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Signed-Rank Tests of V3-V2 Difference

Purpose: To determine the immunologic effects of neoadjuvant chemotherapy plus ipilimumab in early-stage non–small cell lung cancer (NSCLC) patients.Experimental Design: This is a single-arm chemotherapy plus phased ipilimumab phase II study of 24 treatment-naïve patients with stage IB–IIIA NSCLC. Patients received neoadjuvant therapy consisting of 3 cycles of paclitaxel with either cisplatin or carboplatin and ipilimumab included in the last 2 cycles.Results: Chemotherapy alone had little effect on immune parameters in PBMCs. Profound CD28-dependent activation of both CD4 and CD8 cells was observed following ipilimumab. Significant increases in the frequencies of CD4+ cells expressing activation markers ICOS, HLA-DR, CTLA-4, and PD-1 were apparent. Likewise, increased frequencies of CD8+ cells expressing the same activation markers, with the exception of PD-1, were observed. We also examined 7 resected tumors and found higher frequencies of activated tumor-infiltrating lymphocytes than those observed in PBMCs. Surprisingly, we found 4 cases of preexisting tumor-associated antigens (TAA) responses against survivin, PRAME, or MAGE-A3 present in PBMC at baseline, but neither increased frequencies nor the appearance of newly detectable responses following ipilimumab therapy. Ipilimumab had little effect on the frequencies of circulating regulatory T cells and MDSCs.Conclusions: This study did not meet the primary endpoint of detecting an increase in blood-based TAA T-cell responses after ipilimumab. Collectively, these results highlight the immune activating properties of ipilimumab in early-stage NSCLC. The immune profiling data for ipilimumab alone can contribute to the interpretation of immunologic data from combined immune checkpoint blockade immunotherapies. Clin Cancer Res; 23(24); 7474–82. ©2017 AACR.

List of antibodies used for flow cytometry analysis

Demographics

Spaghetti plots of MDSC and Tregs by visits; stratified by overall response.

Spaghetti plots of CD4 and CD8 T cells by visits; stratified by overall response.

Diffuse lung disease, frequently referred to as interstitial lung disease, encompasses numerous disorders affecting the lung parenchyma. The potential etiologies of diffuse lung disease are broad with several hundred established clinical syndromes and pathologies currently identified. Imaging plays a critical role in diagnosis and follow-up of many of these diseases, although multidisciplinary discussion is the current standard for diagnosis of several DLDs. This document aims to establish guidelines for evaluation of diffuse lung diseases for 1) initial imaging of suspected diffuse lung disease, 2) initial imaging of suspected acute exacerbation or acute deterioration in cases of confirmed diffuse lung disease, and 3) clinically indicated routine follow-up of confirmed diffuse lung disease without acute deterioration. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Chest pain is a common reason that patients may present for evaluation in both ambulatory and emergency department settings, and is often of musculoskeletal origin in the former. Chest wall syndrome collectively describes the various entities that can contribute to chest wall pain of musculoskeletal origin and may affect any chest wall structure. Various imaging modalities may be employed for the diagnosis of nontraumatic chest wall conditions, each with variable utility depending on the clinical scenario. We review the evidence for or against use of various imaging modalities for the diagnosis of nontraumatic chest wall pain. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

In 2014, the American College of Radiology (ACR) created Lung-RADS 1.0. The system was updated to Lung-RADS 1.1 in 2019, and further updates are anticipated as additional data become available. Lung-RADS provides a common lexicon and standardized nodule follow-up management paradigm for use when reporting lung cancer screening (LCS) low-dose CT (LDCT) chest examinations and serves as a quality assurance and outcome monitoring tool. The use of Lung-RADS is intended to improve LCS performance and lead to better patient outcomes. To date, the ACR's Lung Cancer Screening Registry is the only LCS registry approved by the Centers for Medicare & Medicaid Services and requires the use of Lung-RADS categories for reimbursement. Numerous challenges have emerged regarding the use of Lung-RADS in clinical practice, including the timing of return to LCS after planned follow-up diagnostic evaluation; potential substitution of interval diagnostic CT for future LDCT; role of volumetric analysis in assessing nodule size; assessment of nodule growth; assessment of cavitary, subpleural, and category 4X nodules; and variability in reporting of the S modifier. This article highlights the major updates between versions 1.0 and 1.1 of Lung-RADS, describes the system's ongoing challenges, and summarizes current evidence and recommendations.

