Search

To determine the incidence and various patterns of radiation-induced liver injury (RILI) and its temporal evolution on fluorodeoxiglucose-positron emission tomography/computed tomography (FDG-PET/CT) after neoadjuvant chemoradiation using precision radiation in patients with esophageal carcinoma.We evaluated 639 patients with locally advanced esophageal carcinoma who had serial FDG-PET/CTs after neoadjuvant chemoradiation. Two readers reviewed the imaging studies in consensus and recorded the cases where new foci of increased FDG uptake were identified within the radiated liver parenchyma. RILI was confirmed by follow-up imaging or percutaneous biopsy.FDG-avid RILI developed in 39/639 (6%) of patients. The caudate and left hepatic lobe were involved in all cases. There were various patterns of increased FDG uptake: 38% of patients had a single focus of increased FDG uptake and 62% had 2 regions of increased FDG uptake, which were focal nodular or diffuse or a combination of focal nodular and diffuse FDG uptake. On CT, 72% of patients had a poorly-marginated region of low attenuation and 28% had a well-defined region of low attenuation with sharp, well-defined linear borders in the location of the radiation, as confirmed by the treatment plan.The caudate and left hepatic lobes were involved in all cases of RILI. The various imaging patterns of RILI on FDG-PET/CT include 1 or 2 regions of increased FDG uptake with a nodular, diffuse, or combined appearance. Awareness of this potential complication of radiation therapy and knowledge of the imaging manifestations of RILI is important to avoid misinterpretation as a metastasis.

Background The assumption that increased [18F] fluoro-2-deoxy-d-glucose (FDG) uptake in hilar nodes on PET/CT imaging is indicative of distant metastasis can result in palliative rather than curative care in patients with esophageal cancer. This study aims to determine the significance of increased FDG uptake in hilar nodes in patients with potentially curable, locally advanced disease at initial staging. Methods We included patients with biopsy-proven esophageal carcinoma who had pretreatment FDG-PET/CT at initial staging, and follow-up imaging >1 year. We excluded patients with distant hematogeneous metastases. Hilar nodes were considered concerning for metastatic disease when SUV max was >2.5 or FDG uptake was visually > mediastinal background were examined. Results We reviewed FDG-PET CT scans from 806 patients treated for esophageal cancer from 2010-2018 and identified 42 patients with FDG avid hilar adenopathy. Thirteen patients underwent histological assessment and 29 were followed with imaging. None of the 42 patients were found to have distant metastatic disease on initial work up and all were treated curatively. In follow up, 2/42 patients eventually manifested hilar nodal metastases after treatment; one who had a biopsy-negative hilar node at initial staging and another who did not have a biopsy of the hilar node. Conclusions Increased FDG uptake in hilar nodes in patients with localized esophageal cancer was not indicative of non-regional nodal metastasis. Patients in these situations should be approached with curative intent. The need for biopsy of FDG avid hilar nodes in this cohort should be carefully considered due to the low diagnostic utility.

The management of patients with esophageal carcinoma (EC) requires accurate clinical staging and post-therapeutic evaluation. Currently, esophagogastroduodenoscopy/endoscopic ultrasound (EGD/EUS), endoscopic ultrasound-fine needle aspiration (EUS-FNA), computed tomography (CT), 18F- fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (FDG-PET/CT) and magnetic resonance (MR) imaging are used for the initial clinical staging, evaluation of therapeutic response and follow-up in patients with EC. However, there are limitations and pitfalls that are commonly encountered when imaging these patients that can limit accurate assessment. Knowledge of the limitations and pitfalls associated with the use of these different imaging modalities is essential in avoiding misinterpretation and guaranteeing the appropriate management for patient with EC.

Esophageal cancer is an uncommon malignancy that ranks sixth in terms of mortality worldwide. Squamous cell carcinoma is the predominant histologic subtype worldwide whereas adenocarcinoma represents the majority of cases in North America, Australia, and Europe. Esophageal cancer is staged using the American Joint Committee on Cancer and the International Union for Cancer Control TNM system and has separate classifications for the clinical, pathologic, and postneoadjuvant pathologic stage groups. The determination of clinical TNM is based on complementary imaging modalities, including esophagogastroduodenoscopy/endoscopic ultrasound; endoscopic ultrasound-fine-needle aspiration; computed tomography of the chest, abdomen, and pelvis; and fluorodeoxyglucose PET/computed tomography.

Thymic epithelial neoplasms are a group of malignant tumors that includes thymoma, thymic carcinoma, and thymic neuroendocrine tumors. Although several staging systems have been developed over the years for use with these cancers, they have been interpreted and implemented in a nonuniform manner. Recently, the International Association for the study of Lung Cancer and the International Thymic Malignancy Interest Group developed a tumor-node-metastasis staging system that has been universally accepted and correlates with patient survival and outcomes. Although pathologic staging is determined by histologic examination of the resected tumor, imaging plays an important role in clinical staging and is important for informing therapeutic decisions.

