Multidetector-Row CT of the Thorax


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Joseph, Meinel , Felix G. Since the first edition of this book was published in , computed tomography has seen groundbreaking technical innovations that have transformed the field of thoracic imaging and opened novel possibilities for the detection of thoracic pathologies. This book highlights cutting-edge thoracic applications of CT imaging in the context of these technical innovations and discusses the latest opportunities, with critical appraisal of challenges and controversies.

All topics are covered by renowned international experts. Chapters from the original edition have been thoroughly updated to reflect the state of the art in technology and scientific evidence, and new contributions included on recent developments such as dual-energy CT and CT imaging in patients with acute chest pain. The book is abundantly illustrated with high-quality images and illustrations. Schoepf, a native of Austria, graduated from the medical school of Ludwig Maximilians University in Munich, Germany, in His main clinical and scientific interest is non-invasive cardiovascular and thoracic imaging, especially the use of advanced CT and MRI techniques for diagnosing disorders of the heart and lung.

Felix G. Meinel received his medical degree from Ludwig-Maximilians-University in Munich and trained in Radiology at the same institution. He was a visiting instructor in the Division of Cardiovascular Imaging at the Medical University of South Carolina Charleston, SC from to before returning to Munich to complete his clinical training. His main research interests include thoracic and cardiovascular CT imaging — both the advancement of CT technique and how CT imaging can be used to gain novel insights into disease.

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Introduction

Diagnostic Imaging Free Preview. If the surgeon could not find the nodules that were depicted in TSMDCT, the nodules were recorded separately as missing nodules. All resected nodules were sent individually for histologic analysis. The recorded data included the number and location of nodules suspected preoperatively, the number and location of nodules palpated and resected intraoperatively, and the number, location, and size of the nodules that were confirmed to be malignant metastases on pathologic evaluation.

The nodules detected by TSMDCT were compared with the nodules detected intraoperatively by analyzing the pathologic data in each case on a lesion-by-lesion basis. Subset analysis was performed on a per-nodule basis. Since this strategy resulted in greater precision it served as an exploratory analysis to determine whether a unique subgroup could be identified. For all analyses, a p value of 0. Mann—Whitney test was used for the comparison of size between benign and metastatic nodules.

A chi-square test was used for the histologic and maximum nodule size subset analyses. Ninety-five percent confidence intervals were calculated for all proportions. The sensitivity the number of pathologically proven metastatic nodules detected on the preoperative TSMDCT divided by the total number of pathologically proven metastatic nodules , specificity the number of pathologically proven non-metastatic nodules missed on the preoperative TSMDCT divided by the total number of pathologically proven non-metastatic nodules , positive predictive value the number of pathologically proven metastatic nodules divided by the number of nodules detected on preoperative TSMDCT , and negative predictive value the number of pathologically proven non-metastatic nodules divided by the number of resected nodules that were not detected on preoperative TSMDCT were calculated in each group.

The study group included 27 patients 9 females, 18 males; age range, 17—79 years; median age, 57 years. The primary tumors included were colorectal carcinoma in 11 patients, renal cell carcinoma in 5, osteosarcoma in 3, hepatobiliary carcinoma in 3, thymic tumor in 2, bladder cancer in 1, thyroid cancer in 1, and primitive neuroectodermal tumor in 1 patient. The disease-free interval DFI for the patients ranged from 0 to months median 22 months. DFIs less than 12 months were identified in nine patients, 12—24 months in eight patients, 24—36 months in six patients, and greater than 36 months in four patients.

Unilateral thoracotomy was performed in 18 patients, and sequential bilateral thoracotomy was performed in 9 patients. Most of the metastatic nodules were resected by wedge resection or enucleation. Centrally located nodules were removed by lobectomy and segmentectomy in four and three patients. Six patients had received previous metastasectomy and underwent repeated metastasectomy for recurrence. A total of pulmonary lesions were palpated and resected during the operations. The average number of resected nodules was 5. Histological examination revealed metastatic nodules, 96 benign nodules, and 1 bronchioloalveolar carcinoma.

Of 96 benign nodules, there were 39 focal fibrosis, and 33 intrapulmonary lymph nodes, 1 chondroid hamartoma, and 23 completely normal lung parenchyma on pathologic examination. There was a significant difference in the size distribution of the metastatic and benign nodules Fig. The average size of the distribution of metastatic nodules in the osteosarcoma group was 3. The size distribution graphs of benign and metastatic nodules. There was a difference in pattern of the size distribution between benign and metastatic nodules.

Box plot for size distribution of metastatic nodules according to cell types. The size of the metastatic nodules in osteosarcoma was smaller than the sizes of other cell types. PNET: primitive neuroectodermal tumor. Three of the patients in the osteosarcoma group underwent four thoracotomies, including one bilateral thoracotomy. A total of 46 nodules were resected during the operations, and 32 of the nodules were confirmed to be metastatic nodules by pathological review.


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In the non-osteosarcoma group, 32 thoracotomies were performed in 24 patients, including 8 bilateral thoracotomies. A total of nodules were resected, and 69 of those nodules were confirmed to be metastatic nodules by pathological review. The two missed nodules were detected during the operation in only one patient with renal cell carcinoma. We evaluated the appropriateness of radiological dictation and the grading system by generating free-response receiver operating characteristic plots and calculating the sensitivity and specificity in non-osteosarcoma group.