Background Left ventricular assist devices (LVAD) are increasingly used for durable mechanical circulatory support in advanced heart failure. While LVAD therapy provides substantial improvement in mortality and quality of life, long-term therapy confers increased risk for device complications. We evaluated if cardiac computed tomography (CCT) improves the detection of cardiomechanical complications among patients with LVAD and suspected device malfunction. Methods In this study, we compared the diagnostic performance of CCT and transthoracic echocardiography (TTE) for the identification of cardiomechanical LVAD complications, including thrombus or neointimal hyperplasia, inflow cannula malposition with dynamic obstruction, fixed outflow obstruction, device infection, and severe aortic regurgitation. Complications were confirmed with surgical evaluation, pathologic assessment, or response to therapeutic intervention. Results Among 58 LVAD patients, who underwent CCT and TTE for suspected LVAD dysfunction, there were 49 confirmed cardiomechanical LVAD complications among 43 (74.1%) patients. The most common LVAD complication was thrombus or neointimal hyperplasia (65.3%), followed by dynamic obstruction (26.5%). Individually, CCT identified 29 of the 49 (59.2%) confirmed LVAD cardiomechanical complications, whereas TTE alone identified a complication in 11 cases (22.4%). However, diagnostic performance was greatest when the two modalities were used in combination, yielding a sensitivity of 67%, specificity of 93%, PPV of 97%, NPV of 47% and diagnostic accuracy of 73%. Conclusion The novel and complementary use of CCT with TTE for the evaluation of suspected device malfunction improves the accurate identification of cardiomechanical LVAD complication compared to either modality alone.

The chest radiograph is the most common imaging examination performed in most radiology departments, and one of the more common indications for these studies is suspected infection. Radiologists must therefore be aware of less common radiographic patterns of pulmonary infection if they are to add value in the interpretation of chest radiographs for this indication. This review uses a case-based format to illustrate a range of imaging findings that can be associated with acute pulmonary infection and highlight findings that should prompt investigation for diseases other than community-acquired pneumonia to prevent misdiagnosis and delays in appropriate management.

Purpose Spatial access to health care resources is a requisite for utilization. Our purpose was to determine, at a census tract level, the geographic distribution of US smokers and their driving distance to an ACR-accredited CT facility. Methods The number of smokers per US census tract was determined from US Census Bureau data (American Community Survey, 2011-2015) and census tract smoking prevalence estimates. Driving distance, from the centroid of each census tract to the nearest CT facility, was determined using a geographic information system. Distance variations were assessed, and relationships with tract population density were examined with regression models. Results Most US smokers (81.8%) were within 15 miles of a CT facility; however, there was considerable inter- and intrastate variability. For census tracts containing ≥500 smokers, median distance to a CT was 4.3 miles. At the state level, median distance ranged from 1.4 (Washington DC) to 29.1 miles (Wyoming). Within each state, this variation was higher, with Washington, DC, exhibiting the lowest range (range, 4.3; 0.2-4.5 miles) and Maine exhibiting the highest range (range, 244.8; 0.2-245.0 miles). Distance to a CT facility was inversely associated with census tract population density. Conclusions Geographic variability in CT facility access has implications for lung cancer screening (LCS) implementation. Individuals in densely populated areas have relatively greater spatial access to CT facilities than those in sparsely populated tracts. Further work is needed to identify access disparities to LCS to optimize LCS for all eligible populations.

In 2014, the American College of Radiology (ACR) created Lung-RADS 1.0. The system was updated to Lung-RADS 1.1 in 2019, and further updates are anticipated as additional data become available. Lung-RADS provides a common lexicon and standardized nodule follow-up management paradigm for use when reporting lung cancer screening (LCS) low-dose CT (LDCT) chest examinations and serves as a quality assurance and outcome monitoring tool. The use of Lung-RADS is intended to improve LCS performance and lead to better patient outcomes. To date, the ACR's Lung Cancer Screening Registry is the only LCS registry approved by the Centers for MedicareMedicaid Services and requires the use of Lung-RADS categories for reimbursement. Numerous challenges have emerged regarding the use of Lung-RADS in clinical practice, including the timing of return to LCS after planned follow-up diagnostic evaluation; potential substitution of interval diagnostic CT for future LDCT; role of volumetric analysis in assessing nodule size; assessment of nodule growth; assessment of cavitary, subpleural, and category 4X nodules; and variability in reporting of the S modifier. This article highlights the major updates between versions 1.0 and 1.1 of Lung-RADS, describes the system's ongoing challenges, and summarizes current evidence and recommendations.