Background Metastatic head and neck cancers (HNCs) predominantly affect the lungs and have a two-year overall survival (OS) of 15% to 50%, if amenable for pulmonary metastasectomy. Methods Retrospective review of the two-year local control (LC), local-regional control (LRC) within the same lobe, OS, and toxicity rates in consecutive patients with metastatic pulmonary HNC who underwent stereotactic ablative radiotherapy (SABR) January 2007 to May 2018. Results Evaluated 82 patients with 107 lung lesions, most commonly squamous cell carcinoma (SCC; 64%). Median follow-up was 20 months (range: 9.0-97.6). Systemic therapy administered in 34%. LC, LRC, and OS rates were 94%, 90%, and 62%. Patients with oligometastatic disease had a higher OS than polymetastatic disease, 72% vs 44% (HR = 0.30, 95% CI: 0.14-0.64; P = .008). OS in oligometastatic non-SCC and SCC were 100% and 66% (P = .03). There were no grade ≥3 toxicities. Conclusions Metastatic pulmonary HNCs after SABR have a two-year OS rate comparable to pulmonary metastasectomy.

Radiotherapy is one of the cornerstones for the treatment of thoracic malignancies. The goal of radiotherapy is to deliver maximal dose to the tumor while minimizing damage to surrounding normal anatomical structures. Although advances in radiotherapy technology have considerably improved radiation delivery, potential adverse effects are still common. Post radiation changes to the chest may include different structures such as the lung, heart, great vessels, and esophagus. The purpose of this manuscript is to illustrate the post radiotherapy changes to these anatomical structures resulting from external beam radiotherapy, as well as discuss imaging pitfalls to prevent radiologist's interpretation errors.

Medical imaging and the resultant ionizing radiation exposure is a public concern due to the possible risk of cancer induction.To assess the accuracy of ultra-low-dose (ULD) chest computed tomography (CT) with denoising versus normal dose (ND) chest CT using the Lung CT Screening Reporting and Data System (Lung-RADS).This prospective single-arm study comprised 52 patients who underwent both ND and ULD scans. Subsequently AI-based denoising methods were applied to produce a denoised ULD scan. Two chest radiologists independently and blindly assessed all scans. Each scan was assigned a Lung-RADS score and grouped as 1 + 2 and 3 + 4.The study included 30 men (58%) and 22 women (42%); mean age 69.9 ± 9 years (range 54-88). ULD scan radiation exposure was comparable on average to 3.6-4.8% of the radiation depending on patient BMI. Denoising increased signal-to-noise ratio by 27.7%. We found substantial inter-observer agreement in all scans for Lung-RADS grouping. Denoised scans performed better than ULD scans when negative likelihood ratio (LR-) was calculated (0.04--0.08 vs. 0.08-0.12). Other than radiation changes, diameter measurement differences and part-solid nodules misclassification as a ground-glass nodule caused most Lung-RADS miscategorization.When assessing asymptomatic patients for pulmonary nodules, finding a negative screen using ULD CT with denoising makes it highly unlikely for a patient to have a pulmonary nodule that requires aggressive investigation. Future studies of this technique should include larger cohorts and be considered for lung cancer screening as radiation exposure is radically reduced.

Genitourinary (GU) malignancies are a diverse group of common and uncommon neoplasms that may be associated with significant mortality. Metastases from GU neoplasms are frequently encountered in the chest, and virtually all thoracic structures can be involved. Although the most common imaging manifestations include hematogenous dissemination manifesting with peripheral predominant bilateral pulmonary nodules and lymphatic metastases manifesting with mediastinal and hilar lymphadenopathy, some GU malignancies exhibit unique features. We review the general patterns, pathways, and thoracic imaging features of renal, adrenal, urothelial, prostatic, and testicular metastatic neoplasms, as well as provide a discussion of treatment-related complications that might manifest in the chest. Detailed reporting of these patterns will allow the imager to assist the referring clinicians and surgeons in accurate determination of the stage, prognosis, and treatment options available for the patient. Awareness of specific treatment-related complications further allows the imager to enhance patient safety through accurate and timely reporting of potentially life-threatening consequences of therapies.

Radiation therapy is one of the cornerstones for the treatment of thoracic malignancies. Although advances in radiation therapy technology have improved the delivery of radiation considerably, adverse effects are still common. Postirradiation changes affect the organ or tissue treated and the neighboring structures. Advances in external-beam radiation delivery techniques and how these techniques affect the expected thoracic radiation-induced changes are described. In addition, how to distinguish these expected changes from complications such as infection and radiation-induced malignancy, and identify treatment failure, that is, local tumor recurrence, is reviewed. ©RSNA, 2019.

The assumption that increased [We included patients with biopsy specimen-proven esophageal carcinoma who had pretreatment FDG-PET/CT at initial staging and follow-up imaging1 year. We excluded patients with distant hematogeneous metastases. Hilar nodes were considered concerning for metastatic disease when the maximum standardized uptake value was2.5 or FDG uptake was visually greater than the mediastinal background.We reviewed FDG-PET CT scans from 806 patients treated for esophageal cancer from 2010 to 2018 and identified 42 patients with FDG-avid hilar adenopathy. Thirteen patients underwent histologic assessment, and 29 were monitored with imaging. None of the 42 patients had distant metastatic disease on the initial workup, and all were treated curatively. In follow-up, 2 of 42 patients eventually manifested hilar nodal metastases after treatment; 1 who had a biopsy specimen-negative hilar node at initial staging and another who did not have a biopsy of the hilar node.Increased FDG uptake in hilar nodes in patients with localized esophageal cancer was not indicative of nonregional nodal metastasis. Patients in these situations should be approached with curative intent. The need for biopsy of FDG-avid hilar nodes in this cohort should be carefully considered due to the low diagnostic utility.

