1
|
Lin Y, Khurelsukh K, Li IG, Wu CT, Wu YM, Lin G, Toh CH, Wan YL. Incidental Findings in Lung Cancer Screening. Cancers (Basel) 2024; 16:2600. [PMID: 39061238 PMCID: PMC11274500 DOI: 10.3390/cancers16142600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Revised: 07/18/2024] [Accepted: 07/19/2024] [Indexed: 07/28/2024] Open
Abstract
While low-dose computed tomography (LDCT) for lung cancer screening (LCS) has been recognized for its effectiveness in reducing lung cancer mortality, it often simultaneously leads to the detection of incidental findings (IFs) unrelated to the primary screening indication. These IFs present diagnostic and management challenges, potentially causing unnecessary anxiety and further invasive diagnostic procedures for patients. This review article provides an overview of IFs encountered in LDCT, emphasizing their clinical significance and recommended management strategies. We categorize IFs based on their anatomical locations (intrathoracic-intrapulmonary, intrathoracic-extrapulmonary, and extrathoracic) and discuss the most common findings. We highlight the importance of utilizing guidelines and standardized reporting systems by the American College of Radiology (ACR) to guide appropriate follow-ups. For each category, we present specific IF examples, their radiologic features, and the suggested management approach. This review aims to provide radiologists and clinicians with a comprehensive understanding of IFs in LCS for accurate assessment and management, ultimately enhancing patient care. Finally, we outline a few key aspects for future research and development in managing IFs.
Collapse
Affiliation(s)
- Yenpo Lin
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital at Linkou, Taoyuan City 333, Taiwan; (Y.L.); (K.K.); (C.-T.W.); (Y.-M.W.); (G.L.); (C.-H.T.)
| | - Khulan Khurelsukh
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital at Linkou, Taoyuan City 333, Taiwan; (Y.L.); (K.K.); (C.-T.W.); (Y.-M.W.); (G.L.); (C.-H.T.)
| | - I-Gung Li
- Department of Medical Imaging and Intervention, New Taipei Municipal Tucheng Hospital, New Taipei City 236, Taiwan;
| | - Chen-Te Wu
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital at Linkou, Taoyuan City 333, Taiwan; (Y.L.); (K.K.); (C.-T.W.); (Y.-M.W.); (G.L.); (C.-H.T.)
- Department of Medical Imaging and Radiological Sciences, College of Medicine, Chang Gung University, Taoyuan City 333, Taiwan
| | - Yi-Ming Wu
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital at Linkou, Taoyuan City 333, Taiwan; (Y.L.); (K.K.); (C.-T.W.); (Y.-M.W.); (G.L.); (C.-H.T.)
- Department of Medical Imaging and Radiological Sciences, College of Medicine, Chang Gung University, Taoyuan City 333, Taiwan
| | - Gigin Lin
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital at Linkou, Taoyuan City 333, Taiwan; (Y.L.); (K.K.); (C.-T.W.); (Y.-M.W.); (G.L.); (C.-H.T.)
- Department of Medical Imaging and Radiological Sciences, College of Medicine, Chang Gung University, Taoyuan City 333, Taiwan
| | - Cheng-Hong Toh
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital at Linkou, Taoyuan City 333, Taiwan; (Y.L.); (K.K.); (C.-T.W.); (Y.-M.W.); (G.L.); (C.-H.T.)
- Department of Medical Imaging and Radiological Sciences, College of Medicine, Chang Gung University, Taoyuan City 333, Taiwan
| | - Yung-Liang Wan
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital at Linkou, Taoyuan City 333, Taiwan; (Y.L.); (K.K.); (C.-T.W.); (Y.-M.W.); (G.L.); (C.-H.T.)
- Department of Medical Imaging and Radiological Sciences, College of Medicine, Chang Gung University, Taoyuan City 333, Taiwan
| |
Collapse
|
2
|
Zhu Y, Yip R, Jirapatnakul AC, Huang M, Cai Q, Dayan E, Liu L, Reeves AP, Henschke CI, Yankelevitz DF. Visual scoring of osteoporosis on low-dose CT in lung cancer screening population. Clin Imaging 2024; 109:110115. [PMID: 38547669 DOI: 10.1016/j.clinimag.2024.110115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 02/08/2024] [Accepted: 02/28/2024] [Indexed: 04/17/2024]
Abstract
OBJECTIVES The risk factors for lung cancer screening eligibility, age as well as smoking history, are also present for osteoporosis. This study aims to develop a visual scoring system to identify osteoporosis that can be applied to low-dose CT scans obtained for lung cancer screening. MATERIALS AND METHODS We retrospectively reviewed 1000 prospectively enrolled participants in the lung cancer screening program at the Mount Sinai Hospital. Optimal window width and level settings for the visual assessment were chosen based on a previously described approach. Visual scoring of osteoporosis and automated measurement using dedicated software were compared. Inter-reader agreement was conducted using six readers with different levels of experience who independently visually assessed 30 CT scans. RESULTS Based on previously validated formulas for choosing window and level settings, we chose osteoporosis settings of Width = 230 and Level = 80. Of the 1000 participants, automated measurement was successfully performed on 774 (77.4 %). Among these, 138 (17.8 %) had osteoporosis. There was a significant correlation between the automated measurement and the visual score categories for osteoporosis (Kendall's Tau = -0.64, p < 0.0001; Spearman's rho = -0.77, p < 0.0001). We also found substantial to excellent inter-reader agreement on the osteoporosis classification among the 6 radiologists (Fleiss κ = 0.91). CONCLUSIONS Our study shows that a simple approach of applying specific window width and level settings to already reconstructed sagittal images obtained in the context of low-dose CT screening for lung cancer is highly feasible and useful in identifying osteoporosis.
Collapse
Affiliation(s)
- Yeqing Zhu
- Department of Diagnostic, Molecular, and Interventional Radiology, Icahn School of Medicine at Mount Sinai, One Gustave Levy L. Place, New York, NY 10029, United States of America
| | - Rowena Yip
- Department of Diagnostic, Molecular, and Interventional Radiology, Icahn School of Medicine at Mount Sinai, One Gustave Levy L. Place, New York, NY 10029, United States of America
| | - Artit C Jirapatnakul
- Department of Diagnostic, Molecular, and Interventional Radiology, Icahn School of Medicine at Mount Sinai, One Gustave Levy L. Place, New York, NY 10029, United States of America
| | - Mingqian Huang
- Department of Diagnostic, Molecular, and Interventional Radiology, Icahn School of Medicine at Mount Sinai, One Gustave Levy L. Place, New York, NY 10029, United States of America
| | - Qiang Cai
- Department of Diagnostic, Molecular, and Interventional Radiology, Icahn School of Medicine at Mount Sinai, One Gustave Levy L. Place, New York, NY 10029, United States of America; Department of Radiology, Shanxi Provincial People's Hospital, Taiyuan, Shanxi 030012, China
| | - Etan Dayan
- Department of Diagnostic, Molecular, and Interventional Radiology, Icahn School of Medicine at Mount Sinai, One Gustave Levy L. Place, New York, NY 10029, United States of America
| | - Li Liu
- Department of Diagnostic Radiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Anthony P Reeves
- School of Electrical and Computer Engineering, Cornell University, Ithaca, NY, United States of America
| | - Claudia I Henschke
- Department of Diagnostic, Molecular, and Interventional Radiology, Icahn School of Medicine at Mount Sinai, One Gustave Levy L. Place, New York, NY 10029, United States of America
| | - David F Yankelevitz
- Department of Diagnostic, Molecular, and Interventional Radiology, Icahn School of Medicine at Mount Sinai, One Gustave Levy L. Place, New York, NY 10029, United States of America.
| |
Collapse
|
3
|
Ebstein E, Brocard P, Soussi G, Khoury R, Forien M, Khalil A, Vauchier C, Juge PA, Léger B, Ottaviani S, Dieudé P, Zalcman G, Gounant V. Burden of comorbidities: Osteoporotic vertebral fracture during non-small cell lung cancer - the BONE study. Eur J Cancer 2024; 200:113604. [PMID: 38340385 DOI: 10.1016/j.ejca.2024.113604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 11/29/2023] [Accepted: 02/01/2024] [Indexed: 02/12/2024]
Abstract
INTRODUCTION Immunotherapy and targeted therapy have extended life expectancy in non-small cell lung cancer (NSCLC) patients, shifting it into a chronic condition with comorbidities, including osteoporosis. This study aims to evaluate the prevalence and incidence of osteoporotic vertebral fracture (OPVF) during NSCLC follow-up, identify risk factors of OPVF, and determine the impact on overall survival (OS). METHODS We performed a longitudinal single-center retrospective cohort study involving patients with histologically proven NSCLC of any stage. Chest-abdomen-pelvis computed tomography (CAP CT) at diagnosis and during follow-up were double-blind reviewed to determine OPVF site, count, type, time to incident OPVF, and trabecular volumetric bone density (TVBD). An institutional expert committee adjudicated discrepancies. Binary logistic regression was used to predict the occurrence of incident OPVF. OS was calculated using the Kaplan-Meier method. RESULTS We included 289 patients with a median follow-up of 29.7 months. OPVF prevalence was 10.7% at inclusion and 23.2% at the end of follow-up. Cumulative incidence was 12.5%, with an incidence rate of 4 per 100 patient-years. Median time to incident OPVF was 13 months (IQR: 6.7-21.2). Seven of the 36 patients with incident OPVF received denosumab or bisphosphonates. In multivariable analysis, independent risk factors for incident OPVF were BMI < 19 kg/m2 (OR: 5.62, 95%CI 1.84-17.20, p = 0.002), lower TVBD (OR: 0.982 per HU, 95%CI 0.97-0.99, p = 0.001) and corticosteroid use (OR: 4.77, 95%CI: 1.76-12.89, p = 0.001). OPVF was not significantly associated with OS. CONCLUSIONS Osteoporosis should be screened for in NSCLC patients. Thoracic oncologists must broaden the use of steroid-induced osteoporosis recommendations.
Collapse
Affiliation(s)
- E Ebstein
- Université Paris Cité, Rheumatology Department, Hôpital Bichat Claude-Bernard, Paris, France
| | - P Brocard
- Université Paris Cité, Rheumatology Department, Hôpital Bichat Claude-Bernard, Paris, France
| | - G Soussi
- Pulmonology Department, Hôpital Forcilles - Fondation Cognacq-Jay, 77150 Férolles-Attily, France
| | - R Khoury
- Université Paris Cité, Radiology Department, Hôpital Bichat Claude-Bernard, Paris, France
| | - M Forien
- Université Paris Cité, Rheumatology Department, Hôpital Bichat Claude-Bernard, Paris, France
| | - A Khalil
- Université Paris Cité, Radiology Department, Hôpital Bichat Claude-Bernard, Paris, France
| | - C Vauchier
- Université Paris Cité, Thoracic Oncology Department, CIC INSERM 1425, Institut du Cancer AP-HP.Nord, Hôpital Bichat Claude-Bernard, Paris, France
| | - P A Juge
- Université Paris Cité, Rheumatology Department, Hôpital Bichat Claude-Bernard, Paris, France
| | - B Léger
- Université Paris Cité, Rheumatology Department, Hôpital Bichat Claude-Bernard, Paris, France
| | - S Ottaviani
- Université Paris Cité, Rheumatology Department, Hôpital Bichat Claude-Bernard, Paris, France
| | - P Dieudé
- Université Paris Cité, Rheumatology Department, Hôpital Bichat Claude-Bernard, Paris, France
| | - G Zalcman
- Université Paris Cité, Thoracic Oncology Department, CIC INSERM 1425, Institut du Cancer AP-HP.Nord, Hôpital Bichat Claude-Bernard, Paris, France
| | - V Gounant
- Université Paris Cité, Thoracic Oncology Department, CIC INSERM 1425, Institut du Cancer AP-HP.Nord, Hôpital Bichat Claude-Bernard, Paris, France.
| |
Collapse
|
4
|
Adams SJ, Mikhael P, Wohlwend J, Barzilay R, Sequist LV, Fintelmann FJ. Artificial Intelligence and Machine Learning in Lung Cancer Screening. Thorac Surg Clin 2023; 33:401-409. [PMID: 37806742 DOI: 10.1016/j.thorsurg.2023.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Recent advances in artificial intelligence and machine learning (AI/ML) hold substantial promise to address some of the current challenges in lung cancer screening and improve health equity. This article reviews the status and future directions of AI/ML tools in the lung cancer screening workflow, focusing on determining screening eligibility, radiation dose reduction and image denoising for low-dose chest computed tomography (CT), lung nodule detection, lung nodule classification, and determining optimal screening intervals. AI/ML tools can assess for chronic diseases on CT, which creates opportunities to improve population health through opportunistic screening.