Soft tissue sarcomas (STS) encompass a group of rare but heterogeneous diseases. Nevertheless, many patients, particularly those with oligometastatic disease can benefit from thoughtful multimodality evaluation and treatment regardless of the STS subtype. Here, we review surgical, interventional radiology, radiation, and chemotherapy approaches to maximize disease palliation and improve survival, including occasionally long-term disease-free survival. Surgical resection can include lung or other visceral, soft tissue and bone metastases with a goal of rendering the patient disease free. Staged resections can be appropriate, and serial resection of oligometastatic recurrent disease can be appropriate. Retrospective series suggest survival benefit from this approach, although selection bias may contribute. Interventional radiology techniques such as percutaneous thermal ablation (PTA) and arterial embolization can present nonoperative local approaches in patients who are not medically fit for surgery, surgery is too morbid, or patients who decline surgery. Similarly, radiation therapy can be delivered safely to areas that are inaccessible surgically or would result in excessive morbidity. Currently no randomized trials exist comparing interventional radiologic approaches or radiation therapy to surgery but retrospective reviews show relatively similar magnitude of benefit in terms of disease palliation and survival, although it is felt unlikely that these procedures will render a patient to long-term disease-free status. Chemotherapy has evolved recently with the addition of several new treatment options, briefly reviewed here. Importantly, if a patient sustains a good response to chemotherapy resulting in true oligometastatic disease, consideration of multimodality local therapy approaches can be considered in the appropriate patient.

Purpose: To determine the immunologic effects of neoadjuvant chemotherapy plus ipilimumab in early-stage non–small cell lung cancer (NSCLC) patients. Experimental Design: This is a single-arm chemotherapy plus phased ipilimumab phase II study of 24 treatment-naïve patients with stage IB–IIIA NSCLC. Patients received neoadjuvant therapy consisting of 3 cycles of paclitaxel with either cisplatin or carboplatin and ipilimumab included in the last 2 cycles. Results: Chemotherapy alone had little effect on immune parameters in PBMCs. Profound CD28-dependent activation of both CD4 and CD8 cells was observed following ipilimumab. Significant increases in the frequencies of CD4+ cells expressing activation markers ICOS, HLA-DR, CTLA-4, and PD-1 were apparent. Likewise, increased frequencies of CD8+ cells expressing the same activation markers, with the exception of PD-1, were observed. We also examined 7 resected tumors and found higher frequencies of activated tumor-infiltrating lymphocytes than those observed in PBMCs. Surprisingly, we found 4 cases of preexisting tumor-associated antigens (TAA) responses against survivin, PRAME, or MAGE-A3 present in PBMC at baseline, but neither increased frequencies nor the appearance of newly detectable responses following ipilimumab therapy. Ipilimumab had little effect on the frequencies of circulating regulatory T cells and MDSCs. Conclusions: This study did not meet the primary endpoint of detecting an increase in blood-based TAA T-cell responses after ipilimumab. Collectively, these results highlight the immune activating properties of ipilimumab in early-stage NSCLC. The immune profiling data for ipilimumab alone can contribute to the interpretation of immunologic data from combined immune checkpoint blockade immunotherapies. Clin Cancer Res; 23(24); 7474–82. ©2017 AACR.