Esophageal cancer is an uncommon malignancy that ranks sixth in terms of mortality worldwide. Squamous cell carcinoma is the predominant histologic subtype worldwide whereas adenocarcinoma represents the majority of cases in North America, Australia, and Europe. Esophageal cancer is staged using the American Joint Committee on Cancer and the International Union for Cancer Control TNM system and has separate classifications for the clinical, pathologic, and postneoadjuvant pathologic stage groups. The determination of clinical TNM is based on complementary imaging modalities, including esophagogastroduodenoscopy/endoscopic ultrasound; endoscopic ultrasound-fine-needle aspiration; computed tomography of the chest, abdomen, and pelvis; and fluorodeoxyglucose PET/computed tomography.

Thymic epithelial neoplasms are a group of malignant tumors that includes thymoma, thymic carcinoma, and thymic neuroendocrine tumors. Although several staging systems have been developed over the years for use with these cancers, they have been interpreted and implemented in a nonuniform manner. Recently, the International Association for the study of Lung Cancer and the International Thymic Malignancy Interest Group developed a tumor-node-metastasis staging system that has been universally accepted and correlates with patient survival and outcomes. Although pathologic staging is determined by histologic examination of the resected tumor, imaging plays an important role in clinical staging and is important for informing therapeutic decisions.

In this review, we discuss the different radiation delivery techniques available to treat non-small cell lung cancer, typical radiologic manifestations of conventional radiotherapy, and different patterns of lung injury and temporal evolution of the newer radiotherapy techniques. More sophisticated techniques include intensity-modulated radiotherapy, stereotactic body radiotherapy, proton therapy, and respiration-correlated computed tomography or 4-dimensional computed tomography for radiotherapy planning. Knowledge of the radiation treatment plan and technique, the completion date of radiotherapy, and the temporal evolution of radiation-induced lung injury is important to identify expected manifestations of radiation-induced lung injury and differentiate them from tumor recurrence or infection.

The pleura may be affected by primary tumors or metastatic spread of intrathoracic or extrathoracic neoplasms. Primary pleural neoplasms represent ∼10% of all pleural tumors, and malignant lesions are more common than benign lesions. The most common primary tumors include malignant pleural mesothelioma and solitary fibrous tumor. Although pleural neoplasms may initially be evaluated with computed tomography (CT) and/or fluorodeoxyglucose positron emission tomography (PET)/CT, magnetic resonance (MR) imaging is complementary to these other imaging modalities for disease staging and evaluation of patients. In this article, we discuss the etiology, clinical presentation, and imaging of pleural neoplasms, with specific attention given to the role of MR imaging.

Preclinical data suggest that combining a checkpoint inhibition with immunomodulatory derivative can increase anticancer response. We designed a dose-escalation study using a 3 + 3 design to determine the safety, maximum tolerated dose (MTD) or recommended phase II dose (R2PD) and dose-limiting toxicities (DLT) of the anti–CTLA-4 antibody ipilimumab (1.5–3 mg/kg intravenously every 28 days × 4) and lenalidomide (10–25 mg orally daily for 21 of 28 days until disease progression or unacceptable toxicity) in advanced cancers. Total of 36 patients (Hodgkin lymphoma, 7; melanoma, 5; leiomyosarcoma, 4; renal cancer, 3; thyroid cancer, 3; other cancers, 14; median of 3 prior therapies) were enrolled. The MTD has not been reached and ipilimumab 3 mg/kg and lenalidomide 25 mg have been declared as R2PD. DLT were grade (G) 3 rash (3 patients) and G3 pancreatitis (1 patient). G3/4 drug-related toxicities other than DLT were G3 anemia (5 patients), G3 thromboembolism (2 patients), G3 thrombocytopenia, G3 rash, G3 hypopituitarism, G3 pneumonitis, G3 transaminitis, and G4 hypopituitarism (all in 1 patient). Eight patients had tumor shrinkage per immune-related response criteria (−79% to −2%) including a PR (−79% for 7.2+ months) in a refractory Hodgkin lymphoma. Using comprehensive genomic profiling, a total mutation burden (mutations/Mb) was evaluated in 17 patients, with one of the patients achieving a PR demonstrated intermediate mutation burden. In conclusion, combination of ipilimumab and lenalidomide is well tolerated and demonstrated preliminary signals of activity in patients with refractory Hodgkin lymphoma and other advanced cancers. Mol Cancer Ther; 17(3); 671–6. ©2017 AACR.

