YVMA insertion and one with VAG insertion. Two patients with partial responses were previously treated with trastuzumab and pertuzumab. Median duration of response to afatinib was 6 months (range 5–10); median time on treatment was 3 months (range 1–30) and median overall survival from the date of diagnosis of metastatic or recurrent disease was 23 months (95% CI 18–53 months). Conclusions Afatinib is modestly active in patients with HER2-mutant lung adenocarcinomas, including responses after progression on prior HER2-targeted therapies. However, investigations into the biology of HER2-mutant lung adenocarcinomas and development of better HER2-directed therapies are warranted.

Purpose To assess the incidence of lung cancer in a cohort of patients with negative findings at previous lung cancer screening. Materials and Methods In this prospective cohort study, the authors first identified 4782 individuals who had negative screening results as part of the International Early Lung Cancer Action Program (1993-2005). Subjects were assigned a lung cancer risk score by using a validated risk model. Starting with those at highest risk, subjects were interviewed by phone and invited to undergo low-dose CT between March 2013 and October 2016. Subjects with a diagnosis of lung cancer and those who had died of lung cancer were determined. Descriptive statistics were used to summarize data. The independent samples t test and Fisher exact test were used to compare age, sex, and risk scores. Results A total of 327 study participants were contacted, and 200 subjects participated in this study. The average age was 74 years (range, 57-88 years), and the median time since previous CT was 7 years. The incidence rate of developing lung cancer during the next 6 years was estimated at 5.6%. The period prevalence of lung cancer was 20.8% (new and preexisting lung cancer, 68 of total cohort of 327). The detection rate of low-dose CT was 7% (14 of 200 subjects). Of the 14 screening-detected cancers, 12 were stage I or II. Conclusion High-risk individuals have a high incidence of lung cancer after previous negative lung cancer screening. Early-stage lung cancer can be successfully detected in older high-risk individuals. © RSNA, 2018 Online supplemental material is available for this article.

The ability to image biological tissues is critical to our understanding of a range of systems and processes. In the case of in situ living tissue, such imaging is hampered by the innate mechanical properties of the tissue. In many cases, this provides challenges in how to process large amounts of image data which may contain aberrations from movement. Generally, current tools require the provision of reference images and are unable to maintain temporal correlations within an image set. Here, we describe a tool-Tify-which can accurately predict a numerical quality score versus human scoring and can analyse image sets in a manner that allows the maintenance of temporal relationships. The tool uses regression-based techniques to link image statistics to image quality based on user provided scores from a sample of images. Scores calculated by the software correlate strongly with the scores provided by human users. We identified that, in most cases, the software requires users to score between 20-30 frames in order to be able to accurately calculate the remaining images. Importantly, our results suggest that the software can use coefficients generated from consolidated image sets to process images without the need for additional manual scoring. Finally, the tool is able to use a frame windowing technique to identify the highest quality frame from a moving window, thus retaining macro-chronological connections between frames. In summary, Tify is able to successfully predict the quality of images in an image set based on a small number of sample scores provided by end-users. This software has the potential to improve the effectiveness of biological imaging techniques where motion artefacts, even in the presence of stabilisation, pose a significant problem.

Background: SCOPE is a quality improvement initiative that addresses the challenge of an aging population’s increasing care needs and the reduced capacity of primary care providers (PCPs) unaffiliated with interdisciplinary teams, to manage this population. SCOPE aims to integrate care so that patients and their families experience one care team across primary, community and hospital sectors. SCOPE’s success in offering a virtual interdisciplinary team via a centralized hub rests on grassroots co-design with PCPs and their patients. Since launching in 2012, SCOPE has grown from 30 PCPs located in one region in Toronto (Canada), to support over 300 PCPs in 4 regions. To date SCOPE has received approximately 15,000 total calls, currently averaging >400 calls/month. Half of these calls were perceived to have avoided an ED visit. The majority of SCOPE physicians (97.7%) felt they are able to access specialty care in a timely manner. Qualitative research demonstrated that PCPs felt less isolated, more confident in managing complex patients, and that their patients received more comprehensive care with more appropriate usage of healthcare resources. SCOPE was recognized in 2018 with a provincial integration award. Aims and Objectives: Demonstrate the co-design process to inform the model Reveal the infrastructure that facilitates linkages Convey an adaptable communication strategy to drive primary care integration Establish key metrics to measure successful adoption and sustainability Frame first principles for successful scale and spread of a patient-centered, provider-enhanced model Format: The SCOPE workshop will use didactic and experiential interactive learning methods to meet its objectives: Patient Narrative Video: Mr. Kandil Gudka (5 minutes) Context of co-design strategy: Dr. Pauline Pariser, Primary Care Lead, University Health Network (UHN) (6 minutes) Key elements of SCOPE Model: Acute Ambulatory Care Unit: Dr. Tara O’Brien, Medical Director, Women’s College Hospital (WCH) (7 minutes) Home and Community Care: Marni Salkovitch, Toronto Central LHIN (5 minutes) Nurse Navigation: Magdalena Rybak, UHN (5 minutes) Radiology: Dr. John Kavanagh, Chief of Radiology, WCH (7 minutes) Evaluation, Patient Outcomes and Process Measures: Dr. Pauline Pariser (5 minutes) Scale and Spread: An interactive forum using breakout groups to respond to standardized practices in building sustained relationships with PCPs and patients and what can be customized to local contexts, highlighting: patient and PCP co-design, integrated home and hospital care, and an incremental maturity model. Participants will have the opportunity to reflect how these methodologies are adaptable to their local settings (40 minutes; 25 minutes for discussion and 15 minutes report back) Facilitated by SCOPE team Closing Remarks/Questions: SCOPE team (10 minutes) Target Audience: Primary care thought leaders, hospital and community service managers, patients and consultants interested in primary care integration. Learnings/Take Away: SCOPE offers a transferable platform connecting primary care to hospital and community resources and building a community of practice SCOPE demonstrates proof of concept to successfully engage patients and providers in implementing a primary care integration strategy SCOPE provides the scaffolding to link other services as determined by local needs