Collapse
Affiliation(s)
- Scott J Adams
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Peter Mikhael
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA; Jameel Clinic, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Jeremy Wohlwend
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA; Jameel Clinic, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Regina Barzilay
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA; Jameel Clinic, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Lecia V Sequist
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA; Harvard Medical School, Boston, MA, USA.
| | - Florian J Fintelmann
- Harvard Medical School, Boston, MA, USA; Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
| |
Collapse
|
5
|
Revel MP, Chassagnon G. Ten reasons to screen women at risk of lung cancer. Insights Imaging 2023; 14:176. [PMID: 37857978 PMCID: PMC10587052 DOI: 10.1186/s13244-023-01512-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 08/29/2023] [Indexed: 10/21/2023] Open
Abstract
This opinion piece reviews major reasons for promoting lung cancer screening in at-risk women who are smokers or ex-smokers, from the age of 50. The epidemiology of lung cancer in European women is extremely worrying, with lung cancer mortality expected to surpass breast cancer mortality in most European countries. There are conflicting data as to whether women are at increased risk of developing lung cancer compared to men who have a similar tobacco exposure. The sharp increase in the incidence of lung cancer in women exceeds the increase in their smoking exposure which is in favor of greater susceptibility. Lung and breast cancer screening could be carried out simultaneously, as the screening ages largely coincide. In addition, lung cancer screening could be carried out every 2 years, as is the case for breast cancer screening, if the baseline CT scan is negative.As well as detecting early curable lung cancer, screening can also detect coronary heart disease and osteoporosis induced by smoking. This enables preventive measures to be taken in addition to smoking cessation assistance, to reduce morbidity and mortality in the female population. Key points • The epidemiology of lung cancer in European women is very worrying.• Lung cancer is becoming the leading cause of cancer mortality in European women.• Women benefit greatly from screening in terms of reduced risk of death from lung cancer.
Collapse
Affiliation(s)
- Marie-Pierre Revel
- Université Paris Cité, 85 Boulevard Saint-Germain, Paris, 75006, France.
- Department of Radiology, Assistance publique des Hôpitaux de Paris, Hôpital Cochin, 27 Rue du Faubourg Saint-Jacques, Paris, 75014, France.
| | - Guillaume Chassagnon
- Université Paris Cité, 85 Boulevard Saint-Germain, Paris, 75006, France
- Department of Radiology, Assistance publique des Hôpitaux de Paris, Hôpital Cochin, 27 Rue du Faubourg Saint-Jacques, Paris, 75014, France
| |
Collapse
|
6
|
O'Dowd EL, Tietzova I, Bartlett E, Devaraj A, Biederer J, Brambilla M, Brunelli A, Chorostowska J, Decaluwe H, Deruysscher D, De Wever W, Donoghue M, Fabre A, Gaga M, van Geffen W, Hardavella G, Kauczor HU, Kerpel-Fronius A, van Meerbeeck J, Nagavci B, Nestle U, Novoa N, Prosch H, Prokop M, Putora PM, Rawlinson J, Revel MP, Snoeckx A, Veronesi G, Vliegenthart R, Weckbach S, Blum TG, Baldwin DR. ERS/ESTS/ESTRO/ESR/ESTI/EFOMP statement on management of incidental findings from low dose CT screening for lung cancer. Eur J Cardiothorac Surg 2023; 64:ezad302. [PMID: 37804174 PMCID: PMC10876118 DOI: 10.1093/ejcts/ezad302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 06/06/2023] [Indexed: 10/09/2023] Open
Abstract
BACKGROUND Screening for lung cancer with low radiation dose computed tomography has a strong evidence base, is being introduced in several European countries and is recommended as a new targeted cancer screening programme. The imperative now is to ensure that implementation follows an evidence-based process that will ensure clinical and cost effectiveness. This European Respiratory Society (ERS) task force was formed to provide an expert consensus for the management of incidental findings which can be adapted and followed during implementation. METHODS A multi-European society collaborative group was convened. 23 topics were identified, primarily from an ERS statement on lung cancer screening, and a systematic review of the literature was conducted according to ERS standards. Initial review of abstracts was completed and full text was provided to members of the group for each topic. Sections were edited and the final document approved by all members and the ERS Science Council. RESULTS Nine topics considered most important and frequent were reviewed as standalone topics (interstitial lung abnormalities, emphysema, bronchiectasis, consolidation, coronary calcification, aortic valve disease, mediastinal mass, mediastinal lymph nodes and thyroid abnormalities). Other topics considered of lower importance or infrequent were grouped into generic categories, suitable for general statements. CONCLUSIONS This European collaborative group has produced an incidental findings statement that can be followed during lung cancer screening. It will ensure that an evidence-based approach is used for reporting and managing incidental findings, which will mean that harms are minimised and any programme is as cost-effective as possible.
Collapse
Affiliation(s)
- Emma L O'Dowd
- Nottingham University Hospitals NHS Trust, Nottingham, UK
- University of Nottingham, Faculty of Medicine and Health Sciences, Nottingham, UK
| | - Ilona Tietzova
- Charles University, First Faculty of Medicine, Department of Tuberculosis and Respiratory Diseases, Prague, Czech Republic
| | - Emily Bartlett
- Royal Brompton and Harefield NHS Foundation Trust, Radiology, London, UK
| | - Anand Devaraj
- Royal Brompton and Harefield NHS Foundation Trust, Radiology, London, UK
| | - Jürgen Biederer
- University of Heidelberg, Diagnostic and Interventional Radiology, Heidelberg, Germany
- German Center for Lung Research DZL, Translational Lung Research Center TLRC, Heidelberg, Germany
- University of Latvia, Faculty of Medicine, Riga, Latvia
- Christian-Albrechts-Universität zu Kiel, Faculty of Medicine, Kiel, Germany
| | - Marco Brambilla
- Azienda Ospedaliero-Universitaria Maggiore della Carità di Novara, Novara, Italy
| | | | - Joanna Chorostowska
- Institute of Tuberculosis and Lung Diseases, Warsaw, Genetics and Clinical Immunology, Warsaw, Poland
| | | | - Dirk Deruysscher
- Maastricht University Medical Centre, Department of Radiation Oncology (MAASTRO Clinic), GROW-School for Oncology and Developmental Biology, Limburg, The Netherlands
| | - Walter De Wever
- Universitaire Ziekenhuizen Leuven, Radiology, Leuven, Belgium
| | | | - Aurelie Fabre
- University College Dublin School of Medicine, Histopathology, Dublin, Ireland
| | - Mina Gaga
- Sotiria General Hospital of Chest Diseases of Athens, 7th Respiratory Medicine Department, Athens, Greece
| | - Wouter van Geffen
- Medical Centre Leeuwarden, Department of Respiratory Medicine, Leeuwarden, The Netherlands
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases, Groningen, The Netherlands
| | - Georgia Hardavella
- Sotiria General Hospital of Chest Diseases of Athens, Respiratory Medicine, Athens, Greece
| | - Hans-Ulrich Kauczor
- University of Heidelberg, Diagnostic and Interventional Radiology, Heidelberg, Germany
- German Center for Lung Research DZL, Translational Lung Research Center TLRC, Heidelberg, Germany
| | - Anna Kerpel-Fronius
- National Koranyi Institute of Pulmonology, Department of Radiology, Budapest, Hungary
| | | | - Blin Nagavci
- Institute for Evidence in Medicine, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Ursula Nestle
- Kliniken Maria Hilf GmbH Monchengladbach, Nordrhein-Westfalen, Germany
| | - Nuria Novoa
- University Hospital of Salamanca, Thoracic Surgery, Salamanca, Spain
| | - Helmut Prosch
- Medical University of Vienna, Department of Biomedical Imaging and Image-guided Therapy, Vienna, Austria
| | - Mathias Prokop
- Radboud University Nijmegen Medical Center, Department of Radiology, Nijmegen, The Netherlands
| | - Paul Martin Putora
- Kantonsspital Sankt Gallen, Radiation Oncology, Sankt Gallen, Switzerland
- Inselspital Universitatsspital Bern, Radiation Oncology, Bern, Switzerland
| | | | - Marie-Pierre Revel
- Cochin Hospital, APHP, Radiology Department, Paris, France
- Université de Paris, Paris, France
| | | | - Giulia Veronesi
- Humanitas Research Hospital, Division of Thoracic and General Surgery, Rozzano, Italy
| | | | - Sabine Weckbach
- UniversitatsKlinikum Heidelberg, Heidelberg, Germany
- Bayer AG, Research and Development, Pharmaceuticals, Radiology, Berlin, Germany
| | - Torsten G Blum
- HELIOS Klinikum Emil von Behring GmbH, Lungenklinik Heckeshorn, Berlin, Germany
| | - David R Baldwin
- University of Nottingham, Faculty of Medicine and Health Sciences, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Department of Respiratory Medicine, Nottingham, UK
| |
Collapse
|
7
|
O'Dowd EL, Tietzova I, Bartlett E, Devaraj A, Biederer J, Brambilla M, Brunelli A, Chorostowska-Wynimko J, Decaluwe H, Deruysscher D, De Wever W, Donoghue M, Fabre A, Gaga M, van Geffen W, Hardavella G, Kauczor HU, Kerpel-Fronius A, van Meerbeeck J, Nagavci B, Nestle U, Novoa N, Prosch H, Prokop M, Putora PM, Rawlinson J, Revel MP, Snoeckx A, Veronesi G, Vliegenthart R, Weckbach S, Blum TG, Baldwin DR. ERS/ESTS/ESTRO/ESR/ESTI/EFOMP statement on management of incidental findings from low dose CT screening for lung cancer. Eur Respir J 2023; 62:2300533. [PMID: 37802631 DOI: 10.1183/13993003.00533-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 06/06/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Screening for lung cancer with low radiation dose computed tomography has a strong evidence base, is being introduced in several European countries and is recommended as a new targeted cancer screening programme. The imperative now is to ensure that implementation follows an evidence-based process that will ensure clinical and cost effectiveness. This European Respiratory Society (ERS) task force was formed to provide an expert consensus for the management of incidental findings which can be adapted and followed during implementation. METHODS A multi-European society collaborative group was convened. 23 topics were identified, primarily from an ERS statement on lung cancer screening, and a systematic review of the literature was conducted according to ERS standards. Initial review of abstracts was completed and full text was provided to members of the group for each topic. Sections were edited and the final document approved by all members and the ERS Science Council. RESULTS Nine topics considered most important and frequent were reviewed as standalone topics (interstitial lung abnormalities, emphysema, bronchiectasis, consolidation, coronary calcification, aortic valve disease, mediastinal mass, mediastinal lymph nodes and thyroid abnormalities). Other topics considered of lower importance or infrequent were grouped into generic categories, suitable for general statements. CONCLUSIONS This European collaborative group has produced an incidental findings statement that can be followed during lung cancer screening. It will ensure that an evidence-based approach is used for reporting and managing incidental findings, which will mean that harms are minimised and any programme is as cost-effective as possible.