Squamous cell carcinoma and adenocarcinoma represent approximately 98% of esophageal malignant tumors. During the last 30 years, the incidence of adenocarcinoma has increased in Western countries (including the USA) where adenocarcinoma currently represents more than 60% of esophageal malignancies, although, worldwide, squamous cell carcinoma continues to be the predominant histologic type. Integrated positron emission tomography or computed tomography with 2-[fluorine18] fluro-2-deoxy-d-glucose is used in many institutions routinely as a tool in the initial staging and then repeated after therapy for the assessment of response to neoadjuvant therapy and detection of recurrent disease in patients with esophageal carcinoma. As with any other imaging modality, 2-[fluorine18] fluro-2-deoxy-d-glucose-positron emission tomography or computed tomography has strengths and limitations that should be understood in order to maximize its utility.

Purpose: Radiomics has shown great promise to use quantifiable imaging characteristics to predict the behavior and prognosis of neoplasms. This is the first study to evaluate whether radiomic texture analysis can predict outcomes in gastroesophageal junction adenocarcinoma (GEJAC) treated with neoadjuvant chemoradiotherapy (CRT). Materials and Methods: Pretreatment contrast-enhanced CT images of 146 patients with stage II-III GEJAC were reviewed (2009–2011), and randomly split into training and validation groups at a 1:1 ratio stratified with baseline clinical characteristics. Whole-tumor texture was assessed using quantitative image features based on intensity, shape, and gray-level co-occurrence matrix. The relevant pretreatment texture features, in addition to the significant baseline clinical features to predict survival, were identified using multivariate Cox proportional hazard regression model with stepwise variable selection in the training sample and verified in the validation sample, to facilitate the proposal of a multi-point index for standard patient pre-treatment risk classification. Results: Of the factors identified in the training cohort independently associated with OS, only shape compactness (p = 0.04) and pathologic grade differentiation (PDG) (p = 0.02) were confirmed in the validation sample. Using both parameters, we created a 3-point risk classification index: low-risk (well-moderate PDG and high compactness), medium-risk (poor PDG or low compactness), and high-risk (poor PDG and low compactness). The risk index showed a strong negative association with postoperative pathologic complete response (pCR) (p = 0.04). Median OS for the high-, medium-, and low-risk groups were 23, 51, and ≥72 months, respectively (p

Radiologists consciously or unconsciously encounter bronchiolitis on images frequently. The purpose of this article is to simplify the concept of bronchiolitis to facilitate the formulation of a succinct and accurate differential diagnosis and suggest potential causes for the imaging findings. Direct and indirect signs of bronchiolitis that are seen on computed tomographic images are detailed. The most common causes of bronchiolitis are covered, including several distinct entities to be considered in specific clinical scenarios. In order of prevalence, the top two causes of bronchiolitis are infection and aspiration. Less common entities include respiratory bronchiolitis and hypersensitivity pneumonitis, which tend to manifest with ground-glass centrilobular nodules. Some types of bronchiolitis affect specific ethnic groups or are associated with a characteristic clinical history. For example, diffuse panbronchiolitis typically affects Japanese subjects. Constrictive bronchiolitis should be considered in lung transplant recipients with ongoing rejection. Given the high frequency of bronchiolitis, radiologists should develop a systematic approach to both cellular and constrictive bronchiolitis. Recognition of specific clinical or imaging characteristics may be sufficient for providing a relevant differential diagnosis.

OBJECTIVE The aim of this study was to present the imaging findings of pleural metastases from head and neck cancer and correlate them with prognosis for overall survival, which to our knowledge have not received much attention in radiology literature. METHODS We reviewed 23 cases of head and neck cancer with pleural metastases that were seen on head and neck imaging. Computed tomography (CT), magnetic resonance imaging, and positron emission tomography/CT imaging findings were reviewed. The location and cell type of the primary cancer were studied. The effect of the pleural metastases on patient survival was analyzed. RESULTS Twelve (57%) of the 21 cases of pleural metastasis were missed initially on the neck CT but were visible in retrospect. Nine of 11 patients whom we had followed up for 1.5 years or longer have died, often within a few of months of presenting with pleural metastases. CONCLUSIONS The presence of pleural metastasis in head and neck cancer is an extremely poor prognostic indicator for survival. They are potentially missed on the neck CT. Given its significant clinical impact, head and neck radiologists should specifically look for pleural metastasis when reviewing imaging studies of patients with head and neck cancer.