Purpose/Objective(s) Stereotactic body radiation therapy (SBRT) is an established treatment option for stage I non-small cell lung cancer. SBRT often causes acute inflammatory changes in the lung as well as chronic fibrosis. These radiologic findings evolve over time and complicate the interpretation of surveillance imaging. Evolving inflammatory/fibrotic changes in the lung can be difficult to distinguish from malignant progression and radiologists and radiation oncologists (ROs) may interpret the same imaging study differently. With increasing access to the electronic medical record, patient's discovery of these disagreements can lead to confusion, fear, or mistrust. We assessed the frequency of discordant radiologic interpretations between radiologists and ROs after lung SBRT and investigated whether certain variables are associated with a higher frequency of inconsistencies. Materials/Methods As part of an IRB-approved study, data were collected on patients treated with SBRT at our institution for stage I NSCLC between 2007 and 2014. Every RO encounter that included a CT or PET-CT scan was evaluated. Based on language used, interpretations were scored as “concerning for progression” (CFP), “neutral differential” (ND), or “favor stability or post-radiation changes” (FS). ND required that malignancy was included. Results were considered discordant if one provider interpreted the imaging as CFP and the other as either ND or FS. Results were scored as concordant if radiology interpretations and RO interpretations were both scored as CFP or both scored as either ND or FS. A univariate analysis was conducted exploring the relationship between discordance and the type and timing of scans. Results During the time interval, 97 patients underwent SBRT for stage I NSCLC. Median follow-up was 15 months. Median (Q1, Q3) number of follow-up scans per patient was 3 (2, 5). Of 273 encounters, 18 (6.6%) had discordant interpretations. A ND was listed more frequently by radiology (18% vs 5%). When ND was listed by radiology (n = 49), RO interpretations favored stability 92% of the time. Local failure occurred in 9 cases, of which 2 patients had discordant reads prior to recurrence. Both were read as CFP by radiology (ND and FS by RO). The remaining 7 were concordantly read as CFP. Neither the type of scan (CT vs PET-CT), year of scan, nor the time from treatment were associated with discordant interpretations on univariate analyses. Conclusion Surveillance imaging after lung SBRT is often interpreted differently by radiologists and ROs. While outright discordance between impressions at our institution was low, radiologists were more likely to list a differential that included disease progression. In these cases, ROs more often favored stability or post-radiation changes. A recognition of these discrepancies is important when considering patient's access to their medical record.

Purpose To evaluate the feasibility of adaptive planning using positron emission tomography–computed tomography (PET-CT) in locally advanced non-small cell lung cancer. Methods and materials Patients with locally advanced non-small cell lung cancer receiving definitive radiation therapy (RT) were eligible. Initial planning PET-CT was performed and a conventional RT plan (2 Gy/fraction to 60 Gy) was designed. A second planning PET-CT was obtained at ~50 Gy. Dose escalation to ~70 Gy for residual fludeoxyglucose-avid disease was pursued at the discretion of the treating oncologists. The primary endpoint was feasibility of adaptive planning using interim PET-CT. Normal tissue dose-volume parameters were calculated for both adaptive and simulated nonadaptive plans. Results From 2012 to 2014, 33 eligible patients were enrolled and underwent planning PET-CT, 3 of which were found to have new distant metastases. Of 30 patients who initiated RT, interim PET-CT was obtained in 29. This showed complete response in 2 patients, partial response/stable disease in 24, and new distant metastases in 3. Selective dose escalation was performed in 17 patients. For those receiving a boost, the median gross tumor volumes pre-RT and at ~50 Gy were 78 mL and 29 mL, respectively ( P = .01). Reasons for no dose escalation were normal tissue constraints (n = 3), poorly defined residual disease (n = 2), acute toxicity (n = 1), and refusal of further therapy (n = 1). Adaptive planning compared with a simulated nonadaptive approach allowed for significant dose reductions to the lungs, heart, and esophagus (all P Conclusions Adaptive planning using PET-CT was feasible and allows for significant dose reductions to normal tissues compared with traditional planning techniques.

Discordance between Echocardiographic (ECHO) and invasive (CATH) post-TAVR mean gradient (MG) has been reported. We sought to compare immediate post TAVR ECHO and CATH MG obtained simultaneously in balloon expanding (BEV) vs. self expanding valves (SEV) in a multicenter study. Post-TAVR ECHO and