Collapse
Affiliation(s)
- Emma L O'Dowd
- Nottingham University Hospitals NHS Trust, Nottingham, UK
- University of Nottingham, Faculty of Medicine and Health Sciences, Nottingham, UK
| | - Ilona Tietzova
- Charles University, First Faculty of Medicine, Department of Tuberculosis and Respiratory Diseases, Prague, Czech Republic
| | - Emily Bartlett
- Royal Brompton and Harefield NHS Foundation Trust, Radiology, London, UK
| | - Anand Devaraj
- Royal Brompton and Harefield NHS Foundation Trust, Radiology, London, UK
| | - Jürgen Biederer
- University of Heidelberg, Diagnostic and Interventional Radiology, Heidelberg, Germany
- German Center for Lung Research DZL, Translational Lung Research Center TLRC, Heidelberg, Germany
- University of Latvia, Faculty of Medicine, Riga, Latvia
- Christian-Albrechts-Universität zu Kiel, Faculty of Medicine, Kiel, Germany
| | - Marco Brambilla
- Azienda Ospedaliero-Universitaria Maggiore della Carità di Novara, Novara, Italy
| | | | | | | | - Dirk Deruysscher
- Maastricht University Medical Centre, Department of Radiation Oncology (MAASTRO Clinic), GROW-School for Oncology and Developmental Biology, Limburg, The Netherlands
| | - Walter De Wever
- Universitaire Ziekenhuizen Leuven, Radiology, Leuven, Belgium
| | | | - Aurelie Fabre
- University College Dublin School of Medicine, Histopathology, Dublin, Ireland
| | - Mina Gaga
- Sotiria General Hospital of Chest Diseases of Athens, 7th Respiratory Medicine Department, Athens, Greece
| | - Wouter van Geffen
- Medical Centre Leeuwarden, Department of Respiratory Medicine, Leeuwarden, The Netherlands
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases, Groningen, The Netherlands
| | - Georgia Hardavella
- Sotiria General Hospital of Chest Diseases of Athens, Respiratory Medicine, Athens, Greece
| | - Hans-Ulrich Kauczor
- University of Heidelberg, Diagnostic and Interventional Radiology, Heidelberg, Germany
- German Center for Lung Research DZL, Translational Lung Research Center TLRC, Heidelberg, Germany
| | - Anna Kerpel-Fronius
- National Koranyi Institute of Pulmonology, Department of Radiology, Budapest, Hungary
| | | | - Blin Nagavci
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Ursula Nestle
- Kliniken Maria Hilf GmbH Monchengladbach, Nordrhein-Westfalen, Germany
| | - Nuria Novoa
- University Hospital of Salamanca, Thoracic Surgery, Salamanca, Spain
| | - Helmut Prosch
- Medical University of Vienna, Department of Biomedical Imaging and Image-guided Therapy, Vienna, Austria
| | - Mathias Prokop
- Radboud University Nijmegen Medical Center, Department of Radiology, Nijmegen, The Netherlands
| | - Paul Martin Putora
- Kantonsspital Sankt Gallen, Radiation Oncology, Sankt Gallen, Switzerland
- Inselspital Universitatsspital Bern, Radiation Oncology, Bern, Switzerland
| | | | - Marie-Pierre Revel
- Cochin Hospital, APHP, Radiology Department, Paris, France
- Université de Paris, Paris, France
| | | | - Giulia Veronesi
- Humanitas Research Hospital, Division of Thoracic and General Surgery, Rozzano, Italy
| | | | - Sabine Weckbach
- UniversitatsKlinikum Heidelberg, Heidelberg, Germany
- Bayer AG, Research and Development, Pharmaceuticals, Radiology, Berlin, Germany
| | - Torsten G Blum
- HELIOS Klinikum Emil von Behring GmbH, Lungenklinik Heckeshorn, Berlin, Germany
| | - David R Baldwin
- Nottingham University Hospitals NHS Trust, Nottingham, UK
- University of Nottingham, Faculty of Medicine and Health Sciences, Nottingham, UK
| |
Collapse
|
8
|
Dyer DS, White C, Conley Thomson C, Gieske MR, Kanne JP, Chiles C, Parker MS, Menchaca M, Wu CC, Kazerooni EA. A Quick Reference Guide for Incidental Findings on Lung Cancer Screening CT Examinations. J Am Coll Radiol 2023; 20:162-172. [PMID: 36509659 DOI: 10.1016/j.jacr.2022.08.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE The US Preventive Services Task Force has recommended lung cancer screening (LCS) with low-dose CT (LDCT) in high-risk individuals since 2013. Because LDCT encompasses the lower neck, chest, and upper abdomen, many incidental findings (IFs) are detected. The authors created a quick reference guide to describe common IFs in LCS to assist LCS program navigators and ordering providers in managing the care continuum in LCS. METHODS The ACR IF white papers were reviewed for findings on LDCT that were age appropriate for LCS. A draft guide was created on the basis of recommendations in the IF white papers, the medical literature, and input from subspecialty content experts. The draft was piloted with LCS program navigators recruited through contacts by the ACR LCS Steering Committee. The navigators completed a survey on overall usefulness, clarity, adequacy of content, and user experience with the guide. RESULTS Seven anatomic regions including 15 discrete organs with 45 management recommendations were identified as relevant to the age of individuals eligible for LCS. The draft was piloted by 49 LCS program navigators from 32 facilities. The guide was rated as useful and clear by 95% of users. No unexpected or adverse experiences were reported in using the guide. On the basis of feedback, relevant sections were reviewed and edited. CONCLUSIONS The ACR Lung Cancer Screening CT Incidental Findings Quick Reference Guide outlines the common IFs in LCS and can serve as an easy-to-use resource for ordering providers and LCS program navigators to help guide management.
Collapse
Affiliation(s)
- Debra S Dyer
- Chair, Department of Radiology, Director, Lung Cancer Screening Program, and Director, Incidental Lung Nodule Program & Lung Nodule Registry, National Jewish Health, Denver, Colorado.
| | - Charles White
- Vice Chair, Clinical Affairs, University of Maryland School of Medicine, Baltimore, Maryland. https://twitter.com/
| | - Carey Conley Thomson
- Chair, Department of Medicine and Director, Multidisciplinary Thoracic Oncology and Lung Cancer Screening Program, Department of Medicine, Mount Auburn Hospital/Beth Israel Lahey Health, Cambridge, Massachusetts; and Harvard Medical School, Boston, Massachusetts
| | - Michael R Gieske
- Director, Lung Cancer Screening Physician, Director, Virtual Health Director, Primary Care East Department, Lead Provider, Ft. Mitchell St. Elizabeth Primary Care, Physician Director, Policy and Government Relations, St Elizabeth Healthcare, Edgewood, Kentucky
| | - Jeffrey P Kanne
- Chief, Thoracic Imaging and Vice Chair, Quality and Safety, Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. https://twitter.com/
| | - Caroline Chiles
- Director, Lung Cancer Screening Program, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina. https://twitter.com/
| | - Mark S Parker
- Director, Thoracic Imaging Section and Director, Thoracic Imaging Fellowship Program, Early Detection Lung Screening Program, VCU Health Systems, Richmond, Virginia
| | - Martha Menchaca
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
| | - Carol C Wu
- Deputy Chair Ad Interim, Department of Thoracic Imaging, MD Anderson Cancer Center, Houston, Texas. https://twitter.com/
| | - Ella A Kazerooni
- Associate Chief Clinical Officer for Diagnostics and Clinical Information Management, University of Michigan Medical School, Ann Arbor, Michigan. https://twitter.com/
| |
Collapse
|
9
|
Ma Y, Qiu S, Zhou R. Osteoporosis in Patients With Respiratory Diseases. Front Physiol 2022; 13:939253. [PMID: 35903070 PMCID: PMC9315364 DOI: 10.3389/fphys.2022.939253] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 06/07/2022] [Indexed: 11/13/2022] Open
Abstract
Climate change, environmental pollution, and virus epidemics have sharply increased the number of patients suffering from respiratory diseases in recent years. Prolonged periods of illness and drug use increase the occurrence of complications in these patients. Osteoporosis is the common bone metabolism disease with respiratory disturbance, which affects prognosis and increases mortality of patients. The problem of osteoporosis in patients with respiratory diseases needs more attention. In this review, we concluded the characteristics of osteoporosis in some respiratory diseases including COPD, asthma, COVID-19, tuberculosis, and lung cancer. We revealed that hypoxia was the common pathogenesis of osteoporosis secondary to respiratory diseases, with malnutrition and corticosteroid abuse driving the progression of osteoporosis. Hypoxia-induced ROS accumulation and activated HIF-1α lead to attenuated osteogenesis and enhanced osteoclastogenesis in patients with respiratory diseases. Tuberculosis and cancer also invaded bone tissue and reduced bone strength by direct infiltration. For the treatment of osteoporosis in respiratory patients, oral-optimized bisphosphonates were the best treatment modality. Vitamin D was a necessary supplement, both for calcium absorption in osteogenesis and for improvement of respiratory lesions. Reasonable adjustment of the dose and course of corticosteroids according to the etiology and condition of patients is beneficial to prevent the occurrence and development of osteoporosis. Additionally, HIF-1α was a potential target for the treatment of osteoporosis in respiratory patients, which could be activated under hypoxia condition and involved in the process of bone remodeling.
Collapse
Affiliation(s)
- Yue Ma
- Department of Pulmonary and Critical Care Medicine, Shengjing Hospital of China Medical University, Shenyang, China
| | - Shui Qiu
- Department of Orthopedics, First Hospital of China Medical University, Shenyang, China
| | - Renyi Zhou
- Department of Orthopedics, First Hospital of China Medical University, Shenyang, China
- *Correspondence: Renyi Zhou,
| |
Collapse
|
10
|
CT-Derived Body Composition Assessment as a Prognostic Tool in Oncologic Patients: From Opportunistic Research to Artificial Intelligence-Based Clinical Implementation. AJR Am J Roentgenol 2022; 219:671-680. [PMID: 35642760 DOI: 10.2214/ajr.22.27749] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
CT-based body composition measures are well established in research settings as prognostic markers in oncologic patients. Numerous retrospective studies have shown the role of objective measurements extracted from abdominal CT images of skeletal muscle, abdominal fat, and bone mineral density in providing more accurate assessments of frailty and cancer cachexia in comparison with traditional clinical methods. Quantitative CT-based measurements of liver fat and aortic atherosclerotic calcification have received relatively less attention in cancer care but also provide prognostic information. Patients with cancer routinely undergo serial CT scans for staging, treatment response, and surveillance, providing the opportunity for performing quantitative body composition assessment as part of routine clinical care. The emergence of fully automated artificial intelligence-based segmentation and quantification tools to replace earlier time-consuming manual and semi-automated methods for body composition analysis will allow these opportunistic measures to transition from the research realm to clinical practice. With continued investigation, the measurements may ultimately be applied to achieve more precise risk stratification as a component of personalized oncologic care.
Collapse
|
11
|
Utility of Noncancerous Chest CT Features for Predicting Overall Survival and Noncancer Death in Patients With Stage I Lung Cancer Treated With Stereotactic Body Radiotherapy. AJR Am J Roentgenol 2022; 219:579-589. [PMID: 35416054 DOI: 10.2214/ajr.22.27484] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background: Noncancerous imaging markers can be readily derived from pretreatment diagnostic and radiotherapy planning chest CT examinations. Objective: To explore the ability of noncancerous features on chest CT to predict overall survival (OS) and noncancer-related death in patients with stage I lung cancer treated with stereotactic body radiation therapy (SBRT). Methods: This retrospective study included 282 patients (168 female, 114 male; median age, 75 years) with stage I lung cancer treated with SBRT between January 2009 and June 2017. Pretreatment chest CT was used to quantify coronary artery calcium (CAC) score, pulmonary artery (PA)-to-aorta ratio, emphysema, and body composition in terms of the cross-sectional area and attenuation of skeletal muscle and subcutaneous adipose tissue at the T5, T8, and T10 vertebral levels. Associations of clinical and imaging features with OS were quantified using a multivariable Cox proportional hazards (PH) model. Penalized multivariable Cox PH models to predict OS were constructed using clinical features only and using both clinical and imaging features. Models' discriminatory ability was assessed by constructing time-varying ROC curves and computing AUC at prespecified times. Results: After a median OS of 60.8 months (95% CI 55.8-68.9), 148 (52.5%) patients died, including 83 (56.1%) with noncancer deaths. Higher CAC score (11-399: hazard ratio [HR] 1.83 [95% CI 1.15-2.91], P=.01; ≥400: HR 1.63 [95% CI 1.01-2.63], P=.04), higher PA-to-aorta ratio (HR 1.33 [95% CI 1.16-1.52], P<.001, per 0.1-unit increase), and lower thoracic skeletal muscle index (HR 0.88 [95% CI 0.79-0.98], P=.02, per 10 cm2/m2 increase) were independently associated with shorter OS. Discriminatory ability for 5-year OS was greater for the model including clinical and imaging features than for the model including clinical features only (AUC, 0.75 [95% CI 0.68-0.83] versus 0.61 [95% CI 0.53-0.70], p < .01). The model's most important clinical or imaging feature based on mean standardized regression coefficients was the PA-to-aorta ratio. Conclusions: In patients undergoing SBRT for stage I lung cancer, higher CAC score, higher PA-to-aorta ratio, and lower thoracic skeletal muscle index independently predicted worse OS. Clinical Impact: Noncancerous imaging features on chest CT performed before SBRT improve survival prediction compared with clinical features alone.
Collapse
|
12
|
Penha D, Pinto E, Monaghan C, Hochhegger B, Marchiori E, Taborda-Barata L, Irion K, Ravara S, Kauczor HU. Incidental findings on lung cancer screening: pictorial essay and systematic checklist. J Bras Pneumol 2022; 48:e20210371. [PMID: 35137873 PMCID: PMC8836644 DOI: 10.36416/1806-3756/e20210371] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 11/05/2021] [Indexed: 11/23/2022] Open
Abstract
Lung cancer screening (LCS) programs are increasing worldwide. Incidental findings (IFs) on LCS are defined as low-dose CT findings unrelated to the primary purpose of identifying lung cancer. Most IFs on LCS are benign and clinically insignificant but are being increasingly recognized, and some require urgent referral for further diagnostic workup. Other findings are expected and are known as smoking-related comorbidities, including COPD, cardiovascular disease, emphysema, and interstitial lung disease, and their diagnosis can have a significant impact on patient prognosis. The purpose of this pictorial essay is to illustrate the most common IFs on LCS, organized by organ. We will discuss the current literature on IFs on LCS, focusing on their prevalence, appropriate communication, and triggering of clinical pathway systems.