Respiratory motion during the CT and PET parts of a PET/CT scan leads to imperfect alignment of anatomic features seen by the 2 modalities. In this work, we concentrate on the effects of motion during CT. We propose a novel approach for improving the alignment. Methods: Respiratory waveform data were gathered during the CT and PET parts of 28 PET/CT scans of cancer patients with 40 lesions up to 3 cm in size in the lung or upper abdomen. PET list-mode data were reconstructed by 3 reconstruction methods: PET/static (the standard method with no motion correction); PET/ex (a method that calculates a range of expiratory amplitudes from the lowest one to the highest one); and PET/matched (a novel method that uses both waveforms). The 3 methods were compared. The distance between tumor positions in PET and CT were characterized in visual interpretation by physicians as well as quantitatively. Tumor SUVs (SUVmax and SUVpeak) were determined relative to SUV based on the static method. Image noise was evaluated in the liver and compared with PET/static. Results: In visual interpretation, the rate of good alignment was 13 of 21, 13 of 23, and 18 of 21 for the PET/static, PET/ex, and PET/matched methods, respectively, and the mean PET/CT distances were 3.5, 5.1, and 2.8 mm. In visual comparison with PET/ex, the rate of good alignment was increased in 1 of 10 and 7 of 10 cases for PET/static and PET/matched, respectively. SUVmax was on average 21% higher than PET/static when either PET/ex or PET/matched was used. SUVpeak was 12% higher. Image noise in the liver was 15% higher than PET/static for the PET/ex method, and 40% higher for PET/matched; that is, noise was much lower than in gated PET. Conclusion: Acquiring respiratory waveforms both in PET (as in the current state of the art) and in CT (an unusual key step in this approach) has the potential to improve the alignment of PET and CT images. A proposed method for using this information was tested. Improved alignment was demonstrated.

Stereotactic ablative radiation therapy (SABR) is an emerging treatment option for patients with pulmonary metastases; identifying patients who would benefit from SABR can improve outcomes.We retrospectively analyzed local failure (LF), distant failure (DF), overall survival (OS), and toxicity in 317 patients with 406 pulmonary metastases treated with SABR in January 2006-September 2017 at a tertiary cancer center.Median follow-up time was 23 months. Primary adrenal, colorectal, sarcoma, or pancreatic ("less responsive") tumors led to high rates of LF. LF rates for patients with less responsive vs. responsive tumors were 4.6% vs. 1.6% at 12 months and 12.8% vs. 3.9% at 24 months (hazard ratio [HR] 0.29, 95% confidence interval [CI] 0.11-0.73; Log-Rank P = 0.0087). A nomogram for 24-month local control was created using Cox multivariate factors (surgical history, planning target volume, primary disease site, lung lobe location). Treating patients with ≤3 pulmonary metastases vs.3 pulmonary metastases was associated with improved 24-month (74.2% vs. 59.3%) and 48-month (47.7% vs. 35.1%) OS (HR 0.66, 95% CI 0.47-0.95; Log-Rank P = 0.043), and reduced 12-month (22.5% vs. 50.8%) and 24-month (31.8% vs. 61.4%) intrathoracic DF (HR 0.53, 95% CI 0.38-0.74; Log-Rank P 0.0001). The most common toxicity was asymptomatic pneumonitis (14.8%). Six patients had grade 3 events (5 pneumonitis, 1 brachial plexus).SABR for pulmonary metastases was effective and well tolerated. Irradiating limited intrathoracic sites of disease led to improved OS and intrathoracic DM. Higher SABR doses or surgery could be considered for less radio-responsive primary tumors.

Pneumonia refers to acute inflammation of the lower respiratory tract and lung parenchyma. Community Acquired Pneumonia (CAP) refers to pneumonia acquired outside of hospitals or long-term care facilities in patients without known inherited or acquired immunodeficiency or active cancer or within 48 hours after hospital admission. Chest radiographic demonstration of airspace disease helps support the diagnosis in the appropriate clinical setting. Patients with CAP are treated with antibiotics regardless of chest radiography findings. Further evaluation with Computed tomography (CT), bronchoscopy, pleural fluid analysis, etc., are reserved for patients that do not respond to treatment or in whom complications are suspected. CT is useful in assessing complications such as empyema, bronchopleural fistula, abscess, and necrotizing pneumonia. Lung abscesses and empyema are frequently associated with aspiration pneumonia.

Opportunistic fungal infections are caused by fungi that are nonpathogenic in the immunocompetent host, many of which are part of the normal upper respiratory tract flora. These organisms may cause pulmonary infection in immunocompromised hosts. Immunocompromised patients and patients with febrile neutropenia with opportunistic fungal infections may have normal chest radiographs. Thus, chest CT should be performed for further evaluation. Imaging abnormalities in this patient population should raise suspicion for opportunistic infection. Neutropenia is the single most important risk factor for Aspergillosis. Aspergillus is the most common opportunistic infection in patients with hematologic malignancy and bone marrow transplantation. Aspergillus spp., Candida spp., and Cryptococcus spp. are the most common fungal infections in patients with solid organ transplantation. Pneumocystis jirovecii is the most common fungal infection in patients AIDS with CD4 count s3. Cryptococcal pneumonia is also common in this population. There has been a recent increase in uncommon fungal pathogens causing invasive pulmonary disease.

Tuberculosis (TB) is an airborne infection caused by Mycobacterium tuberculosis, an obligate aerobe, nonmotile, non-spore-forming bacillus. TB is a major cause of morbidity and mortality especially in developing countries. Patients with impaired cellular immunity including HIV (+), elderly, prisoners, and indigents and homeless patients have an increased susceptibility for active TB disease. Primary infection usually resolves without complications in immunocompetent patients. The most common radiologic manifestations of primary TB in children are consolidation and lymphadenopathy. Progressive primary TB with widespread hamatogenous dissemination may rarely occur. Patchy or nodular opacities in the upper lobes with associated cavitation are characteristic radiologic findings of active infection. While this pattern often correlates with relatively spared immunity, it denotes highly infectious individuals who require isolation.CT is very sensitive for the detection of bronchogenic spread of infection manifesting with discrete nodules, tree-in-bud opacities and cavitation.Miliary TB refers to hematogenous spread of infection.