Background The objective of this study was to evaluate the safety and feasibility of using neoadjuvant chemotherapy plus ipilimumab followed by surgery as a treatment strategy for stage II-IIIA non-small cell lung cancer. Methods From 2013 to 2017, postoperative data from patients who underwent surgery after neoadjuvant chemotherapy plus ipilimumab in the TOP1201 trial, an open label phase II trial (NCT01820754), were prospectively collected. The surgical outcomes from TOP1201 were compared with outcomes in a historical cohort of patients receiving standard preoperative chemotherapy followed by surgery identified from our institution's prospectively collected thoracic surgery database. Results In the TOP1201 trial, 13 patients were treated with preoperative chemotherapy and ipilimumab followed by surgery. In the historical cohort, 42 patients received preoperative chemotherapy by a platinum doublet regimen preoperative chemotherapy by a platinum doublet regimen without ipilimumab followed by lobectomy or pneumonectomy. The 30-day mortality in both groups was 0%. The most frequently occurring perioperative complications in the TOP1201 group were prolonged air leak (n = 2, 15%) and urinary tract infection (n = 2, 15%). The most common perioperative complication in the preoperative chemotherapy alone group was atrial fibrillation (n = 6, 14%). One patient (8%) had atrial fibrillation in the TOP1201 group. There was no apparent increased occurrence of adverse surgical outcomes for patients in the TOP1201 group compared with patients receiving standard of care neoadjuvant chemotherapy alone before surgery for stage II–IIIA non-small cell lung cancer. Conclusions This report is the first to demonstrate the safety and feasibility of surgical resection after treatment with ipilimumab and chemotherapy in stage II–IIIA non-small-cell lung cancer.

Iatrogenic complications of thoracic and cardiovascular surgery are relatively uncommon, but contribute to potentially significant patient morbidity and mortality. The incidence of iatrogenic disease reflects the complexity of surgical procedures, including lung resection, esophagectomy, coronary artery bypass grafting, thoracic aorta repair, and cardiac valve replacement. Some iatrogenic complications are minor and common to all procedures, whereas others can be potentially devastating and are associated with precise technical components of specific surgeries. Multimodality imaging plays an important role in the diagnosis and management of operative thoracic and cardiovascular iatrogenic disease.

The biopsy collection data from two lung cancer trials that required fresh tumor samples be obtained for microarray analysis were reviewed. In the trial for advanced disease, microarray data were obtained on 50 patient samples, giving an overall success rate of 60.2%. The majority of the specimens were obtained through CT-guided lung biopsies (N = 30). In the trial for early-stage patients, 28 tissue specimens were collected from excess tumor after surgical resection with a success rate of 85.7%. This tissue procurement program documents the feasibility in obtaining fresh tumor specimens prospectively that could be used for molecular testing.

This retrospective study assessed whether dual-source high-pitch computed tomographic angiography (CTA) offered advantages over single-source standard-pitch techniques in the evaluation of the ascending aorta. Twenty patients who received both thoracic dual-source high-pitch and single-source standard-pitch CTAs within 1 year were assessed. Dual-source CTAs were performed; standard-pitch imaging used dose-modulated 120 kVp/150 mAs and 0.8 pitch compared with high-pitch protocols employing dose-modulated 120 kVp/250 mAs and 2.4 target pitch. Radiation dose was documented. Contrast-to-noise ratios (CNRs) at sinuses of the Valsalva (CNRValsalva) and ascending aorta (CNRAorta) were calculated. Dose/CNR for each technique was compared with paired t-tests. Motion at aortic valve, aortic root and ascending aorta were assessed with four-point scales and Mann–Whitney U tests; longitudinal extension of motion was compared with paired t-tests. Significantly lower motion scores for high-pitch, compared with standard-pitch acquisitions for aortic annulus, 0 vs. 2, aortic root, 0 vs. 3, and ascending aorta, 0 vs. 2, were achieved. Significantly reduced longitudinal extension of motion at aortic root, 4.9 mm vs 15.7 mm, and ascending aorta, 4.9 mm vs 21.6 mm, was observed. Contrast was not impacted: CNRValsalva, 45.6 vs 46.3, and CNRAorta, 45.3 vs 47.1. CTDIvol was significantly decreased for high-pitch acquisitions, 13.9 mGy vs 15.8 mGy. Dual-source high-pitch CTAs significantly decreased motion artefact without negatively impacting vascular contrast and radiation dose. • Dual-source high-pitch CTA significantly decreased motion artefact of the ascending aorta. • Dual-source high-pitch CTA did not negatively impact on vascular contrast. • Dual-source high-pitch CTA significantly decreased radiation dose compared with single-source standard-pitch acquisitions.

