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Hirata T, Yoshimura N, Yagi T, Yamazaki M, Horii Y, Ishikawa H. Association between pre-treatment computed tomography findings and post-treatment persistent decrease in lung perfusion blood volume. Sci Rep 2024; 14:11919. [PMID: 38789497 PMCID: PMC11126722 DOI: 10.1038/s41598-024-62890-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 05/22/2024] [Indexed: 05/26/2024] Open
Abstract
The purpose of this study was to evaluate pre-treatment CT findings in patients with acute pulmonary embolism (PE) and determine the imaging findings associated with residual hypoperfused segments in post-treatment lung perfused blood volume (LPBV). We evaluated 91 patients with acute PE who underwent dual-energy CT before and after treatment. The location of thrombi (proximal or distal) and patency of the pulmonary artery (occlusive or non-occlusive) were recorded using pre-treatment computed tomography pulmonary angiography (CTPA). Residual hypoperfusion was defined as a perfusion-decreased area seen in both the pre- and post-treatment LPBVs. The association of the location of the thrombus and vascular patency of pre-treatment CTPA with residual hypoperfusion on a segmental and patient basis was examined. In the segment-based analysis, the proportion of residual hypoperfusion in the proximal group was significantly higher than that in the peripheral group (33/125 [26.4%] vs. 9/87 [10.3%], P = 0.004). Patient-based analysis also showed that the proportion of residual hypoperfusion in patients with pre-treatment proximal thrombus was significantly higher than those without (16/42 [38.1%] vs. 3/25 (12.0%); P = 0.022). Pre-treatment vascular patency was not significantly associated with residual hypoperfusion (P > 0.05). Therefore, careful follow-up is necessary, especially in patients with proximal thrombi.
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Affiliation(s)
- Tetsuhiro Hirata
- Department of Radiology and Radiation Oncology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-Ku, Niigata-City, Niigata, 951-8510, Japan.
| | - Norihiko Yoshimura
- Department of Radiology, Niigata City General Hospital, 463-7 Syumoku, Chuo-Ku, Niigata-City, Niigata, 950-1141, Japan
| | - Takuya Yagi
- Department of Radiology and Radiation Oncology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-Ku, Niigata-City, Niigata, 951-8510, Japan
| | - Motohiko Yamazaki
- Department of Radiology and Radiation Oncology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-Ku, Niigata-City, Niigata, 951-8510, Japan
| | - Yosuke Horii
- Department of Radiology and Radiation Oncology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-Ku, Niigata-City, Niigata, 951-8510, Japan
| | - Hiroyuki Ishikawa
- Department of Radiology and Radiation Oncology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-Ku, Niigata-City, Niigata, 951-8510, Japan
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Vlahos I, Jacobsen MC, Godoy MC, Stefanidis K, Layman RR. Dual-energy CT in pulmonary vascular disease. Br J Radiol 2022; 95:20210699. [PMID: 34538091 PMCID: PMC8722250 DOI: 10.1259/bjr.20210699] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Dual-energy CT (DECT) imaging is a technique that extends the capabilities of CT beyond that of established densitometric evaluations. CT pulmonary angiography (CTPA) performed with dual-energy technique benefits from both the availability of low kVp CT data and also the concurrent ability to quantify iodine enhancement in the lung parenchyma. Parenchymal enhancement, presented as pulmonary perfused blood volume maps, may be considered as a surrogate of pulmonary perfusion. These distinct capabilities have led to new opportunities in the evaluation of pulmonary vascular diseases. Dual-energy CTPA offers the potential for improvements in pulmonary emboli detection, diagnostic confidence, and most notably severity stratification. Furthermore, the appreciated insights of pulmonary vascular physiology conferred by DECT have resulted in increased use for the assessment of pulmonary hypertension, with particular utility in the subset of patients with chronic thromboembolic pulmonary hypertension. With the increasing availability of dual energy-capable CT systems, dual energy CTPA is becoming a standard-of-care protocol for CTPA acquisition in acute PE. Furthermore, qualitative and quantitative pulmonary vascular DECT data heralds promise for the technique as a "one-stop shop" for diagnosis and surveillance assessment in patients with pulmonary hypertension. This review explores the current application, clinical value, and limitations of DECT imaging in acute and chronic pulmonary vascular conditions. It should be noted that certain manufacturers and investigators prefer alternative terms, such as spectral or multi-energy CT imaging. In this review, the term dual energy is utilised, although readers can consider these terms synonymous for purposes of the principles explained.