Endemic fungi (EF) live in soil as saprophytes, infect humans when their spores are inhaled, and often affect healthy individuals that live in or have visited certain areas. EF infection should be suspected in patients from endemic areas who present with pulmonary opacities and/or cavitary disease on imaging. However, disseminated life-threatening disease may affect also immunocompromised patients (e.g. AIDS). Consider EF infection in patients with bronchopneumonia associated with lymphadenopathy that does not respond to antibiotics. Fungal infection may mimic tuberculosis, metastatic disease, lung cancer. Immunosupression is frequently associated with disseminated EF infection. Chronic mediastinal histoplasmosis is a common benign etiology of superior vena cava syndrome.

Cavitation is low-attenuation or lucency within a consolidation, nodule, or mass. While infection is the most common etiology of cavitation, other entities should also be considered. Cavitation of nodules, masses or consolidations is often related to infection, but can also occur in septic embolism, vasculitides, and pulmonary infarction. Aspiration pneumonia may manifest with cavitation and is common in institutionalized patients with altered state of consciousness. Anaerobes and enterobacteria are common etiologic agents. Mycobacterium tuberculosis should always be considered in patients with upper lobe cavitary disease. These patients should be isolated until etiology is proven. Aspergillus spp, nocardia spp, and Pneumocystis jiroveci should be considered in immunocompromised patients. Staphylococcus aureus is the most common cause of septic emboli. In patients without clinical evidence of infection, granulomatosis with polyangiitis and metastatic disease should be considered.

SUMMARY Endoscopic mucosal resection (EMR) can be an effective therapy for superficial esophageal cancer. Many patients with cT2 invasion by endoscopic ultrasound (EUS) receive surgery but are subsequently found to have superficial disease. The purpose of this study was to investigate the safety profile and the added value of attempting EMR for EUS-staged cT2N0 esophageal cancer. A retrospective review was performed at a single institution from 2008 to 2017. Patients who were staged cT2N0 by EUS were identified from a prospectively maintained surgical database. Among 75 patients identified for analysis, 30 underwent an attempt at EMR. No perforations or other immediate complications occurred. EMR was more likely to be attempted among older patients (P = 0.001) with smaller tumor size (P < 0.001) and diminished SUVmax (P = 0.001). At the time of treatment, EMR was successful in clearing all known disease among 17/30 patients, with 12 representing pT1a or less and 5 representing pT1b with negative margins. Among the 17 patients for whom EMR was able to clear all known disease, there were no recurrences or cancer-related deaths. Although all the patients were staged as cT2N0 by EUS, many patients were identified by EMR to have superficial disease. There were no perforations or other adverse events related to EMR. Furthermore, EMR cleared all known disease among 17 patients with no known recurrences or cancer-related deaths. The results indicate that EMR for cT2N0 esophageal cancer is a safe diagnostic option that is therapeutic for some.

Radiotherapy is one of the cornerstones for treatment of patients with cancer. Although advances in radiotherapy technology have considerably improved radiation delivery, potential adverse effects are still common. Postradiation changes to the mediastinum can include different structures such as the heart, great vessels, and esophagus. The purpose of the article was to illustrate the expected variety of changes to the mediastinum and adjacent lung resulting from external beam radiotherapy and radiotherapy-induced complications to the mediastinum and to discuss different radiotherapy delivery techniques.

Radiation therapy is an important modality in the treatment of patients with lung cancer. Recent advances in delivering radiotherapy were designed to improve loco-regional tumor control by focusing higher doses on the tumor. More sophisticated techniques in treatment planning include 3-dimensional conformal radiation therapy, intensity-modulated radiotherapy, stereotactic body radiotherapy, and proton therapy. These methods may result in nontraditional patterns of radiation injury and various radiologic appearances that can be mistaken for recurrence, infection and other lung diseases. Knowledge of radiological manifestations, awareness of new radiation delivery techniques and correlation with radiation treatment plans are essential in order to correctly interpret imaging in these patients.