Collapse
Affiliation(s)
- Diana Penha
- . Faculdade de Ciências da Saúde, Universidade da Beira Interior, Covilhã, Portugal.,. Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Erique Pinto
- . Faculdade de Ciências da Saúde, Universidade da Beira Interior, Covilhã, Portugal
| | - Colin Monaghan
- . Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Bruno Hochhegger
- . Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre (RS) Brasil.,. University of Florida. Department of Radiology. Gainesville (FL) USA
| | - Edson Marchiori
- . Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro (RJ) Brasil.,. Faculdade de Medicina, Universidade Federal Fluminense, Niterói (RJ) Brasil
| | - Luís Taborda-Barata
- . Faculdade de Ciências da Saúde, Universidade da Beira Interior, Covilhã, Portugal.,. Centro de Investigação em Ciências da Saúde, Universidade da Beira Interior - CICS-UBI - Covilhã, Portugal
| | - Klaus Irion
- . Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Sofia Ravara
- . Centro de Investigação em Ciências da Saúde, Universidade da Beira Interior - CICS-UBI - Covilhã, Portugal.,. Centro de Investigação em Saúde Pública, Escola Nacional de Saúde Pública, Universidade NOVA de Lisboa, Lisboa, Portugal.,. Setor de Pneumologia, Centro Hospitalar Universitário Cova da Beira, Covilhã, Portugal
| | - Hans-Ulrich Kauczor
- . Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany.,. Translational Lung Research Center, Heidelberg, Germany
| |
Collapse
|
13
|
Jing X, Tan L, Fu H, Yang L, Yang M. Associations of ADL Disability With Trunk Muscle Mass and Muscle Quality Indicators Measured by Opportunistic Chest Computed Tomography Imaging Among Older Inpatients. Front Med (Lausanne) 2021; 8:743698. [PMID: 34778305 PMCID: PMC8581194 DOI: 10.3389/fmed.2021.743698] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 10/05/2021] [Indexed: 02/05/2023] Open
Abstract
Objectives: Sarcopenia is an important predictor of dependence in activities of daily living (ADL disability); however, the association between muscle quality and ADL disability has not been established. We aimed (1) to assess the feasibility of measuring trunk muscle mass and muscle quality by chest CT images; and (2) to explore the possible associations of ADL disability with these muscle mass and muscle quality indicators among older inpatients. Methods: We included older patients in an acute care ward. ADL disability was defined as the Barthel Index (BI) score ≤ 60 points. Unenhanced chest CT images at the 12th thorax (T12) vertebral level were used to segment skeletal muscle area (SMA) and intermuscular adipose tissue (IMAT) and to measure the mean skeletal muscle radiodensity (SMD). Skeletal muscle index (SMI), the muscle mass indicator, was calculated by SMA (cm2)/body height squared (m2). The percentage of IMAT (IMAT%) was calculated using the equation: IMAT% = IMAT/(SMA+ IMAT) ×100%. Skeletal muscle radiodensity, IMAT, and IMAT% were the muscle quality indicators. Kendall's tau rank correlation coefficients (τ) were calculated to explore the correlations. Univariate and multivariate logistic regression models were performed to calculate odds ratios (OR) and 95% confidence interval (CI). Results: We included 212 participants. Skeletal muscle index and SMD were positively and significantly associated with the BI score (τ = 0.14 and 0.31, respectively, both P < 0.001); whereas IMAT and IMAT% were negatively and significantly associated with the BI score (τ = -0.21, P < 0.001; τ = -0.21, P < 0.012). After adjusting for confounders, SMI (adjusted OR 1.03, 95% CI 0.97-1.09) was not independently associated with ADL disability; however, SMD (adjusted OR 0.94, 95% CI 0.88-0.99), IMAT (adjusted OR 1.11, 95% CI 1.03-1.20), and IMAT% (adjusted OR 1.09, 95% CI 1.02-1.16) were independently associated with ADL disability. Subgroup analysis found similar results in men; however, none of these indicators were independently associated with ADL disability in women. Conclusion: Trunk muscle quality indicators (SMD, IMAT, and IMAT%) measured by chest CT images, but not SMI, are independently associated with ADL disability in a single-center study population of older inpatients, especially in men. Further research is necessary to validate our findings.
Collapse
Affiliation(s)
- Xiaofan Jing
- Department of Clinical Nutrition, West China Hospital, Sichuan University, Chengdu, China
| | - Lingling Tan
- Center of Gerontology and Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Hongbo Fu
- Center of Gerontology and Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Ling Yang
- Outpatient Department, West China Hospital, Sichuan University, Chengdu, China
| | - Ming Yang
- Center of Gerontology and Geriatrics, West China Hospital, Sichuan University, Chengdu, China.,National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
14
|
Tan L, Ji G, Bao T, Fu H, Yang L, Yang M. Diagnosing sarcopenia and myosteatosis based on chest computed tomography images in healthy Chinese adults. Insights Imaging 2021; 12:163. [PMID: 34743259 PMCID: PMC8572237 DOI: 10.1186/s13244-021-01106-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 10/05/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Measuring muscle mass and muscle quality based on chest Computed Tomography (CT) images would facilitate sarcopenia and myosteatosis research. We aimed (1) to measure muscle mass and myosteatosis based on chest CT images at the 12th thoracic vertebra level and compare the relevant indicators with whole-body skeletal muscle mass (BSM) and whole-body fat mass (BFM) measured by bioelectrical impedance analysis; and (2) to determine the cut-off points of these indicators for diagnosing sarcopenia or myosteatosis in healthy Chinese adults. METHODS Chest CT images were analyzed using a segmentation software. Skeletal muscle area (SMA), skeletal muscle radiodensity (SMD), and intermuscular adiposity tissue (IMAT) were measured. Skeletal muscle indices (SMIs) and IMAT/SMA ratio were calculated. RESULTS We included 569 participants. SMA, SMA/height2, and SMA/BMI were strongly and positively correlated with BSM (r = 0.90, 0.72, and 0.69, respectively, all p < 0.001); whereas SMA/weight was moderately and positively correlated with BSM (r = 0.38, p < 0.001). IMAT and IMAT/SMA were strongly and positively correlated with BFM (r = 0.67 and 0.58, respectively, both p < 0.001). SMD was moderately and negatively correlated with BFM (r = - 0.40, p < 0.001). We suggest SMA/height2 (< 25.75 cm2/m2 in men and < 20.16 cm2/m2 in women) for diagnosing sarcopenia and SMD (< 37.42 HU in men and < 33.17 HU in women) or IMAT (> 8.72 cm2 in men and > 4.58 cm2 in women) for diagnosing myosteatosis. CONCLUSIONS Muscle mass indicators (SMA and SMIs) and muscle quality indicators (SMD, IMAT, and IMAT/SMA) measured by chest CT images are valuable for diagnosing sarcopenia and myosteatosis, respectively.
Collapse
Affiliation(s)
- Lingling Tan
- Center of Gerontology and Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Guiyi Ji
- Health Management Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ting Bao
- Health Management Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hongbo Fu
- Center of Gerontology and Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ling Yang
- Outpatient Department, West China Hospital, Sichuan University, No 37 Guoxue Lane, Chengdu, 610041, Sichuan, China.
| | - Ming Yang
- Center of Gerontology and Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
- National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, No 37 Guoxue Lane, Chengdu, 610041, Sichuan, China.
- Precision Medicine Research Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
| |
Collapse
|
15
|
Yang M, Tan L, Xie L, Hu S, Liu D, Wang J, Li W. Factors That Improve Chest Computed Tomography-Defined Sarcopenia Prognosis in Advanced Non-Small Cell Lung Cancer. Front Oncol 2021; 11:754975. [PMID: 34660324 PMCID: PMC8517486 DOI: 10.3389/fonc.2021.754975] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 09/20/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Whether muscle strength and physical performance should be components of sarcopenia remains controversial. This study evaluated the skeletal muscle index derived from computed tomography images at the 12th thoracic vertebra level (T12 SMI), handgrip strength, performance status, and their combination for predicting overall survival in patients with advanced non-small cell lung cancer. METHODS Chest computed tomography, handgrip strength measurement, and bioelectrical impedance analysis were performed. Sarcopenia was defined based on the T12 SMI alone or the T12 SMI, handgrip, and/or physical performance (i.e. Asian Working Group for Sarcopenia [AWGS]-defined sarcopenia or severe sarcopenia). RESULTS Overall, 639 participants were included; 488 (76.4%) died. At baseline, 160 (25.0%), 141 (22.1%), and 42 (6.6%) patients had computed tomography-defined sarcopenia, AWGS-defined sarcopenia, and AWGS-defined severe sarcopenia, respectively. Chest computed tomography-defined sarcopenia (hazard ratio [HR], 2.00; 95% confidence interval [CI], 1.65-2.43), AWGS-defined sarcopenia (HR, 2.00; 95% CI, 1.59-2.49), and AWGS-defined severe sarcopenia (HR, 3.01; 95% CI, 2.21-4.09) were more strongly associated with poor prognosis than a performance status score ≥2 (HR, 1.37; 95% CI, 1.10-1.73). CONCLUSIONS Adding handgrip strength and the performance status score to chest computed tomography-defined sarcopenia improved its prognostic ability. Oncological sarcopenia research should focus on muscle mass, strength, and function.
Collapse
Affiliation(s)
- Ming Yang
- The Center of Gerontology and Geriatrics, West China Hospital, Sichuan University, Chengdu, China
- Precision Medicine Research Center, West China Hospital, Sichuan University, Chengdu, China
- National Clinical Research Center for Geriatrics (WCH), West China Hospital, Sichuan University, Chengdu, China
| | - Lingling Tan
- The Center of Gerontology and Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Lingling Xie
- West China School of Nursing, West China Hospital, Sichuan University/ Department of Oncology, Shangjin Nanfu Hospital, Sichuan University, Chengdu, China
| | - Song Hu
- Department of Radiology, Shangjin Nanfu Hospital, Sichuan University, Chengdu, China
| | - Dan Liu
- Population Health Sciences, German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - Jing Wang
- West China School of Nursing, West China Hospital, Sichuan University/ Department of Oncology, Shangjin Nanfu Hospital, Sichuan University, Chengdu, China
| | - Weimin Li
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
- Institute of Respiratory Health, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
- The Research Units of West China, Chinese Academy of Medical Sciences, Chengdu, China
| |
Collapse
|
16
|
Rankin NM, McWilliams A, Marshall HM. Lung cancer screening implementation: Complexities and priorities. Respirology 2021; 25 Suppl 2:5-23. [PMID: 33200529 DOI: 10.1111/resp.13963] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 10/06/2020] [Indexed: 12/17/2022]
Abstract
Lung cancer is the number one cause of cancer death worldwide. The benefits of lung cancer screening to reduce mortality and detect early-stage disease are no longer in any doubt based on the results of two landmark trials using LDCT. Lung cancer screening has been implemented in the US and South Korea and is under consideration by other communities. Successful translation of demonstrated research outcomes into the routine clinical setting requires careful implementation and co-ordinated input from multiple stakeholders. Implementation aspects may be specific to different healthcare settings. Important knowledge gaps remain, which must be addressed in order to optimize screening benefits and minimize screening harms. Lung cancer screening differs from all other cancer screening programmes as lung cancer risk is driven by smoking, a highly stigmatized behaviour. Stigma, along with other factors, can impact smokers' engagement with screening, meaning that smokers are generally 'hard to reach'. This review considers critical points along the patient journey. The first steps include selecting a risk threshold at which to screen, successfully engaging the target population and maximizing screening uptake. We review barriers to smoker engagement in lung and other cancer screening programmes. Recruitment strategies used in trials and real-world (clinical) programmes and associated screening uptake are reviewed. To aid cross-study comparisons, we propose a standardized nomenclature for recording and calculating recruitment outcomes. Once participants have engaged with the screening programme, we discuss programme components that are critical to maximize net benefit. A whole-of-programme approach is required including a standardized and multidisciplinary approach to pulmonary nodule management, incorporating probabilistic nodule risk assessment and longitudinal volumetric analysis, to reduce unnecessary downstream investigations and surgery; the integration of smoking cessation; and identification and intervention for other tobacco related diseases, such as coronary artery calcification and chronic obstructive pulmonary disease. National support, integrated with tobacco control programmes, and with appropriate funding, accreditation, data collection, quality assurance and reporting mechanisms will enhance lung cancer screening programme success and reduce the risks associated with opportunistic, ad hoc screening. Finally, implementation research must play a greater role in informing policy change about targeted LDCT screening programmes.