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Affiliation(s)
- Ioannis Vlahos
- Department of Thoracic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Megan C Jacobsen
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Myrna C Godoy
- Department of Thoracic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Rick R Layman
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Zhang J, Cai J, Liu S, Zhang X. Value of Dual-energy Lung Perfusion Imaging Using a Dual-source CT System for the Pulmonary Embolism. Open Life Sci 2018; 13:107-111. [PMID: 33817075 PMCID: PMC7874688 DOI: 10.1515/biol-2018-0015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 10/17/2017] [Indexed: 12/01/2022] Open
Abstract
Objective To investigate the diagnostic value of dual-energy lung perfusion imaging (DEPI) using a dual-source CT system for the pulmonary embolism (PE). Methods 50 patients in high acute PE prevalence were enrolled to accept the DEPI (lung perfusion image and CTA image of pulmonary artery acquired through the Dual Energy software) and emergent DSA angiography (golden diagnostic criterion). Results Patients using CT had significantly reduced examination duration and dosage of contrast agent than those using DSA examination, (P < 0.05). In total, 260 pulmonary arteries and 1020 pulmonary segments were examined through CTA, in which embolisms were identified in 50 lobes of lung, 108 pulmonary segments and 82 sub-segments. Reduction or lack of perfusion was identified through DEPI in 48 lobes of lung (concordance rate of 96.0%), 103 pulmonary segments (concordance rate of 95.4%) and 78 subsegments (concordance rate of 95.1%). The comparison of embolism quantity and morphological characteristics of pulmonary artery between CTA images and DEPI images showed no statistically significant difference. Conclusion Better application value can be achieved in the diagnosis of pulmonary embolism by dual-energy lung perfusion imaging using a dual-source CT system.
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Affiliation(s)
- Jinshan Zhang
- Department of Medical lmaging, LinYi People's Hospital, LinYi 276000, P.R. China
| | - Jing Cai
- Department of Neurosurgery, LinYi People's Hospital, LinYi, 276000, P.R. China
| | - Shulan Liu
- Department of Medical lmaging, LinYi People's Hospital, LinYi 276000, P.R. China
| | - Xianmei Zhang
- Department of Ultrasound, Linyi Women and Children Hospital, LinYi 276000, P.R. China
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Hisatake S, Kabuki T, Kiuchi S, Oka T, Dobashi S, Fujii T, Iwasaki Y, Ikeda T. Short-Term Subcutaneous Fondaparinux and Oral Edoxaban for Acute Venous Thromboembolism. Circ J 2017; 81:855-861. [PMID: 28239036 DOI: 10.1253/circj.cj-16-1012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND No studies have compared treatment efficacy between subcutaneous (SC) fondaparinux and oral edoxaban, which are categorized as factor Xa inhibitors, for venous thromboembolism (VTE) in the acute phase, and only a limited number of imaging-based quantitative studies have evaluated treatment.Methods and Results:In this open-label, randomized study, 50 patients with acute non-massive pulmonary embolism (PE) and/or deep-vein thrombosis (DVT) were assigned to fondaparinux or edoxaban groups. Lower-limb venous ultrasonography (US), and chest computed tomography (CT) were compared before and 7 days after treatment. Thrombus volume in DVT was calculated using quantitative ultrasound thrombosis (QUT) score on US. For evaluation of PE thrombus volume, lung perfused blood volume (PBV) on CT was calculated. The measurements before and after treatment, respectively, were as follows: QUT score: fondaparinux, 8.1±7.3 to 4.1±4.5; edoxaban, 7.7±6.3 to 4.4±4.3, both significant decreases (P=0.001, P<0.001, respectively); lung PBV: fondaparinux, 32.0±7.8 to 32.1±8.2 HU; edoxaban, 34.2±8.6 to 38.5±11.8 HU (P=0.732, P=0.426, respectively). On subjective CT-based evaluation, all pulmonary artery-related filling defects decreased/disappeared after treatment in both groups (P=NS). CONCLUSIONS Both SC fondaparinux and oral edoxaban are effective in acute VTE. Effects on thrombus regression on imaging-based quantitative measurement did not differ between the 2 drugs.