Our aim is to evaluate in phantom and patient studies a recently developed elastic motion debluring (EMDB) technique which makes use of all the acquired PET data and compare its performance to other conventional techniques such as phase based gating (PBG) and HDChest (HDC) both of which use fractions of the acquired data. Comparisons were made with respect to static whole-body (SWB) images with no motion correction. Methods: A phantom simulating respiratory motion of the thorax with lung lesions (5 spheres with ID=10- 28 mm) was scanned with 0, 1, 2, and 3 cm motion. Four reconstructions were performed: SWB, PBG, HDC, and EMDB. For PBG, the average (PBGave) and maximum bin (PBGmax) were used. To compare the reconstructions, the ratios of SUVmax (RSmax), SUVpeak (RSpeak), and CNR (RCNR) were calculated with respect to SWB. Additionally, 46 patients with lung or liver tumors 0.54 HDC > 0.41 PBGmax > 0.31 PBGave). Similar results were seen in patient studies. The SUVmax/SUVpeak were higher by 19.3/11.1% EMDB, 21.6/13.9% HDC, 22.8/12.8% PBGave, and 45.6/26.8% PBGmax compared to SWB. Lung/liver noise increased EMDB (3/15%), HDC (35/56%), PBGave (100/170%), and PBGmax (146/219%). CNR increased in lung/liver tumors only for EMDB (18/13%), and decreased for HDC (-14/-23%), PBGave (-39/-63%), and PBGmax (-18/-46%). Average radiologist scores of image quality were SWB (4.0 ± 0.8) > EMDB (3.7 ± 1.0) > HDC (3.1 ± 1.0) > PBG (1.5 ± 0.7). Conclusion: The EMDB algorithm had the least increase in image noise, improved lesion CNR, and had the highest overall image quality score.

Objective:The purpose of this study was to evaluate fludeoxyglucose-positron emission ;tomography/CT's (FDG-PET/CT) performance in the follow ;up of patients with surgically treated oesophageal adenocarcinoma.Methods:The follow-up FDG-PET/CT scans of 162 consecutive patients with surgically treated oesophageal adenocarcinoma were retrospectively reviewed. Histopathological and/or imaging examinations confirmed recurrent disease. The accuracy, sensitivity, specificity and negative and positive predictive values were calculated.Results:Recurrence occurred in 71 (43%) patients, usually within the first year following surgery (60%) and in more than one site (76%). The sensitivity, specificity, positive-predictive value, negative-predictive value and accuracy of FDG-PET/CT for anastomotic recurrence were 77, 76, 16, 98 and 76%; for regional nodal recurrence were 88, 85, 43, 97 and 86%; and for distant metastatic recurrence were: 97, 96, 91, 99 and 96%. In 5 of the 42 patients (12%) with distant metastases, the...

This article reviews common and uncommon patterns of thoracic metastatic disease in primary hepatobiliary and pancreatic malignancies that are often overlooked or improperly diagnosed because of atypical location or imaging appearance. An understanding of the pathophysiology and routes of tumor spread aids in tailoring a search pattern allowing for more accurate evaluation of disease activity.

Introduction F (FDG) positron emission tomography (PET)/computed tomography (CT) is widely used in current clinical practice. Most of the PET/CT applications in the thorax involve the evaluation of solitary pulmonary nodules for malignancy, staging and restaging of oncologic patients, assessment of treatment response following therapy, and identification of residual or recurrent disease. These functions reflect the fact that cancer cells demonstrate increased uptake of glucose and glucose analogues such as FDG, as well as an increased rate of glycolysis. Although FDG undergoes uptake by the same transporter proteins as glucose, it becomes sequestered in cancer cells owing to its inability to participate in glycolytic pathways. The standardized uptake value (SUV) based on body weight, defined as the ratio of radiotracer accumulation (mCi/mL) in the area of interest divided by the injected dose (mCi) normalized by the patient’s bodyweight (g), is themost common semiquantitativemethod of evaluating abnormalities on PET/CT. Studies have suggested that an SUV cutoff of 2.5 can be used to separate benign from malignant abnormalities.

Primary lung cancer is the leading cause of cancer mortality in the world. Thorough clinical staging of patients with lung cancer is important, because therapeutic options and management are to a considerable degree dependent on stage at presentation. Radiologic imaging is an essential component of clinical staging, including chest radiography in some cases, computed tomography, MRI, and PET. Multiplanar imaging modalities allow assessment of features that are important for surgical, oncologic, and radiation therapy planning, including size of the primary tumor, location and relationship to normal anatomic structures in the thorax, and existence of nodal and/or metastatic disease.

Background and Relevance Atherosclerosis is an immune-inflammatory process with lipid andfibrous accumulationwithin the intimal layer of medium-sized and large arteries, resulting in plaque deposition. In the coronary arteries, most plaques remain silent; but some become obstructive, resulting in a coronary event. “Hard” coronary events include unstable angina, myocardial infarction (MI), and sudden death, which are also regarded as acute coronary syndrome (ACS). “Soft” coronary events are considered minor adverse events, such as stable angina, revascularization, or percutaneous catheter insertion. Atherosclerosis, seen inmost of the adult population all over the world, accounts for more than 19 million deaths every year. Despite the decrease in mortality from coronary heart disease (CHD) in the United States, CHD still remains the leading cause of death in both men and women with approximately 600,000 people dying every year. Cardiovascular disease and stroke cumulatively cause more annual deaths than cancer, respiratory disease, accidents, and diabetes combined. The cost of the US health care system related to cardiovascular disease was estimated to be more than $400 billion in 2008. The reduction inCHD-relatedUS deaths from1980-2000 is attributed equally to improvedmajor risk factors and to the use of evidence-based medical therapies. The latter category, focused on secondary prevention, has been the most dramatic advance in reducing the likelihood of recurrentmajor coronary

Improvements in surgical technique over the last decade enable surgeons to perform extensive resection and reconstruction in patients presenting with tumors involving the soft tissue or bony structures of the chest wall. The type of surgical resection and its size, depend on the type of tumor resected and its location. In addition to providing a better esthetic result, the reconstruction restores support and functionality of the thoracic cage. The approach to chest wall repair includes primary closure or reconstruction by using transposition flaps, free flaps, prosthetic material, or a mixture of a flap and prosthetic material.