Gout is an arthropathy characterized by an elevated IL-1β state. Previous studies have shown a relationship between systemic inflammation and coronary calcification. We sought to determine relationship between gout and coronary artery calcium scores (CACS) derived from lung cancer screening CT (

Low-dose computed tomography (LDCT) screening has been shown to result in detection of earlier-stage lung cancers, with a 20% reduction in cancer-related deaths. LDCT screening offers significant potential benefits to selected patients; however, many questions remain, including questions about the applicability of lung cancer screening in clinical practice.

The purpose of this article is to assess whether iopamidol-370 provides superior vascular contrast of the coronaries and depiction of anatomic detail without affecting heart rate and beat-to-beat variability during coronary dual-source MDCT compared with iodixanol-320.In this prospective trial, coronary CT angiography was performed on 60 adult patients using either iopamidol-370 or iodixanol-320. Cohorts were matched by age, habitus, sex, and baseline heart rate, with cohort sizes determined by power analysis. All studies were performed on a dual-source MDCT scanner with retrospective ECG-gating utilizing automatic pitch adjustment. Data assessment focused on heart rate variability during contrast administration statistically evaluated as Student t test comparisons within and between cohorts, coronary contrast-to-noise ratio analysis of the main coronary arteries utilizing Student t test comparisons between cohorts, and coronary branch depiction and distribution analysis in dual-reader consensus decisions between cohorts.Thirty patients matched for age, habitus, sex, and heart rate were evaluated in each cohort. ECG analyses found a statistically significant (p = 0.013) decrease in heart rate during administration of iodixanol-320. Beat-to-beat variations, expressed as coefficient of variation, within and among cohorts were low (coefficient of variation,0.05). Contrast-to-noise ratio was significantly increased for iopamidol-370 versus iodixanol-320 (aortic root, p = 0.021; left main, p = 0.032; left anterior descending, p = 0.033; left circumflex, p = 0.039; and right, p = 0.009). Analysis of coronary branch visualization revealed improved depiction for iopamidol-370 compared with iodixanol-320.Iopamidol-370, with its higher iodine concentration, provided greater vascular contrast of the arterial coronary tree and improved depiction of anatomic detail without significantly impacting cardiac heart rate during coronary MDCT imaging, as compared with iodixanol-320.

Inflammatory disorders of the cardiovascular system can affect the myocardium, pericardium, or vessel walls. Patients with myocardial and pericardial disease may present with chest pain, palpitations, and shortness of breath, symptoms resembling myocardial ischemia or infarction. The manifestations of vasculitis may include fever, weight loss, and fatigue, mimicking infectious or malignant processes. Because of the difficulty of differentiating these disease processes, patients frequently undergo multiple diagnostic examinations before obtaining a final diagnosis of myocarditis, pericarditis, or vasculitis. Computed tomography (CT) and magnetic resonance imaging play important roles in the assessment of structural abnormalities of the cardiovascular system, and combined positron emission tomography (PET) and CT may depict inflammatory processes before structural changes occur. Familiarity with the PET/CT appearances of inflammatory processes in the myocardium, pericardium, and vessels is important for accurate and prompt diagnosis.

Sonoelastography has been developed as an ultrasound-based elasticity imaging technique. In this technique, external vibration is induced into the target tissue. In general, tissue stiffness is inversely proportional to the amplitude of tissue vibration. Imaging tissue vibration will provide the elasticity distribution in the target region. This study investigated the feasibility of using real-time sonoelastography to detect and estimate the volume of thermal lesions in porcine livers in vivo. A total of 32 thermal lesions with volumes ranging from 0.2 to 5.3 cm3 were created using radiofrequency ablation (RFA) or high-intensity focused ultrasound (HIFU) technique. Lesions were imaged using sonoelastography and coregistered B-mode ultrasound. Volumes were reconstructed from a sequence of two-dimensional scans. The comparison of sonoelastographic measurements and pathology findings showed good correlation with respect to the area of the lesions (r2=0.8823 for RFA lesions, r2=0.9543 for HIFU lesions). In addition, good correspondence was found between three-dimensional sonoelastography and gross pathology (3.6% underestimate), demonstrating the feasibility of sonoelastography for volume estimation of thermal lesions. These results support that sonoelastography outperforms conventional B-mode ultrasound and could potentially be used for assessment of thermal therapies.