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Affiliation(s)
- Shinji Hisatake
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | - Takayuki Kabuki
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | - Shunsuke Kiuchi
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | - Takashi Oka
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | - Shintaro Dobashi
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | - Takahiro Fujii
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | - Yoshihiro Iwasaki
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
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White Paper of the Society of Computed Body Tomography and Magnetic Resonance on Dual-Energy CT, Part 3. J Comput Assist Tomogr 2017; 41:1-7. [DOI: 10.1097/rct.0000000000000538] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Detection of pulmonary fat embolism with dual-energy CT: an experimental study in rabbits. Eur Radiol 2016; 27:1377-1385. [PMID: 27510627 DOI: 10.1007/s00330-016-4512-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 05/16/2016] [Accepted: 07/18/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To evaluate the use of dual-energy CT imaging of the lung perfused blood volume (PBV) for the detection of pulmonary fat embolism (PFE). METHODS Dual-energy CT was performed in 24 rabbits before and 1 hour, 1 day, 4 days and 7 days after artificial induction of PFE via the right ear vein. CT pulmonary angiography (CTPA) and lung PBV images were evaluated by two radiologists, who recorded the presence, number, and location of PFE on a per-lobe basis. Sensitivity, specificity, and accuracy of CTPA and lung PBV for detecting PFE were calculated using histopathological evaluation as the reference standard. RESULTS A total of 144 lung lobes in 24 rabbits were evaluated and 70 fat emboli were detected on histopathological analysis. The overall sensitivity, specificity and accuracy were 25.4 %, 98.6 %, and 62.5 % for CTPA, and 82.6 %, 76.0 %, and 79.2 % for lung PBV. Higher sensitivity (p < 0.001) and accuracy (p < 0.01), but lower specificity (p < 0.001), were found for lung PBV compared with CTPA. Dual-energy CT can detect PFE earlier than CTPA (all p < 0.01). CONCLUSION Dual-energy CT provided higher sensitivity and accuracy in the detection of PFE as well as earlier detection compared with conventional CTPA in this animal model study. KEY POINTS • Fat embolism occurs commonly in patients with traumatic bone injury. • Dual-energy CT improves diagnostic performance for pulmonary fat embolism detection. • Dual-energy CT can detect pulmonary fat embolism earlier than CTPA.
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Koike H, Sueyoshi E, Sakamoto I, Uetani M, Nakata T, Maemura K. Quantification of lung perfusion blood volume (lung PBV) by dual-energy CT in patients with chronic thromboembolic pulmonary hypertension (CTEPH) before and after balloon pulmonary angioplasty (BPA): Preliminary results. Eur J Radiol 2016; 85:1607-12. [PMID: 27501896 DOI: 10.1016/j.ejrad.2016.06.016] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Accepted: 06/20/2016] [Indexed: 01/28/2023]
Abstract
OBJECTIVES Balloon pulmonary angioplasty (BPA) is a treatment option for patients with chronic thromboembolic pulmonary hypertension (CTEPH). Its effect on pulmonary perfusion has not been quantified; we examined the clinical significance of pulmonary blood volume (PBV) using dual-energy computed tomography (DECT) in patients with CTEPH undergoing BPA. METHODS In this retrospective study of 16 BPAs in eight female patients with CTEPH, we evaluated both-lung (n=16), right- or left-lung (n=32), and three right- or left-segment (upper, middle, and lower) (n=96) PBVs before and after BPA, using DECT. We evaluated the relationships between improvement in lung PBV and pulmonary artery (PA) pressure (PAP), cardiac index (CI), pulmonary vascular resistance (PVR), and 6-min walking distance. We measured PA enhancement (PAenh) on DECT images and calculated lung PBV/PAenh to adjust timing. RESULTS Pre- and post-BPA 6-segment lung PBV/PAenh were 0.067±0.021 and 0.077±0.019, respectively, in the treated segment (p<0.0001). There were significant positive correlations between pre- to post-BPA improvements in both-lung PBV/PAenh and PAP (R=0.69, p=0.005), PVR (R=0.56, p=0.03), and 6-min walking distance (R=0.67, p=0.01). CONCLUSIONS Improved PBV after BPA, reflecting increased lung perfusion, was positively correlated with PAP, PVR, and 6-min walking distance. Lung PBV may be an indicator of BPA treatment effect.