The ROC plots are shown in Fig. The area under curve was highest in the criteria of grade 4 AUC 0. These results suggest that the radiological grading system assigning a score grade 4 to metastatic nodules was appropriate in the non-osteosarcoma group. The values of sensitivity, specificity, positive predictive value, and negative predictive value of TSMDCT according to study group are given in Table 1.

The ROC plots based on the radiological grading system for non-osteosarcoma group.


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  6. The most accurate prediction was possible by the criteria of grade 4 marked on ROC curve with a square symbol. Subgroup analysis was performed for each metastatic nodule. Pulmonary metastasectomy has been accepted as an established treatment option for the isolated pulmonary metastasis of extrathoracic malignancy. Although a randomized study has not been performed, many retrospective studies reported favorable long-term survival in the patients who underwent pulmonary metastasectomy [1—3].

    One of the most important prognostic factors in pulmonary metastasectomy is complete resection. The importance of complete resection was also emphasized in other studies [3 , 10].

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    Multidetector-Row CT of the Thorax by M.F. Reiser (ebook)

    Therefore, in patients for whom pulmonary metastasectomy is planned, accurate preoperative detection of metastatic nodules is most important because underdetection of metastatic nodules could lead to an improper treatment plan. However, the reported accuracy of preoperative chest CT scan has not been satisfactory for the accurate detection of multiple metastatic nodules. Current evidences support manual palpation of metastatic nodules via thoracotomy or sternotomy as a standard procedure for the detection of metastatic nodules missed by preoperative CT scan.

    However, there is another opinion regarding pulmonary metastasectomy. Therefore, some authors proposed that equal results might be achieved if only radiologically visible lesions were resected [11]. This hypothesis is based on the idea that the patients who will benefit from metastasectomy are those that have oligometastatic disease. They also point out that complete resection of all palpable metastatic nodules by open surgery is not a complete biologic resection of metastatic deposits [12]. This hypothesis was supported by several studies reporting comparable survival between VATS and open metastasectomy in selected patients [4—6].

    Multidetector-Row CT of the Thorax

    However, the current standard and generally accepted procedure for pulmonary metastasectomy is open thoracotomy or sternotomy concomitant with careful manual palpation of the entire lung. Many studies revealed that the detection rates of chest CT in pulmonary metastasis were not satisfactory. Based on the findings of these studies, open pulmonary metastasectomy is generally regarded as a more favorable and more accurate procedure than the VATS procedure. However, the previous studies used thick-section chest CT image reconstruction.

    Because of motion artifacts and partial volume effects, CT may fail to show lesions with a diameter in the range of the slice thickness or smaller [13 , 14]. However, recent advances in CT technology have made more thinly sectioned and detailed image reconstruction possible. This improvement has the potential to substantially increase the detection performance of metastatic pulmonary nodules, compared with that of single-detector row helical CT.

    Pathologic confirmation was not performed in those studies; therefore, the real sensitivity of thin-section chest CT for metastatic nodules was not evaluated in those studies. Only two additional nodules were detected in one patient. We assumed that the primary reason for the low sensitivity of TSMDCT might be that the nodules of metastatic osteosarcoma were much smaller in size and much greater in number than other histology.

    Thoracic Imaging: Pulmonary Nodule – David Naeger, MD

    The low sensitivity of CT scan in osteosarcoma patients has already been reported in previous studies [18 , 19]. Although the number of cases in the osteosarcoma group was small in this study, the study results indicate that TSMDCT is not an accurate method in patients with osteosarcoma. The size and number of nodules are known to significantly affect the sensitivity of the CT scan. Matsaerts and colleagues [4] reported that the detection rate of preoperative chest CT was high in patients with a single metastatic lesion and low in the patients with more than one lesion.

    We also assumed that a longer disease-free interval was associated with the oligometastatic feature of patients, which enhanced the sensitivity of TSMDCT. Although it might seem evident that the sensitivity for the detection of metastatic pulmonary nodules would substantially increase, one drawback of the higher spatial resolution of MDCT is that many more transverse reconstructions are generated than with single detector CT.


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    The interpreter must examine up to 10 times the number of images than previously had to be examined. Thus, current CT technology presents new challenges and opportunities that should fundamentally alter the paradigms with which lung scans are acquired and interpreted.

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    We believe that computer-aided detection will play a key role in maximizing diagnostic performance when interpreting large, thin-section, multi-detector row CT scans. Computer-aided detection technology showed a substantially higher sensitivity rate than the conventional double reading [20]. Although the result of the thin-section MDCT was favorable in this study, the small number and heterogeneity of study population are limitations of this study.

    Especially, in osteosarcoma patients, the small number of study population could not draw any definite conclusion. Further studies including a larger study population will be necessary. In this study relatively large numbers of nodules were resected. Because the aim of this study was to verify the detection rate of TSMDCT, the authors tried to resect all palpable nodules during the operation. As a result many normal parenchyma or fibrotic lesions were resected, therefore, subsequent high number of resection compared with TSMDCT results and low specificity of manual palpation were inevitable.

    It is our opinion that TSMDCT will be a promising assessment tool for the preoperative evaluation of pulmonary metastasis. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide.

    Multidetector-Row CT of the Thorax

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