Since its clinical introduction in the 1940s, ultrasound has become one of the most widely used imaging modalities in medicine and has emerged as a key diagnostic tool for the evaluation of patients who have genitourinary disease. This is largely attributable to advances in transducer design, signal acquisition, image processing, and system portability resulting in improved resolution, usability, and availability. New innovations and clinical applications, such as ultrasound contrast agents, hybrid technologies, minimally invasive therapies, and molecular imaging techniques, promise to further broaden the role of ultrasound in the diagnosis and management of patients who have genitourinary disease.

This is a cardiothoracic curriculum document for radiology residents meant to serve not only as a study guide for radiology residents but also as a teaching and curriculum reference for radiology educators and radiology residency program directors. This document represents a revision of a cardiothoracic radiology resident curriculum that was published 10 years ago in Academic Radiology. The sections that have been significantly revised, expanded, or added are (1) lung cancer screening, (2) lung cancer genomic profiling, (3) lung adenocarcinoma revised nomenclature, (4) lung biopsy technique, (5) nonvascular thoracic magnetic resonance, (6) updates to the idiopathic interstitial pneumonias, (7) cardiac computed tomography updates, (8) cardiac magnetic resonance updates, and (9) new and emerging techniques in cardiothoracic imaging. This curriculum was written and endorsed by the Education Committee of the Society of Thoracic Radiology. This curriculum operates in conjunction with the Accreditation Council for Graduate Medical Education (ACGME) milestones project that serves as a framework for semiannual evaluation of resident physicians as they progress through their training in an ACGME-accredited residency or fellowship programs. This cardiothoracic curriculum document is meant to serve not only as a more detailed guide for radiology trainees, educators, and program directors but also complementary to and guided by the ACGME milestones.

Low-dose computed tomographic (LDCT) screening is now moving from clinical trials to clinical practice, following the report from the National Lung Screening Trial that LDCT screening for lung cancer can reduce the number of deaths from lung cancer by 20% in current and former smokers, ages 55 to 74 years, with a 30 pack-year smoking history. This article reviews the current evidence for screening, key elements of a successful lung cancer screening clinic, and reporting and management guidelines for LDCT screening findings.

26 Background: Ipilimumab (Ipi) is a humanized CTLA-4 antibody that blocks binding of CTLA-4 to B7, permitting T cell activation through CD28. Phased in Ipi added to chemotherapy (C) may enhance efficacy in NSCLC. Methods: Patients with stage 2 or 3A NSCLC received neoadjuvant carboplatin AUC6 plus paclitaxel 200 mg/m2 every 21 days for 3 cycles and Ipi (10 mg/kg) was given on day 1 for cycles 2 and 3. Blood for immune profiling of circulating T cells was collected at baseline, after chemotherapy alone, and after chemotherapy plus Ipi. Tumor infiltrating lymphocytes (TIL) were derived from 7 available tumors. Polychromatic flow cytometry (PFC) analyses were performed on peripheral blood mononuclear cells (PBMC) and TIL. Objective response rates were assessed according to RECIST 1.1 criteria. Results: Of the 24 patients enrolled on this study, objective responses after 3 cycles of neoadjuvant C plus ipi included 2 PD, 8 SD, and 14 PR. Phenotypic analyses revealed that PBMC from all 24 patients were highly activated following two cycles of Ipi (cycle 3) as evidenced by significantly increased frequencies of CD28, ICOS, HLA-DR, PD-1, and CTLA-4 expressing CD4+ cells; and ICOS, HLA-DR, and CTLA-4 expressing CD8+ cells. The frequencies of Tregs were highly variable among the 24 participants. Two of the 24 participants had levels of MDSC cells above 15%. TIL contained far greater frequencies of activated CD4+ and CD8+ cells than found in the PBMC at cycle 3. Tumor associated antigen (TAA)-specific CD4+ or CD8+ cells were detected at baseline in 4 patients (24%), but their relative frequencies remained unaltered by Ipi therapy. No patients developed detectable de novo TAA reactivities while on Ipi therapy. Conclusions: Combined neoadjuvant Ipi plus chemotherapy produced significantly increased frequencies of highly activated CD4+ and CD8+ populations in the peripheral blood and the tumor microenvironment. TAA-specific CD4+ or CD8+ cells were detected in PBMC at baseline in a subset of patients. No TAA-reactive T cells were detected among the 7 TIL samples analyzed. Analysis for predictive or pharmacodynamic biomarkers is ongoing. Clinical trial information: NCT01820754.