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Affiliation(s)
- Hirofumi Koike
- Department of Radiology, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Eijun Sueyoshi
- Department of Radiology, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Ichiro Sakamoto
- Department of Radiology, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Masataka Uetani
- Department of Radiology, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Tomoo Nakata
- Department of Cardiovascular medicine, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Kouji Maemura
- Department of Cardiovascular medicine, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
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Cimsit NC, Cimsit C, Onaygil C, Kuzan TY. Correlation of clot distribution with morphometric measurements and pleuroparenchymal findings in acute pulmonary embolism: experience with 692 cases. Clin Imaging 2015; 39:1012-7. [DOI: 10.1016/j.clinimag.2015.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 05/19/2015] [Accepted: 07/06/2015] [Indexed: 11/27/2022]
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Okada M, Masuda Y, Nakashima Y, Nomura T, Nakao S, Suga K, Kido S, Matsunaga N. Factors affecting the lung perfused blood volume in patients with intrapulmonary clots after anti-coagulation therapy. Eur J Radiol 2015; 84:1614-1620. [PMID: 26037265 DOI: 10.1016/j.ejrad.2015.05.018] [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: 03/03/2015] [Revised: 04/21/2015] [Accepted: 05/08/2015] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Factors affecting the improvement in the lung perfused blood volume (LPBV) were evaluated based on the presence of intrapulmonary clots (IPCs) after anti-coagulation therapy using 64-slice dual-energy CT. MATERIALS AND METHODS 96 patients exhibiting venous thromboembolism underwent initial and repeated LPBV examinations between December 2008 and July 2014. Fifteen patients were excluded due to pulmonary comorbidities, and a total of 81 patients were included in this study. Acute pulmonary embolism (PE) was diagnosed in 46 of the patients (56.7%). LPBV images were three-dimensionally reconstructed with two threshold ranges: 1-120 HU (V120) and 1-5 HU (V5), and the relative value of V5 per V120 expressed as %V5. These values were subsequently compared with indicators of the severity of PE, such as the D-dimer level, heart rate and CT measurements. This study was approved by the local ethics committee. RESULTS In patients with IPCs, the D-dimer, V5 and %V5values were significantly larger (p≤0.01) in the initial LPBV, although these differences disappeared in subsequent LPBV after treatment. The right ventricular (RV) diameter, RV/left ventricular (RV/LV) diameter ratio and %V5 values were also significantly reduced, whereas the V5 value did not significantly decrease (p=0.07), but V120 value significantly increased (p<0.001) after treatment. However, in patients with IPCs the change rate in %V5 [(subsequent-initial)/initial %V5] showed a better correlation with that in V5 (r=0.94, p<0.001) rate than that in V120 (r=0.19, p=0.19) after treatment. CONCLUSIONS Increased whole lung perfusion (V120) and a decreased low perfusion volume (V5) affect the improvement in the %V5 values after treatment.
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Affiliation(s)
- Munemasa Okada
- Department of Radiology, Yamaguchi University Graduate School of Medicine 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505, Japan.