Collapse
Affiliation(s)
- Nicole M Rankin
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Annette McWilliams
- Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia.,Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, Australia.,Thoracic Tumour Collaborative of Western Australia, Western Australia Cancer and Palliative Care Network, Perth, WA, Australia
| | - Henry M Marshall
- Department of Thoracic Medicine, The Prince Charles Hospital, Brisbane, QLD, Australia.,The University of Queensland Thoracic Research Centre, Brisbane, QLD, Australia
| |
Collapse
|
17
|
Lenchik L, Barnard R, Boutin RD, Kritchevsky SB, Chen H, Tan J, Cawthon PM, Weaver AA, Hsu FC. Automated Muscle Measurement on Chest CT Predicts All-Cause Mortality in Older Adults From the National Lung Screening Trial. J Gerontol A Biol Sci Med Sci 2021; 76:277-285. [PMID: 32504466 PMCID: PMC7812435 DOI: 10.1093/gerona/glaa141] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Muscle metrics derived from computed tomography (CT) are associated with adverse health events in older persons, but obtaining these metrics using current methods is not practical for large datasets. We developed a fully automated method for muscle measurement on CT images. This study aimed to determine the relationship between muscle measurements on CT with survival in a large multicenter trial of older adults. METHOD The relationship between baseline paraspinous skeletal muscle area (SMA) and skeletal muscle density (SMD) and survival over 6 years was determined in 6,803 men and 4,558 women (baseline age: 60-69 years) in the National Lung Screening Trial (NLST). The automated machine learning pipeline selected appropriate CT series, chose a single image at T12, and segmented left paraspinous muscle, recording cross-sectional area and density. Associations between SMA and SMD with all-cause mortality were determined using sex-stratified Cox proportional hazards models, adjusted for age, race, height, weight, pack-years of smoking, and presence of diabetes, chronic lung disease, cardiovascular disease, and cancer at enrollment. RESULTS After a mean 6.44 ± 1.06 years of follow-up, 635 (9.33%) men and 265 (5.81%) women died. In men, higher SMA and SMD were associated with a lower risk of all-cause mortality, in fully adjusted models. A one-unit standard deviation increase was associated with a hazard ratio (HR) = 0.85 (95% confidence interval [CI] = 0.79, 0.91; p < .001) for SMA and HR = 0.91 (95% CI = 0.84, 0.98; p = .012) for SMD. In women, the associations did not reach significance. CONCLUSION Higher paraspinous SMA and SMD, automatically derived from CT exams, were associated with better survival in a large multicenter cohort of community-dwelling older men.
Collapse
Affiliation(s)
- Leon Lenchik
- Department of Radiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Ryan Barnard
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Robert D Boutin
- Department of Radiology, Stanford University Medical Center, California
| | - Stephen B Kritchevsky
- Department of Internal Medicine, Section on Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Haiying Chen
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Josh Tan
- Department of Radiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Peggy M Cawthon
- California Pacific Medical Center Research Institute, San Francisco
| | - Ashley A Weaver
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Fang-Chi Hsu
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| |
Collapse
|
18
|
Osteoporosis screening using computed tomography for men with prostate cancer: results of a prospective study. Arch Osteoporos 2020; 15:32. [PMID: 32112196 PMCID: PMC7402416 DOI: 10.1007/s11657-020-0711-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 01/01/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED We performed a prospective study using both FRAX and computed tomography to screen for osteoporosis in men undergoing radiation for prostate cancer. We found that implementing routine computed tomography (CT)-based screening was feasible in the setting of a prospective study, but the yield of osteoporosis identification was low in this population. PURPOSE Men with prostate cancer (PCa) are at increased risk of hip fracture for multiple reasons. Estimation of hip fracture risk with the FRAX tool is currently recommended, but FRAX alone may not identify a portion of men with osteoporosis. We hypothesized that adding bone mineral density (BMD) screening using CT to FRAX is feasible and would identify more men with osteoporosis. METHODS Men with PCa scheduled to undergo CT simulation for radiation treatment were enrolled in a single-arm prospective study. The mean attenuation of the mid-L5 vertebral body trabecular bone (L5CT) was calculated on a single slice using the radiation simulation CT scan. The 10-year risk of hip fracture was calculated using the FRAX tool. Dual energy X-ray absorptiometry (DXA) was performed for men whose L5CT measurement was less than 130 Hounsfield units (HU). RESULTS A total of 98 eligible men were enrolled and underwent FRAX and CT screening. The median 10-year risk of hip fracture was 1.1% and exceeded 3% in 16 cases; the median L5CT was 162.28 HU (range 55.6-526.1 HU). DXA scan was completed in 15 men who had L5CT < 130 HU but 10-year calculated hip fracture risk < 3%, 1 of whom was found to have osteoporosis (T-score ≤ -2.5). CONCLUSIONS Implementing CT-based BMD screening was feasible in the setting of a prospective study for men receiving radiation for PCa, but fewer cases than anticipated of osteoporosis were identified.
Collapse
|
19
|
Kauczor HU, Baird AM, Blum TG, Bonomo L, Bostantzoglou C, Burghuber O, Čepická B, Comanescu A, Couraud S, Devaraj A, Jespersen V, Morozov S, Nardi Agmon I, Peled N, Powell P, Prosch H, Ravara S, Rawlinson J, Revel MP, Silva M, Snoeckx A, van Ginneken B, van Meerbeeck JP, Vardavas C, von Stackelberg O, Gaga M. ESR/ERS statement paper on lung cancer screening. Eur Respir J 2020; 55:13993003.00506-2019. [PMID: 32051182 DOI: 10.1183/13993003.00506-2019] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 08/16/2019] [Indexed: 12/18/2022]
Abstract
In Europe, lung cancer ranks third among the most common cancers, remaining the biggest killer. Since the publication of the first European Society of Radiology and European Respiratory Society joint white paper on lung cancer screening (LCS) in 2015, many new findings have been published and discussions have increased considerably. Thus, this updated expert opinion represents a narrative, non-systematic review of the evidence from LCS trials and description of the current practice of LCS as well as aspects that have not received adequate attention until now. Reaching out to the potential participants (persons at high risk), optimal communication and shared decision-making will be key starting points. Furthermore, standards for infrastructure, pathways and quality assurance are pivotal, including promoting tobacco cessation, benefits and harms, overdiagnosis, quality, minimum radiation exposure, definition of management of positive screen results and incidental findings linked to respective actions as well as cost-effectiveness. This requires a multidisciplinary team with experts from pulmonology and radiology as well as thoracic oncologists, thoracic surgeons, pathologists, family doctors, patient representatives and others. The ESR and ERS agree that Europe's health systems need to adapt to allow citizens to benefit from organised pathways, rather than unsupervised initiatives, to allow early diagnosis of lung cancer and reduce the mortality rate. Now is the time to set up and conduct demonstration programmes focusing, among other points, on methodology, standardisation, tobacco cessation, education on healthy lifestyle, cost-effectiveness and a central registry.
Collapse
Affiliation(s)
- Hans-Ulrich Kauczor
- Dept of Diagnostic and Interventional Radiology, University Hospital Heidelberg, German Center of Lung Research, Heidelberg, Germany
| | - Anne-Marie Baird
- Central Pathology Laboratory, Trinity College Dublin, St. James's Hospital, Dublin, Ireland
| | | | - Lorenzo Bonomo
- Dept of Radiology, Policlinico Universitario Agostino Gemelli, Rome, Italy
| | | | | | | | | | - Sébastien Couraud
- Service de Pneumologie et Oncologie Thoracique, Hospices Civils de Lyon, CH Lyon Sud, Pierre Bénite, France.,Faculté de Médecine et de Maïeutique Lyon Sud - Charles Mérieux, Université Claude Bernard Lyon I, Oullins, France
| | | | | | - Sergey Morozov
- Dept of Health Care of Moscow, Research and Practical Clinical Center of Diagnostics and Telemedicine Technologies, Moscow, Russian Federation
| | | | - Nir Peled
- Thoracic Cancer Unit, Rabin Medical Center, Petach Tiqwa, Israel
| | | | - Helmut Prosch
- Dept of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Sofia Ravara
- Medical Sciences, Faculty of Health Sciences, University of Beira Interior, Covilha, Portugal.,Tobacco Cessation Unit, CHCB University Hospital, Covilha, Portugal
| | | | | | - Mario Silva
- Section of Radiology, Dept of Medicine and Surgery (DiMeC), University of Parma, Parma, Italy
| | | | - Bram van Ginneken
- Image Sciences Institute, University Medical Centre, Utrecht, The Netherlands.,Dept of Radiology, Nijmegen Medical Centre, Nijmegen, The Netherlands
| | | | - Constantine Vardavas
- Clinic of Social and Family Medicine, Faculty of Medicine, University of Crete, Heraklion, Greece.,Center for Global Tobacco Control, Department of Society, Human Development and Health, Harvard School of Public Health, Boston, MA, USA
| | - Oyunbileg von Stackelberg
- Dept of Diagnostic and Interventional Radiology, University Hospital Heidelberg, German Center of Lung Research, Heidelberg, Germany
| | - Mina Gaga
- 7th Respiratory Medicine Dept, Athens Chest Hospital Sotiria, Athens, Greece
| | | |
Collapse
|
20
|
Kauczor HU, Baird AM, Blum TG, Bonomo L, Bostantzoglou C, Burghuber O, Čepická B, Comanescu A, Couraud S, Devaraj A, Jespersen V, Morozov S, Agmon IN, Peled N, Powell P, Prosch H, Ravara S, Rawlinson J, Revel MP, Silva M, Snoeckx A, van Ginneken B, van Meerbeeck JP, Vardavas C, von Stackelberg O, Gaga M. ESR/ERS statement paper on lung cancer screening. Eur Radiol 2020; 30:3277-3294. [PMID: 32052170 DOI: 10.1007/s00330-020-06727-7] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 08/16/2019] [Indexed: 12/17/2022]
Abstract
In Europe, lung cancer ranks third among the most common cancers, remaining the biggest killer. Since the publication of the first European Society of Radiology and European Respiratory Society joint white paper on lung cancer screening (LCS) in 2015, many new findings have been published and discussions have increased considerably. Thus, this updated expert opinion represents a narrative, non-systematic review of the evidence from LCS trials and description of the current practice of LCS as well as aspects that have not received adequate attention until now. Reaching out to the potential participants (persons at high risk), optimal communication and shared decision-making will be key starting points. Furthermore, standards for infrastructure, pathways and quality assurance are pivotal, including promoting tobacco cessation, benefits and harms, overdiagnosis, quality, minimum radiation exposure, definition of management of positive screen results and incidental findings linked to respective actions as well as cost-effectiveness. This requires a multidisciplinary team with experts from pulmonology and radiology as well as thoracic oncologists, thoracic surgeons, pathologists, family doctors, patient representatives and others. The ESR and ERS agree that Europe's health systems need to adapt to allow citizens to benefit from organised pathways, rather than unsupervised initiatives, to allow early diagnosis of lung cancer and reduce the mortality rate. Now is the time to set up and conduct demonstration programmes focusing, among other points, on methodology, standardisation, tobacco cessation, education on healthy lifestyle, cost-effectiveness and a central registry.Key Points• Pulmonologists and radiologists both have key roles in the set up of multidisciplinary LCS teams with experts from many other fields.• Pulmonologists identify people eligible for LCS, reach out to family doctors, share the decision-making process and promote tobacco cessation.• Radiologists ensure appropriate image quality, minimum dose and a standardised reading/reporting algorithm, together with a clear definition of a "positive screen".• Strict algorithms define the exact management of screen-detected nodules and incidental findings.• For LCS to be (cost-)effective, it has to target a population defined by risk prediction models.
Collapse
Affiliation(s)
- Hans-Ulrich Kauczor
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, German Center of Lung Research, INF 110, 69120, Heidelberg, Germany.
| | - Anne-Marie Baird
- Central Pathology Laboratory, Trinity College Dublin, St. James's Hospital, Dublin, Ireland
| | | | - Lorenzo Bonomo
- Department of Radiology, Policlinico Universitario Agostino Gemelli, Rome, Italy
| | | | | | | | | | - Sébastien Couraud
- Service de Pneumologie et Oncologie Thoracique, Hospices Civils de Lyon, Sud, Pierre Bénite, Lyon, CH, France.,Faculté de Médecine et de Maïeutique Lyon Sud - Charles Mérieux, Université Claude Bernard Lyon I, Oullins, France
| | | | | | - Sergey Morozov
- Department of Health Care of Moscow, Research and Practical Clinical Center of Diagnostics and Telemedicine Technologies, Moscow, Russian Federation
| | | | - Nir Peled
- Thoracic Cancer Unit, Rabin Medical Center, Petach Tiqwa, Israel
| | | | - Helmut Prosch
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Sofia Ravara
- Medical Sciences, Faculty of Health Sciences, University of Beira Interior, Covilha, Portugal.,Tobacco Cessation Unit, CHCB University Hospital, Covilha, Portugal
| | | | | | - Mario Silva
- Section of Radiology, Department of Medicine and Surgery (DiMeC), University of Parma, Parma, Italy
| | | | - Bram van Ginneken
- Image Sciences Institute, University Medical Centre, Utrecht, The Netherlands.,Department of Radiology, Nijmegen Medical Centre, Nijmegen, The Netherlands
| | | | - Constantine Vardavas
- Clinic of Social and Family Medicine, Faculty of Medicine, University of Crete, Heraklion, Greece.,Center for Global Tobacco Control, Department of Society, Human Development and Health, Harvard School of Public Health, Boston, MA, USA
| | - Oyunbileg von Stackelberg
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, German Center of Lung Research, INF 110, 69120, Heidelberg, Germany
| | - Mina Gaga
- 7th Respiratory Medicine Department, Athens Chest Hospital Sotiria, Athens, Greece
| | | |
Collapse
|
21
|
Ferguson MK, Mitzman B, Derstine B, Lee SM, Pienta MJ, Wang SC, Lin J. A Morphomic Index Is an Independent Predictor of Survival After Lung Cancer Resection. Ann Thorac Surg 2019; 109:873-878. [PMID: 31862495 DOI: 10.1016/j.athoracsur.2019.10.064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 09/17/2019] [Accepted: 10/18/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Sarcopenia, visceral fat volume, and bone density have been associated with lung cancer survival. We developed a morphomic index based on computed tomographic measurements of these components, and assessed its relationship to survival after lung cancer resection. METHODS Patients who underwent lung cancer resection from 1995 to 2014 were evaluated. A morphomic index (range of 0 to 3) was developed as the sum of the scores for three body components-dorsal muscle area, vertebral trabecular bone density, and visceral fat area-measured at vertebral levels T10 to T12, with a point assigned to each component when in the lowest tercile. The relationship of the morphomic index to overall survival was assessed by the log rank test. Overall survival was assessed using Cox proportional hazards models adjusted for relevant covariates. RESULTS We included 944 patients (451 women; 48%). The mean age was 66.4 ± 10.3 years. Median follow-up was 4.5 years. Median survival was associated with the morphomic index scores on univariate analysis (P < .001). Morphomic index scores of 2 (P = .026) and 3 (P = .004) referenced to score 0 or 1 were independent predictors of survival on Cox regression analysis. CONCLUSIONS A morphomic index is an independent predictor of survival after lung cancer resection. The index may help in calibrating patient expectations and in shared decision making regarding lung cancer surgery.