A 28-year-old man with no medical history presented with right-sided swelling of the chest. Findings from the CT scan revealed multiple subcutaneous cystic masses and cavitary lung lesions. FDG PET imaging demonstrated hypermetabolic cavitary lung lesions and cyst walls with no central uptake. Polymerase chain reaction fluid analysis confirmed the growth of Mycobacterium tuberculosis. Operative incision and drainage yielded 2.5 L of purulent material. First described in the 17th century, the hallmark presentation of empyema necessitans is anterior chest wall soft-tissue swelling. M. tuberculosis remains its most common cause. Extraparenchymal collections begin with tuberculosis pleuritis followed by caseous material eroding through the chest wall into fascial planes.

Low-dose computed tomography (LDCT) screening has been shown to result in detection of earlier-stage lung cancers, with a 20% reduction in cancer-related deaths. LDCT screening offers significant potential benefits to selected patients; however, many questions remain, including questions about the applicability of lung cancer screening in clinical practice.

Advances in computed tomography (CT) scanners and electrocardiographic gating techniques have resulted in superior image quality of the ascending aorta and increased the use of CT angiography for evaluating the postoperative ascending aorta. Several abnormalities of the ascending aorta and aortic arch often require surgery, and various open techniques may be used to reconstruct the aorta, such as the Wheat procedure, in which both an ascending aortic graft and an aortic valve prosthesis are implanted; the Cabrol and modified Bentall procedures, in which a composite synthetic ascending aorta and aortic valve graft are placed; the Ross procedure, in which the aortic valve and aortic root are replaced with the patient's native pulmonary valve and proximal pulmonary artery; valve-sparing procedures such as the T. David-V technique, which leaves the native aortic valve intact; and more extensive arch repair procedures such as the elephant trunk and arch-first techniques, in which interposition or inclusion grafts are implanted, with or without replacement of the aortic valve. Normal postoperative imaging findings, such as hyperattenuating felt pledgets, prosthetic conduits, and reanastomosis sites, may mimic pathologic processes. Postoperative complications seen at CT angiography that require further intervention include pseudoaneurysms, anastomotic stenoses, dissections, and aneurysms. Radiologists must be familiar with these procedures and their imaging features to identify normal postoperative appearances and complications.

As a highly lipophilic drug, propofol may interact with lipophilic domains in addition to its likely primary site of action on the gamma-aminobutyrateA (GABAA) receptor. likely candidates for such interaction are the G protein-coupled membrane receptors for lipid intercellular mediators. The phospholipid lysophosphatidate (LP) has attracted attention as such a signaling molecule. It has a variety of biological actions, including vasoconstriction. We therefore studied the interaction between propofol and the LP receptor. Intracellular Ca2+ release in response to LP was assessed by measuring Cl- flux through Ca2+ -activated Cl- channels in Xenopus oocytes. The average charge movement in response to LP 10-7 M was 2.0 +/- 0.2 microCoulombs. Propofol in Intralipid[R] (0.01%) dose-dependently inhibited LP signaling (50% inhibitory concentration [IC50] 5.38 micro M). Propofol 28 micro M inhibited LP signaling by 81%. Intralipid[R] (0.01%) was without effect. To ascertain that intracellular signaling pathways and the Ca2+ -activated Cl (-) channel were not affected by propofol, we tested the effects of propofol (5.6 micro M) on currents induced by methylcholine (10-7 M) in oocytes expressing the m1 muscarinic acetylcholine receptor. No inhibition was observed. As both receptors share the same intracellular signaling pathway, we conclude that clinically relevant concentrations of propofol most likely inhibit the LP receptor or its G protein. Inhibition of LP signaling may explain some of propofol's vasodilating actions. (Anesth Analg 1996;83:1090-6)

Left ventricular assist devices (LVAD) are used to support cardiac function in patients with advanced heart failure, however device-related adverse events remain common. Cardiac computed tomography angiography (CCTA) has the potential to provide unique information on cardio-mechanical complications