Positron emission tomography (PET) computed tomography (CT) with 2-[fluorine-18] fluoro-2-deoxy-d-glucose (FDG) has been established as an effective modality for evaluation of cancer. Interpretations of patterns of physiologic 18F-FDG uptake by the heart is particularly difficult given the wide normal variations of 18F-FDG metabolic activity observed. Atypical patterns of focal or diffuse physiologic cardiac 18F-FDG uptake and post-therapeutic effects after radiation therapy, systemic diseases, or cardiomyopathy may also be confused with malignant disease on 18F-FDG PET/CT. In this article, we review the variations of normal cardiac 18F-FDG uptake observed in oncology patients and the appearances of other patterns of pathologic metabolic activity, related or not related to the malignancy being investigated, that may lead to false-negative and false-positive results.

The mediastinum contains vital vascular and nonvascular structures and organs, and a wide variety of abnormalities may arise from this region of the thorax. Although mediastinal masses may be initially detected on chest radiography, cross-sectional imaging plays an important role in the identification and evaluation of mediastinal lesions, enabling the formulation of focused differential diagnoses and ultimately guiding management. Computed tomography (CT) is considered the imaging modality of choice for evaluating most mediastinal masses; however, the role of magnetic resonance (MR) imaging continues to expand, as it is superior to CT in differentiating between cystic and solid masses, identifying cystic and solid components within complex lesions, and distinguishing thymic hyperplasia and normal thymus from thymic epithelial neoplasms and other neoplasms. In addition, it facilitates the staging and restaging of patients with thymic epithelial neoplasms and other tumors that cannot undergo contrast-enhanced CT imaging due to severe contrast allergy and/or impaired renal function. As division of the mediastinum into specific compartments is beneficial for diagnostic and treatment planning purposes and facilitates communication between clinicians in a multidisciplinary setting, a new classification model based on cross-sectional imaging has been developed by the International Thymic Malignancy Interest Group (ITMIG) and accepted as a new standard. In this article, we describe the role of MR imaging in the evaluation of mediastinal masses in conjunction with the new mediastinal compartment classification system introduced by ITMIG.

Objectives Endoscopic mucosal resection (EMR) is a diagnostic and potentially therapeutic option for patients with submucosal esophageal adenocarcinoma. However, there are significant concerns regarding the risk of lymph node metastasis. Our purpose was to construct a comparative effectiveness analysis comparing recurrence patterns after therapeutic EMR or esophagectomy. Methods Patients who underwent therapeutic EMR or esophagectomy from 2007 to 2015 with pathologically staged submucosal adenocarcinoma were identified from a departmental database. Cancer-related outcomes were compared among an unmatched as well as a propensity matched cohort. Risk stratification was also used to compare results among those with a low, medium, or high risk of nodal metastasis. Results Seventy-two patients met criteria for analysis, among whom 23 underwent therapeutic EMR with esophageal preservation and 49 underwent esophagectomy. Median follow-up was 43 months. Patients who underwent esophagectomy had larger, deeper tumors. Esophageal preservation was associated with an increased risk of local recurrence ( P = .01), but not distant recurrence ( P = .44). After propensity matching, there continued to be no difference in distant recurrence rate ( P = .66). In a risk-stratified analysis, low-risk patients showed no recurrences or cancer-related deaths, however, high-risk patients showed a trend toward increased distant recurrence after therapeutic EMR. Conclusions Esophageal preservation after therapeutic EMR was associated with an increased risk of local recurrence. Among low-risk patients, either strategy resulted in excellent cancer control. However, among high-risk patients, esophageal preservation showed a trend toward increased distant failure. These findings should prompt further investigation to determine optimal treatment for patients with submucosal esophageal adenocarcinoma.

Carcinoid tumors are a rare biologically heterogeneous group of neuroendocrine tumors with a spectrum ranging from benign indolent to aggressive metastatic tumors. They belong to the category of amine precursor uptake and decarboxylase tumors, or apudomas. The most common sites for primary locations are the gastrointestinal and respiratory tracts; however, any organ can be involved. The clinical presentation depends on location, aggressiveness, production of biologically active amines and peptides, paraneoplastic syndromes, and tendency for metastasis. Their reported age-adjusted incidence has increased in recent years, partly due to improved detection at radiologic imaging and endoscopy. Not a ll neuroendocrine cell tumors are carcinoids. Numerous systems have been proposed regarding their nomenclature and classification. Cross-sectional and functional imaging plays an important role in diagnosis, lesion characterization, and staging. Awareness of nomenclature, classification, common sites of involvement, and imaging presentation are pivotal for making the diagnosis. Knowledge of the diverse clinical, pathologic, and radiologic spectrum of carcinoid tumors involving various organs of the body is important for diagnosis and patient management. ©RSNA, 2017.