Collapse
Affiliation(s)
- Mark K Ferguson
- Department of Surgery, University of Chicago, Chicago, Illinois.
| | - Brian Mitzman
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
| | - Brian Derstine
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Sang Mee Lee
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois
| | - Michael J Pienta
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Stewart C Wang
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Jules Lin
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
22
|
Löffler MT, Jacob A, Valentinitsch A, Rienmüller A, Zimmer C, Ryang YM, Baum T, Kirschke JS. Improved prediction of incident vertebral fractures using opportunistic QCT compared to DXA. Eur Radiol 2019; 29:4980-4989. [PMID: 30790025 PMCID: PMC6682570 DOI: 10.1007/s00330-019-06018-w] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 12/18/2018] [Accepted: 01/17/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To compare opportunistic quantitative CT (QCT) with dual energy X-ray absorptiometry (DXA) in their ability to predict incident vertebral fractures. METHODS We included 84 patients aged 50 years and older, who had routine CT including the lumbar spine and DXA within a 12-month period (baseline) as well as follow-up imaging after at least 12 months or who sustained an incident vertebral fracture documented earlier. Patients with bone disorders aside from osteoporosis were excluded. Fracture status and trabecular bone mineral density (BMD) were retrospectively evaluated in baseline CT and fracture status was reassessed at follow-up. BMDQCT was assessed by opportunistic QCT with asynchronous calibration of multiple MDCT scanners. RESULTS Sixteen patients had incident vertebral fractures showing lower mean BMDQCT than patients without fracture (p = 0.001). For the risk of incident vertebral fractures, the hazard ratio increased per SD in BMDQCT (4.07; 95% CI, 1.98-8.38), as well as after adjusting for age, sex, and prevalent fractures (2.54; 95% CI, 1.09-5.90). For DXA, a statistically significant increase in relative hazard per SD decrease in T-score was only observed after age and sex adjustment (1.57; 95% CI, 1.04-2.38). The predictability of incident vertebral fractures was good by BMDQCT (AUC = 0.76; 95% CI, 0.64-0.89) and non-significant by T-scores. Asynchronously calibrated CT scanners showed good long-term stability (linear drift ranging from - 0.55 to - 2.29 HU per year). CONCLUSIONS Opportunistic screening of mainly neurosurgical and oncologic patients in CT performed for indications other than densitometry allows for better risk assessment of imminent vertebral fractures than dedicated DXA. KEY POINTS • Opportunistic QCT predicts osteoporotic vertebral fractures better than DXA reference standard in mainly neurosurgical and oncologic patients. • More than every second patient (56%) with an incident vertebral fracture was misdiagnosed not having osteoporosis according to DXA. • Standard ACR QCT-cutoff values for osteoporosis (< 80 mg/cm 3 ) and osteopenia (≤ 120 mg/cm 3 ) can also be applied scanner independently in calibrated opportunistic QCT.
Collapse
Affiliation(s)
- Maximilian T Löffler
- Department of Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Alina Jacob
- Department of Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Alexander Valentinitsch
- Department of Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Anna Rienmüller
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
- Department of Orthopedic and Trauma Surgery, Medical University Vienna, Vienna, Austria
| | - Claus Zimmer
- Department of Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Yu-Mi Ryang
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Thomas Baum
- Department of Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Jan S Kirschke
- Department of Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| |
Collapse
|
23
|
Lenchik L, Weaver AA, Ward RJ, Boone JM, Boutin RD. Opportunistic Screening for Osteoporosis Using Computed Tomography: State of the Art and Argument for Paradigm Shift. Curr Rheumatol Rep 2018; 20:74. [PMID: 30317448 DOI: 10.1007/s11926-018-0784-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Osteoporosis is disproportionately common in rheumatology patients. For the past three decades, the diagnosis of osteoporosis has benefited from well-established practice guidelines that emphasized the use of dual x-ray absorptiometry (DXA). Despite these guidelines and the wide availability of DXA, approximately two thirds of eligible patients do not undergo testing. One strategy to improve osteoporosis testing is to employ computed tomography (CT) examinations obtained as part of routine patient care to "opportunistically" screen for osteoporosis, without additional cost or radiation exposure to patients. This review examines the role of opportunistic CT in the evaluation of osteoporosis. RECENT FINDINGS Recent evidence suggests that opportunistic measurement of bone attenuation (radiodensity) using CT has sensitivity comparable to DXA. More importantly, such an approach has been shown to predict osteoporotic fractures. The paradigm shift of using CTs obtained for other reasons to opportunistically screen for osteoporosis promises to substantially improve patient care.
Collapse
Affiliation(s)
- Leon Lenchik
- Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
| | - Ashley A Weaver
- Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Robert J Ward
- Tufts University School of Medicine, 800 Washington Street, Boston, MA, 02111, USA
| | - John M Boone
- University of California Davis Medical Center, 4860 Y Street, Suite 3100, Sacramento, CA, 95817, USA
| | - Robert D Boutin
- University of California Davis School of Medicine, 4860 Y Street, Suite 3100, Sacramento, CA, 95817, USA
| |
Collapse
|
24
|
Gill CM, Azevedo DC, Oliveira AL, Martinez-Salazar EL, Torriani M, Bredella MA. Sex differences in pericardial adipose tissue assessed by PET/CT and association with cardiometabolic risk. Acta Radiol 2018; 59:1203-1209. [PMID: 29444586 DOI: 10.1177/0284185118756950] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Background Recent studies suggest that pericardial adipose tissue (PAT) is associated with whole body adiposity and insulin resistance. Moreover, the incidence of cardiovascular disease (CVD) differs between men and women. Although CVD is more prevalent in men, women suffering from CVD have a higher mortality compared to men. Differences in PAT may account for some of the observed sex differences in manifestations of CVD. Purpose To assess pericardial adipose tissue (PAT) as a biomarker for cardiometabolic risk and to assess potential sex differences. Material and Methods We studied 303 individuals (151 women, 152 men; mean age = 57 ± 17 years) across the weight spectrum. PAT and abdominal adipose tissue were quantified using clinical computed tomography (CT) scans obtained as part of a positron emission tomography (PET)/CT. Cardiometabolic risk factors were assessed from medical records. Linear regression and receiver operating characteristic (ROC) curve analyses were performed to evaluate associations between PAT and cardiometabolic risk. Results PAT was higher in overweight and obese individuals compared to lean individuals and higher in men compared to women. PAT was positively associated with body mass index, abdominal fat ( P < 0.0001), fasting glucose, and serum lipids ( P < 0.05) with stronger associations in women than in men. PAT was accurate in detecting the prevalence of the metabolic syndrome with 74% sensitivity and 76% specificity (AUC = 0.80). Conclusion PAT is associated with measures of cardiometabolic risk and these associations are stronger in women compared to men. PAT could serve as a biomarker for opportunistic screening for cardiometabolic risk in patients undergoing chest CT.
Collapse
Affiliation(s)
- Corey M Gill
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Current affiliation: Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Debora C Azevedo
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Current affiliation: Hospital Israelita Albert Einstein - Setor de Imaginologia, São Paulo, SP, Brazil
| | - Adriana L Oliveira
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Current affiliation: Clínica Prodimagem, Manaus, AM, Brazil
| | - Edgar L Martinez-Salazar
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Martin Torriani
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Miriam A Bredella
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| |
Collapse
|
25
|
Lenchik L, Register TC, Russell GB, Xu J, Smith SC, Bowden DW, Divers J, Freedman BI. Volumetric bone mineral density of the spine predicts mortality in African-American men with type 2 diabetes. Osteoporos Int 2018; 29:2049-2057. [PMID: 29855664 PMCID: PMC6103915 DOI: 10.1007/s00198-018-4578-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 05/15/2018] [Indexed: 12/21/2022]
Abstract
UNLABELLED The study showed that in African-American men with type 2 diabetes mellitus (T2D), vertebral volumetric bone mineral density (vBMD) predicts all-cause mortality, independent of other risk factors for death. INTRODUCTION Compared to European Americans, African Americans have lower rates of osteoporosis and higher rates of T2D. The relationships between BMD and fractures with mortality are unknown in this population. The aim of this study was to determine relationships between vertebral fractures and vertebral vBMD and mortality in African Americans with T2D. METHODS Associations between vertebral fractures and vBMD with all-cause mortality were examined in 675 participants with T2D (391 women and 284 men) in the African American-Diabetes Heart Study (AA-DHS). Lumbar and thoracic vBMD were measured using quantitative computed tomography (QCT). Vertebral fractures were assessed on sagittal CT images. Associations of vertebral fractures and vBMD with all-cause mortality were determined in sex-stratified analyses and in the full sample. Covariates in a minimally adjusted model included age, sex, BMI, smoking, and alcohol use; the full model was adjusted for those variables plus cardiovascular disease, hypertension, coronary artery calcified plaque, hormone replacement therapy (women), African ancestry proportion, and eGFR. RESULTS After mean 7.6 ± 1.8-year follow-up, 59 (15.1%) of women and 58 (20.4%) of men died. In men, vBMD was inversely associated with mortality in the fully adjusted model: lumbar hazard ratio (HR) per standard deviation (SD) = 0.70 (95% CI 0.52-0.95, p = 0.02) and thoracic HR per SD = 0.71 (95% CI 0.54-0.92, p = 0.01). Only trends toward association between vBMD and mortality were observed in the combined sample of men and women, as significant associations were absent in women. Vertebral fractures were not associated with mortality in either sex. CONCLUSIONS Lower vBMD was associated with increased all-cause mortality in African-American men with T2D, independent of other risk factors for mortality including subclinical atherosclerosis.
Collapse
Affiliation(s)
- L Lenchik
- Department of Radiology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157-1053, USA.
| | - T C Register
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - G B Russell
- Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - J Xu
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - S C Smith
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - D W Bowden
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - J Divers
- Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - B I Freedman
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| |
Collapse
|
26
|
Lenchik L, Register TC, Hsu FC, Xu J, Smith SC, Carr JJ, Freedman BI, Bowden DW. Bone Mineral Density of the Radius Predicts All-Cause Mortality in Patients With Type 2 Diabetes: Diabetes Heart Study. J Clin Densitom 2018; 21:347-354. [PMID: 29284565 PMCID: PMC5984132 DOI: 10.1016/j.jocd.2017.11.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 11/09/2017] [Accepted: 11/16/2017] [Indexed: 12/21/2022]
Abstract
This study aimed to determine the association between areal and volumetric bone mineral density (BMD) with all-cause mortality in patients with type 2 diabetes (T2D). Associations between BMD and all-cause mortality were examined in 576 women and 517 men with T2D in the Diabetes Heart Study. Volumetric BMD in the thoracic and lumbar spine was measured with quantitative computed tomography. Areal BMD (aBMD) in the lumbar spine, total hip, femoral neck, ultradistal radius, mid radius, and whole body was measured using dual X-ray absorptiometry. Association of BMD with all-cause mortality was determined using sequential models, stratified by sex: (1) unadjusted; (2) adjusted for age, race, smoking, alcohol, estrogen use; (3) model 2 plus history of cardiovascular disease, hypertension, and coronary artery calcification; (4) model 3 plus lean mass; and (5) model 3 plus fat mass. At baseline, mean age was 61.2 years for women and 62.7 years for men. At mean 11.0 ± 3.7 years' follow-up, 221 (36.4%) women and 238 (43.6%) men were deceased. In women, BMD at all skeletal sites (except spine aBMD and whole body aBMD) was inversely associated with all-cause mortality in the unadjusted model. These associations remained significant in the mid radius (hazard ratio per standard deviation = 0.79; p = 0.0057) and distal radius (hazard ratio per standard deviation = 0.76; p = 0.0056) after adjusting for all covariates, including lean mass. In men, volumetric BMD measurements but not aBMD were inversely associated with mortality and only in the unadjusted model. In this longitudinal study, lower baseline aBMD in the radius was associated with increased all-cause mortality in women with T2D, but not men, independent of other risk factors for death.