Insertion of an IVC filter can be a safe and effective way to avoid PE in thrombosis patients who cannot be anticoagulated. If temporary filters are not promptly removed they can become difficult to remove, causing avoidable complications and often requiring lifelong warfarin. In this study, two sequential audits of retrieval of temporary IVC filters were conducted before and after the implementation of a coordinated management strategy for IVC filter follow-up. 33 filter placements were examined over a 15-month period (Group A). Following implementation of the strategy a comparable 15-month period in which 33 IVC filters were placed was audited (Group B). Following implementation, failed retrievals dropped from 15% to 9%. The number successfully retrieved did not change at 45%. The number made permanent from the outset following expert discussion increased from 12% to 39%. The number of filters with no attempted retrieval and no consultation about retrieval decreased from 27% to 9% (these patients were lost to follow-up with multiple contact attempts made). In Group B 100% of placed IVC filters were followed up appropriately. The proposed model is an easily implemented plan to avoid patient morbidity caused by temporary IVC filters made unintentionally permanent by loss to follow-up.

This paper introduces the concept of using active waveguides as part of an acoustic emission monitoring system for assessing the stability of soil slopes. In soil, acoustic emissions are generated by inter-particle friction, and hence the detection of acoustic emission is an indication of straining. The components of a field monitoring system are introduced, and the factors controlling design and performance of waveguides are discussed. It is proposed that active waveguides (i.e. those that generate acoustic emission when deformed by the host soil) can be used as an efficient method of obtaining signals from depth within a deforming soil body. The results of laboratory tests conducted to validate the active waveguide model are presented. The role played by the soil surrounding the steel tube waveguide is highlighted. Results from two full-scale field trials that involved monitoring unstable slopes provide evidence for the relationship between detected acoustic emission and slope deformation rate. It is shown that active waveguides in conjunction with relevant signal processing methods can be used to provide an early indication of slope instability.

Phyllodes tumours (PTs) are rare neoplasms accounting for1% of breast lesions. With increased breast awareness and screening programmes, smaller PTs are being detected. The purpose of this study was to determine the clinical, radiological and pathological presentation of PTs and to evaluate the role of imaging follow-up, for which there are no specific guidelines.A retrospective study of all patients diagnosed with PT in a symptomatic unit between January 2006 and March 2013 was carried out. Patients were identified using breast care and electronic patient record databases.53 patients with 54 lesions were diagnosed as having a PT. The median age was 27.5, 35.0 and 38.5 years for benign, borderline and malignant PT, respectively. Borderline and malignant PTs were larger than benign PTs, with mean sizes of 33 and 42 mm compared with 29 mm. 38% of PTs were labelled by the reporting radiologist as fibroadenomas, including two borderline PTs and one malignant PT. In 24% of cases, the radiologist raised the possibility of PT in the report. 17 patients (40%) developed a new fibroepithelial breast lesion during follow-up of which 4 were recurrent PTs.Despite adequate surgical management, the development of further fibroepithelial lesions in the ipsilateral breast is common. 3-year clinical surveillance, with the addition of 6-monthly ultrasound is advised for females with initial borderline or malignant PT histology.We propose a follow-up protocol with ultrasound based on the grade of the PT diagnosed for 3 years to detect recurrence.

Breast cancer is rare in young women under 35 years; however, it can present a diagnostic challenge. This study was undertaken to determine the presentation of breast cancer in young women and the role of imaging including the predictive value in determining tumour size.