| | - Yu Masuda
- 4th Grade of 6-year Medicine Doctor Program, Department of Medicine, Yamaguchi University Faculty of Medicine and Health Sciences 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505, Japan
| | - Yoshiteru Nakashima
- Department of Radiology, Yamaguchi Grand Medical Center, Oosaki 77, Hofu, Yamaguchi 747-8511, Japan
| | - Takafumi Nomura
- Department of Radiology, Yamaguchi University Graduate School of Medicine 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505, Japan
| | - Sei Nakao
- Department of Radiology, Yamaguchi University Graduate School of Medicine 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505, Japan
| | - Kazuyoshi Suga
- Department of Radiology, St Hills Hospital, Imamurakita 3-7-18, Ube, Yamaguchi 755-0155, Japan
| | - Shoji Kido
- Computer-aided Diagnosis and Biomedical Imaging Research Biomedical Engineering, Applied Medical Engineering Science Graduate School of Medicine, Yamaguchi University, Tokiwadai 2-16-1, Ube, Yamaguchi 755-8611, Japan
| | - Naofumi Matsunaga
- Department of Radiology, Yamaguchi University Graduate School of Medicine 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505, Japan
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Quantification of lung perfusion blood volume with dual-energy CT: assessment of the severity of acute pulmonary thromboembolism. AJR Am J Roentgenol 2014; 203:287-91. [PMID: 25055261 DOI: 10.2214/ajr.13.11586] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the usefulness of quantification of lung perfused blood volume (PBV) with dual-energy CT (DECT) for assessment of the severity of acute pulmonary thromboembolism (PTE). MATERIALS AND METHODS We retrospectively analyzed the records of 72 patients with PTE and 168 without PTE who underwent DECT. The PTE patients were divided into high-, intermediate-, and low-risk groups based on clinical symptoms and right ventricular dysfunction. Correlations between quantification of whole-lung PBV and clinical severity were evaluated. Also evaluated was the relation between quantification of whole-lung PBV and right-to-left ventricular diameter ratio on CT images, which was used as an indicator of right ventricular dysfunction. RESULTS In the PTE and control groups, the whole-lung PBVs were 27.6 ± 7.9 and 29.9 ± 6.8 HU with a significant difference between them (p < 0.0281). In the high-, intermediate-, and low-risk PTE groups, the whole-lung PBVs were 16.0 ± 2.9, 21.0 ± 4.2, and 31.4 ± 5.8 HU with a significant difference between them (p < 0.05). There was no significant difference in whole-lung PBV between the control group and the low-risk PTE group, but there was a significant difference between the control group and the other two PTE groups. In PTE patients, whole-lung PBV had negative correlation with right-to-left ventricular diameter ratio (R = -0.567, p < 0.001). CONCLUSION Quantification of lung PBV with DECT is useful for assessment of the clinical severity of PTE and can be used as an indicator of right ventricular dysfunction.
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van Elmpt W, Zegers CML, Das M, De Ruysscher D. Imaging techniques for tumour delineation and heterogeneity quantification of lung cancer: overview of current possibilities. J Thorac Dis 2014; 6:319-27. [PMID: 24688776 DOI: 10.3978/j.issn.2072-1439.2013.08.62] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Accepted: 08/21/2013] [Indexed: 01/05/2023]
Abstract
Imaging techniques for the characterization and delineation of primary lung tumours and lymph nodes are a prerequisite for adequate radiotherapy. Numerous imaging modalities have been proposed for this purpose, but only computed tomography (CT) and FDG-PET have been implemented in clinical routine. Hypoxia PET, dynamic contrast-enhanced CT (DCE-CT), dual energy CT (DECT) and (functional) magnetic resonance imaging (MRI) hold promise for the future. Besides information on the primary tumour, these techniques can be used for quantification of tissue heterogeneity and response. In the future, treatment strategies may be designed which are based on imaging techniques to optimize individual treatment.
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Affiliation(s)
- Wouter van Elmpt
- 1 Department of Radiation Oncology (MAASTRO), 2 Department of Radiology, GROW, School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands ; 3 Radiation Oncology, University Hospitals Leuven/KU Leuven, Leuven, Belgium
| | - Catharina M L Zegers
- 1 Department of Radiation Oncology (MAASTRO), 2 Department of Radiology, GROW, School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands ; 3 Radiation Oncology, University Hospitals Leuven/KU Leuven, Leuven, Belgium
| | - Marco Das
- 1 Department of Radiation Oncology (MAASTRO), 2 Department of Radiology, GROW, School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands ; 3 Radiation Oncology, University Hospitals Leuven/KU Leuven, Leuven, Belgium
| | - Dirk De Ruysscher
- 1 Department of Radiation Oncology (MAASTRO), 2 Department of Radiology, GROW, School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands ; 3 Radiation Oncology, University Hospitals Leuven/KU Leuven, Leuven, Belgium
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