Collapse
Affiliation(s)
- Leon Lenchik
- Department of Radiology, Wake Forest School of Medicine, Winston-Salem, NC, USA.
| | - Thomas C Register
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Fang-Chi Hsu
- Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jianzhao Xu
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - S Carrie Smith
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - J Jeffrey Carr
- Department of Radiology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Barry I Freedman
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Donald W Bowden
- Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| |
Collapse
|
27
|
Gutzwiller JP, Richterich JP, Stanga Z, Nydegger UE, Risch L, Risch M. Osteoporosis, diabetes, and hypertension are major risk factors for mortality in older adults: an intermediate report on a prospective survey of 1467 community-dwelling elderly healthy pensioners in Switzerland. BMC Geriatr 2018; 18:115. [PMID: 29764380 PMCID: PMC5952512 DOI: 10.1186/s12877-018-0809-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 05/07/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Osteoporosis is an important morbidity factor for ageing populations in developed countries. However, compared to the amount of information available on diabetes and cardiovascular disease, little is known about the direct impact of osteoporosis on general mortality in older age. METHODS We obtained data from a prospective population-based cohort of pensioners from the SENIORLAB study who were subjectively healthy. The inclusion criteria were an age of at least 60 years and Swiss residence. We assessed and analysed clinical measures, voluntary reports, and laboratory values. RESULTS In total, 1467 subjects were included in the cohort. The mean follow-up time was 3.68 years (95% confidence interval, 3.64-3.71). The ages of the included participants ranged from 60 to 99 years. At follow-up, there were 1401 survivors, and 66 participants had died. According to the multivariate analysis (Cox regression), osteoporosis was the most important risk factor for all-cause mortality (hazard ratio, 4.46; 95% confidence interval, 1.82-10.91), followed by diabetes (hazard ratio, 2.17; 95% confidence interval, 1.04-4.52) and hypertension (hazard ratio, 1.81; 95% confidence interval, 1.09-3.03). CONCLUSIONS Osteoporosis is a major risk factor for all-cause mortality in a subjectively healthy senior population, followed by type 2 diabetes mellitus and hypertension. Osteoporosis should be more actively diagnosed in healthy pensioners before they develop osteoporosis-associated health incidents. TRIAL REGISTRATION The present study was registered in the International Standard Randomized Controlled Trial Number registry: ISRCTN53778569 .
Collapse
Affiliation(s)
- Jean-Pierre Gutzwiller
- Magendarm Thalwil AG, Zürcherstrasse 61, CH-8800 Thalwil, Switzerland
- University of Basel, Klingelbergstrasse 61, 4056 Basel, Switzerland
| | | | - Zeno Stanga
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Bern University Hospital and University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Urs E. Nydegger
- Divisions of Clinical Chemistry and Haematology, Labormedizinisches Zentrum Dr. Risch, Waldeggstrasse, Liebefeld b, Bern, Switzerland
| | - Lorenz Risch
- Divisions of Clinical Chemistry and Haematology, Labormedizinisches Zentrum Dr. Risch, Waldeggstrasse, Liebefeld b, Bern, Switzerland
- Labormedizinisches Zentrum Dr. Risch, Landstrasse, Schaan, Liechtenstein
| | - Martin Risch
- Central Laboratory, Kantonsspital Graubünden, Loëstrasse, 170 Chur, Switzerland
| |
Collapse
|
28
|
Mei K, Schwaiger BJ, Kopp FK, Ehn S, Gersing AS, Kirschke JS, Muenzel D, Fingerle AA, Rummeny EJ, Pfeiffer F, Baum T, Noël PB. Bone mineral density measurements in vertebral specimens and phantoms using dual-layer spectral computed tomography. Sci Rep 2017; 7:17519. [PMID: 29235542 PMCID: PMC5727524 DOI: 10.1038/s41598-017-17855-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 11/30/2017] [Indexed: 12/13/2022] Open
Abstract
To assess whether phantomless calcium-hydroxyapatite (HA) specific bone mineral density (BMD) measurements with dual-layer spectral computed tomography are accurate in phantoms and vertebral specimens. Ex-vivo human vertebrae (n = 13) and a phantom containing different known HA concentrations were placed in a semi-anthropomorphic abdomen phantom with different extension rings simulating different degrees of obesity. Phantomless dual-layer spectral CT was performed at different tube current settings (500, 250, 125 and 50 mAs). HA-specific BMD was derived from spectral-based virtual monoenergetic images at 50 keV and 200 keV. Values were compared to the HA concentrations of the phantoms and conventional qCT measurements using a reference phantom, respectively. Above 125 mAs, errors for phantom measurements ranged between -1.3% to 4.8%, based on spectral information. In vertebral specimens, high correlations were found between BMD values assessed with spectral CT and conventional qCT (r ranging between 0.96 and 0.99; p < 0.001 for all) with different extension rings, and a high agreement was found in Bland Altman plots. Different degrees of obesity did not have a significant influence on measurements (P > 0.05 for all). These results suggest a high validity of HA-specific BMD measurements based on dual-layer spectral CT examinations in setups simulating different degrees of obesity without the need for a reference phantom, thus demonstrating their feasibility in clinical routine.
Collapse
Affiliation(s)
- Kai Mei
- Department of Radiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Benedikt J Schwaiger
- Department of Radiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
| | - Felix K Kopp
- Department of Radiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Sebastian Ehn
- Physics Department & Munich School of BioEngineering, Technical University of Munich, Munich, Germany
| | - Alexandra S Gersing
- Department of Radiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Jan S Kirschke
- Department of Neuroradiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Daniela Muenzel
- Department of Radiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Alexander A Fingerle
- Department of Radiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Ernst J Rummeny
- Department of Radiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Franz Pfeiffer
- Department of Radiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,Physics Department & Munich School of BioEngineering, Technical University of Munich, Munich, Germany
| | - Thomas Baum
- Department of Neuroradiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Peter B Noël
- Department of Radiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,Physics Department & Munich School of BioEngineering, Technical University of Munich, Munich, Germany
| |
Collapse
|
29
|
He Y, Jiang Z, Tong F, Li M, Yin X, Hu S, Wang L. Experimental study of peripheral-blood pro-surfactant protein B for screening non-small cell lung cancer. Acta Cir Bras 2017; 32:568-575. [PMID: 28793041 DOI: 10.1590/s0102-865020170070000008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 06/14/2017] [Indexed: 12/23/2022] Open
Abstract
Purpose: To evaluate the possibility of using peripheral-blood presurfactant protein B (Pro-SFTPB) for screening non-small cell lung cancer (NSCLC). Methods: A total of 873 healthy volunteers and 165 lung cancer patients hospitalized in the Fifth People's Hospital of Dalian were tested Pro-SFTPB once every half year from January 2014 to September 2015. The healthy volunteers were also conducted spiral computed tomography (CT) examination once every year. The data were then com-pared and statistically analyzed. Results: The positive expression rate of Pro-SFTPB in NSCLC was significantly higher than that in healthy volunteers, and significantly higher in lung adenocarcinoma than in squamous cell carcinoma; additionally, the expression rate was increased with the in-crease of smoking index, and the intergroup differences showed statistical signifi-cance (p≤0.05). The positive rate of newly diagnosed lung cancer was 29.55%, higher than healthy volunteers (22.34%), but there was no significant difference (p>0.05). Conclusion: Pro-SFTPB is over expressed in non-small cell lung cancer, especially in lung adeno-carcinoma, but it can't be used as a clinical screening tool for lung cancer.
Collapse
Affiliation(s)
- Yong He
- Master, Department of Thoracic Surgery, 5th People's Hospital of Dalian, China. Conception of the study, interpretation of data, statistical analysis
| | - Zhenjie Jiang
- Master, Department of Thoracic Surgery, People's Hospital of Dalian, China. Acquisition of data, statistical analysis
| | - Fengzhi Tong
- Master, Clinical Laboratory, People's Hospital of Dalian, China. Acquisition and interpretation of data
| | - Mingwu Li
- Bachelor, Department of Thoracic Surgery, 5th People's Hospital of Dalian, China. Acquisition and interpretation of data
| | - Xingru Yin
- Bachelor, Department of Thoracic Surgery, 5th People's Hospital of Dalian, China. Acquisition of data, statistical analysis
| | - Shixin Hu
- Bachelor, Department of Thoracic Surgery, 5th People's Hospital of Dalian, China. Acquisition of data, statistical analysis
| | - Linlin Wang
- Bachelor, Matron, Department of Thoracic Surgery, 5th People's Hospital of Dalian, China. Acquisition of data, statistical analysis
| |
Collapse
|
30
|
Gausden EB, Nwachukwu BU, Schreiber JJ, Lorich DG, Lane JM. Opportunistic Use of CT Imaging for Osteoporosis Screening and Bone Density Assessment: A Qualitative Systematic Review. J Bone Joint Surg Am 2017; 99:1580-1590. [PMID: 28926388 DOI: 10.2106/jbjs.16.00749] [Citation(s) in RCA: 140] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to determine the clinical opportunities for the use of computed tomography (CT) imaging for inferring bone quality and to critically analyze the correlation between dual x-ray absorptiometry (DXA) and diagnostic CT as reported in the literature. METHODS A systematic review of the MEDLINE database was performed in February 2016 using the PubMed interface. The inclusion criteria were English language, studies performed using living human subjects, studies pertaining to orthopaedics, use of conventional diagnostic CT scans, studies that measured cancellous bone, and studies that reported Hounsfield unit (HU) measurements directly rather than a computed bone mineral density. RESULTS Thirty-seven studies that reported on a total of 9,109 patients were included. Of these, 10 studies correlated HU measurements of trabecular bone with DXA-based bone assessment. Reported correlation coefficients ranged between 0.399 and 0.891, and 5 of the studies reported appropriate threshold HU levels for diagnosing osteoporosis or osteopenia. CONCLUSIONS Direct HU measurement from diagnostic CT scans has the potential to be used opportunistically for osteoporosis screening, but in its current state it is not ready for clinical implementation. There is a lack of exchangeability among different machines that limits its broad applicability. Future research efforts should focus on identifying thresholds at specific anatomic regions in high-risk patients in order to have the greatest impact on patients. However, using diagnostic CT to infer region-specific osteoporosis could be extraordinarily valuable to orthopaedic surgeons and primary care physicians, and merits further research.
Collapse
Affiliation(s)
- Elizabeth B Gausden
- 1Hospital for Special Surgery, New York, NY 2Raleigh Orthopaedic Clinic, Raleigh, North Carolina 3New York Presbyterian Hospital, New York, NY
| | | | | | | | | |
Collapse
|
31
|
Pompe E, de Jong PA, Lynch DA, Lessmann N, Išgum I, van Ginneken B, Lammers JWJ, Mohamed Hoesein FA. Computed tomographic findings in subjects who died from respiratory disease in the National Lung Screening Trial. Eur Respir J 2017; 49:49/4/1601814. [DOI: 10.1183/13993003.01814-2016] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 12/15/2016] [Indexed: 12/18/2022]
Abstract
We evaluated the prevalence of significant lung abnormalities on computed tomography (CT) in patients who died from a respiratory illness other than lung cancer in the National Lung Screening Trial (NLST).In this retrospective case–control study, NLST participants in the CT arm who died of respiratory illness other than lung cancer were matched for age, sex, pack-years and smoking status to a surviving control. A chest radiologist and a radiology resident blinded to the outcome independently scored baseline CT scans visually and qualitatively for the presence of emphysema, airway wall thickening and fibrotic lung disease. The prevalence of CT abnormalities was compared between cases and controls by using chi-squared tests.In total, 167 participants died from a respiratory cause other than lung cancer. The prevalence of severe emphysema, airway wall thickening and fibrotic lung disease were 28.7% versus 4.8%, 26.9% versus 13.2% and 18.6% versus 0.5% in cases and controls, respectively. Radiological findings were significantly more prevalent in deaths compared with controls (all p<0.001).CT-diagnosed severe emphysema, airway wall thickening and fibrosis were much more common in NLST participants who died from respiratory disease, and CT may provide an additional means of identifying these diseases.
Collapse
|
32
|
van Hamersvelt RW, Schilham AMR, Engelke K, den Harder AM, de Keizer B, Verhaar HJ, Leiner T, de Jong PA, Willemink MJ. Accuracy of bone mineral density quantification using dual-layer spectral detector CT: a phantom study. Eur Radiol 2017; 27:4351-4359. [PMID: 28374079 PMCID: PMC5579207 DOI: 10.1007/s00330-017-4801-4] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 03/13/2017] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To investigate the accuracy of bone mineral density (BMD) quantification using dual-layer spectral detector CT (SDCT) at various scan protocols. METHODS Two validated anthropomorphic phantoms containing inserts of 50-200 mg/cm3 calcium hydroxyapatite (HA) were scanned using a 64-slice SDCT scanner at various acquisition protocols (120 and 140 kVp, and 50, 100 and 200 mAs). Regions of interest (ROIs) were placed in each insert and mean attenuation profiles at monochromatic energy levels (90-200 keV) were constructed. These profiles were fitted to attenuation profiles of pure HA and water to calculate HA concentrations. For comparison, one phantom was scanned using dual energy X-ray absorptiometry (DXA). RESULTS At both 120 and 140 kVp, excellent correlations (R = 0.97, P < 0.001) were found between true and measured HA concentrations. Mean error for all measurements at 120 kVp was -5.6 ± 5.7 mg/cm3 (-3.6 ± 3.2%) and at 140 kVp -2.4 ± 3.7 mg/cm3 (-0.8 ± 2.8%). Mean measurement errors were smaller than 6% for all acquisition protocols. Strong linear correlations (R2 ≥ 0.970, P < 0.001) with DXA were found. CONCLUSIONS SDCT allows for accurate BMD quantification and potentially opens up the possibility for osteoporosis evaluation and opportunistic screening in patients undergoing SDCT for other clinical indications. However, patient studies are needed to extend and translate our findings. KEY POINTS • Dual-layer spectral detector CT allows for accurate bone mineral density quantification. • BMD measurements on SDCT are strongly linearly correlated to DXA. • SDCT, acquired for several indications, may allow for evaluation of osteoporosis. • This potentially opens up the possibility for opportunistic osteoporosis screening.
Collapse
Affiliation(s)
- Robbert W van Hamersvelt
- Department of Radiology, University Medical Centre Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands.
| | - Arnold M R Schilham
- Department of Radiology, University Medical Centre Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Klaus Engelke
- Institute of Medical Physics, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Annemarie M den Harder
- Department of Radiology, University Medical Centre Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Bart de Keizer
- Department of Nuclear Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Harald J Verhaar
- Department of Geriatric Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Tim Leiner
- Department of Radiology, University Medical Centre Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Pim A de Jong
- Department of Radiology, University Medical Centre Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Martin J Willemink
- Department of Radiology, University Medical Centre Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| |
Collapse
|
33
|
Pompe E, Bartstra J, Verhaar HJ, de Koning HJ, van der Aalst CM, Oudkerk M, Vliegenthart R, Lammers JWJ, de Jong PA, Mohamed Hoesein FAA. Bone density loss on computed tomography at 3-year follow-up in current compared to former male smokers. Eur J Radiol 2017; 89:177-181. [PMID: 28267536 DOI: 10.1016/j.ejrad.2017.02.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 01/29/2017] [Accepted: 02/07/2017] [Indexed: 01/16/2023]
Abstract
OBJECTIVES Cigarette smoking negatively affects bone quality and increases fracture risk. Little is known on the effect of smoking cessation and computed tomography (CT)-derived bone mineral density (BMD) decline in the spine. We evaluated the association of current and former smoking with BMD decline after 3-year follow-up. METHODS Male current and former smokers participating in a lung cancer screening trial who underwent baseline and 3-year follow-up CT were included. BMD was measured by manual placement of a region of interest in the first lumbar vertebra and expressed in Hounsfield Unit (HU). Multiple linear regression analysis was used to evaluate the association between pack years smoked and smoking status with BMD decline. RESULTS 408 participants were included with median (25th-75th percentile) age of 59.4 (55.9-63.5) years. At the start of the study, 197 (48.3%) participants were current smokers and 211 (51.7%) were former smokers and had a similar amount of pack years. Current smokers had quit smoking for 6 (4-8) years prior to inclusion. There was no difference in BMD between current and former smokers at baseline (109±34 HU vs. 108±32 HU, p=0.96). At 3-year follow-up, current smokers had a mean BMD decline of -3±13 HU (p=0.001), while BMD in former smokers did not change as compared to baseline (1±13 HU, p=0.34). After adjustment for BMD at baseline and body mass index, current smoking was independently associated with BMD decline (-3.8 HU, p=0.003). Age, pack years, and the presence of a fracture at baseline did not associate with BMD decline. CONCLUSIONS Current smokers showed a more rapid BMD decline over a 3-year period compared to former smokers. This information might be important to identify subjects at risk for osteoporosis and emphasizes the importance of smoking cessation in light of BMD decline.
Collapse
Affiliation(s)
- E Pompe
- Department of Pulmonology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - J Bartstra
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - H J Verhaar
- Department of Geriatric Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - H J de Koning
- Department of Public Health, Erasmus MC - University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - C M van der Aalst
- Department of Public Health, Erasmus MC - University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - M Oudkerk
- University of Groningen, University Medical Center Groningen, Groningen, Department of Radiology, The Netherlands
| | - R Vliegenthart
- University of Groningen, University Medical Center Groningen, Groningen, Department of Radiology, The Netherlands; University of Groningen, University Medical Center Groningen, Center for Medical Imaging-North East Netherlands, Groningen, The Netherlands
| | - J-W J Lammers
- Department of Pulmonology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - P A de Jong
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - F A A Mohamed Hoesein
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| |
Collapse
|
34
|
Adamek M, Wachuła E, Szabłowska-Siwik S, Boratyn-Nowicka A, Czyżewski D. Risk factors assessment and risk prediction models in lung cancer screening candidates. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:151. [PMID: 27195269 DOI: 10.21037/atm.2016.04.03] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
From February 2015, low-dose computed tomography (LDCT) screening entered the armamentarium of diagnostic tools broadly available to individuals at high-risk of developing lung cancer. While a huge number of pulmonary nodules are identified, only a small fraction turns out to be early lung cancers. The majority of them constitute a variety of benign lesions. Although it entails a burden of the diagnostic work-up, the undisputable benefit emerges from: (I) lung cancer diagnosis at earlier stages (stage shift); (II) additional findings enabling the implementation of a preventive action beyond the realm of thoracic oncology. This review presents how to utilize the risk factors from distinct categories such as epidemiology, radiology and biomarkers to target the fraction of population, which may benefit most from the introduced screening modality.
Collapse
Affiliation(s)
- Mariusz Adamek
- 1 The Chair and Department of Thoracic Surgery, The Professor S. Szyszko Teaching Hospital No. 1, Zabrze, Poland ; 2 Department of Clinical Oncology, Medical University of Silesia, Katowice, Poland
| | - Ewa Wachuła
- 1 The Chair and Department of Thoracic Surgery, The Professor S. Szyszko Teaching Hospital No. 1, Zabrze, Poland ; 2 Department of Clinical Oncology, Medical University of Silesia, Katowice, Poland
| | - Sylwia Szabłowska-Siwik
- 1 The Chair and Department of Thoracic Surgery, The Professor S. Szyszko Teaching Hospital No. 1, Zabrze, Poland ; 2 Department of Clinical Oncology, Medical University of Silesia, Katowice, Poland
| | - Agnieszka Boratyn-Nowicka
- 1 The Chair and Department of Thoracic Surgery, The Professor S. Szyszko Teaching Hospital No. 1, Zabrze, Poland ; 2 Department of Clinical Oncology, Medical University of Silesia, Katowice, Poland
| | - Damian Czyżewski
- 1 The Chair and Department of Thoracic Surgery, The Professor S. Szyszko Teaching Hospital No. 1, Zabrze, Poland ; 2 Department of Clinical Oncology, Medical University of Silesia, Katowice, Poland
| |
Collapse
|
35
|
Ruparel M, Quaife SL, Navani N, Wardle J, Janes SM, Baldwin DR. Pulmonary nodules and CT screening: the past, present and future. Thorax 2016; 71:367-75. [PMID: 26921304 PMCID: PMC4819623 DOI: 10.1136/thoraxjnl-2015-208107] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Revised: 01/10/2016] [Accepted: 01/12/2016] [Indexed: 12/17/2022]
Abstract
Lung cancer screening has come a long way since the early studies with chest X-ray. Advancing technology and progress in the processing of images have enabled low dose CT to be tried and tested, and evidence suggests its use can result in a significant mortality benefit. There are several issues that need refining in order to successfully implement screening in the UK and elsewhere. Some countries have started patchy implementation of screening and there is increased recognition that the appropriate management of pulmonary nodules is crucial to optimise benefits of early detection, while reducing harm caused by inappropriate medical intervention. This review summarises and differentiates the many recent guidelines on pulmonary nodule management, discusses screening activity in other countries and exposes the present barriers to implementation in the UK.
Collapse
Affiliation(s)
- M Ruparel
- Lungs for Living Research Centre, UCL Respiratory, University College London, London, UK
| | - S L Quaife
- Health Behaviour Research Centre, University College London, London, UK
| | - N Navani
- Lungs for Living Research Centre, UCL Respiratory, University College London, London, UK
- Department of Thoracic Medicine, University College London Hospital, London, UK
| | - J Wardle
- Health Behaviour Research Centre, University College London, London, UK
| | - S M Janes
- Lungs for Living Research Centre, UCL Respiratory, University College London, London, UK
| | - D R Baldwin
- Respiratory Medicine Unit, David Evans Research Centre, Nottingham University Hospitals, Nottingham, UK
| |
Collapse
|
36
|
Pompe E, de Jong PA, de Jong WU, Takx RAP, Eikendal ALM, Willemink MJ, Oudkerk M, Budde RPJ, Lammers JWJ, Mohamed Hoesein FAA. Inter-observer and inter-examination variability of manual vertebral bone attenuation measurements on computed tomography. Eur Radiol 2016; 26:3046-53. [PMID: 26801161 PMCID: PMC4972882 DOI: 10.1007/s00330-015-4145-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 08/25/2015] [Accepted: 11/30/2015] [Indexed: 01/22/2023]
Abstract
Objective To determine inter-observer and inter-examination variability of manual attenuation measurements of the vertebrae in low-dose unenhanced chest computed tomography (CT). Methods Three hundred and sixty-seven lung cancer screening trial participants who underwent baseline and repeat unenhanced low-dose CT after 3 months because of an indeterminate lung nodule were included. The CT attenuation value of the first lumbar vertebrae (L1) was measured in all CTs by one observer to obtain inter-examination reliability. Six observers performed measurements in 100 randomly selected CTs to determine agreement with limits of agreement and Bland-Altman plots and reliability with intraclass correlation coefficients (ICCs). Reclassification analyses were performed using a threshold of 110 HU to define osteoporosis. Results Inter-examination reliability was excellent with an ICC of 0.92 (p < 0.001). Inter-examination limits of agreement ranged from -26 to 28 HU with a mean difference of 1 ± 14 HU. Inter-observer reliability ICCs ranged from 0.70 to 0.91. Inter-examination variability led to 11.2 % reclassification of participants and inter-observer variability led to 22.1 % reclassification. Conclusions Vertebral attenuation values can be manually quantified with good to excellent inter-examination and inter-observer reliability on unenhanced low-dose chest CT. This information is valuable for early detection of osteoporosis on low-dose chest CT. Key Points • Vertebral attenuation values can be manually quantified on low-dose unenhanced CT reliably. • Vertebral attenuation measurements may be helpful in detecting subclinical low bone density. • This could become of importance in the detection of osteoporosis. Electronic supplementary material The online version of this article (doi:10.1007/s00330-015-4145-x) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Esther Pompe
- Department of Pulmonology, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, E.03.511, The Netherlands.
| | - Pim A de Jong
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Werner U de Jong
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Richard A P Takx
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anouk L M Eikendal
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martin J Willemink
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Matthijs Oudkerk
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ricardo P J Budde
- Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jan-Willem J Lammers
- Department of Pulmonology, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, E.03.511, The Netherlands
| | | |
Collapse
|
37
|
Mohamed Hoesein FAA, de Jong PA, Mets OM. Optimizing lung cancer screening: nodule size, volume doubling time, morphology and evaluation of other diseases. ANNALS OF TRANSLATIONAL MEDICINE 2015; 3:19. [PMID: 25738139 PMCID: PMC4322163 DOI: 10.3978/j.issn.2305-5839.2014.11.18] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 11/17/2014] [Indexed: 12/21/2022]
Affiliation(s)
| | - Pim A de Jong
- Department of Radiology, University Medical Center Utrecht, The Netherlands
| | - Onno M Mets
- Department of Radiology, University Medical Center Utrecht, The Netherlands
| |
Collapse
|