Deep Learning-based Fibrosis Extent on Computed Tomography Predicts Outcome of Fibrosing Interstitial Lung Disease Independent of Visually Assessed Computed Tomography Pattern

Rationale: Radiologic pattern has been shown to predict survival in patients with fibrosing interstitial lung disease. The additional prognostic value of fibrosis extent by quantitative computed tomography (CT) is unknown. Objectives: We hypothesized that fibrosis extent provides information beyond visually assessed CT pattern that is useful for outcome prediction. Methods: We performed a retrospective analysis of chest CT, demographics, longitudinal pulmonary function, and transplantation-free survival among participants in the Pulmonary Fibrosis Foundation Patient Registry. CT pattern was classified visually according to the 2018 usual interstitial pneumonia criteria. Extent of fibrosis was objectively quantified using data-driven textural analysis. We used Kaplan-Meier plots and Cox proportional hazards and linear mixed-effects models to evaluate the relationships between CT-derived metrics and outcomes. Results: Visual assessment and quantitative analysis were performed on 979 enrollment CT scans. Linear mixed-effect modeling showed that greater baseline fibrosis extent was significantly associated with the annual rate of decline in forced vital capacity. In multivariable models that included CT pattern and fibrosis extent, quantitative fibrosis extent was strongly associated with transplantation-free survival independent of CT pattern (hazard ratio, 1.04; 95% confidence interval, 1.04-1.05; P < 0.001; C statistic = 0.73). Conclusions: The extent of lung fibrosis by quantitative CT is a strong predictor of physiologic progression and survival, independent of visually assessed CT pattern.

Emotional Distress, Anxiety, and General Health Status in Patients With Newly Identified Small Pulmonary Nodules: Results From the Watch the Spot Trial

BACKGROUND

Anxiety and emotional distress have not been studied in large, diverse samples of patients with pulmonary nodules.

RESEARCH QUESTION

How common are anxiety and distress in patients with newly identified pulmonary nodules, and what factors are associated with these outcomes?

STUDY DESIGN AND METHODS

This study surveyed participants in the Watch the Spot Trial, a large, pragmatic clinical trial of more vs less intensive strategies for radiographic surveillance of patients with small pulmonary nodules. The survey included validated instruments to measure patient-centered outcomes such as nodule-related emotional distress (Impact of Event Scale-Revised) and anxiety (Six-Item State Anxiety Inventory) 6 to 8 weeks following nodule identification. Mixed-effects models were used to compare outcomes between study arms following adjustment for potential confounders and clustering within enrollment site, while also examining a limited number of prespecified explanatory factors, including nodule size, mode of detection, type of ordering clinician, and lack of timely notification prior to contact by the study team.

RESULTS

The trial enrolled 34,699 patients; 2,049 individuals completed the baseline survey (5.9%). Respondents and nonrespondents had similar demographic and nodule characteristics, although more respondents were non-Hispanic and White. Impact of Event Scale-Revised scores indicated mild, moderate, or severe distress in 32.2%, 9.4%, and 7.2% of respondents, respectively, with no difference in scores between study arms. Following adjustment, greater emotional distress was associated with larger nodule size and lack of timely notification by a clinician; distress was also associated with younger age, female sex, ever smoking, Black race, and Hispanic ethnicity. Anxiety was associated with lack of timely notification, ever smoking, and female sex.

INTERPRETATION

Almost one-half of respondents experienced emotional distress 6 to 8 weeks following pulmonary nodule identification. Strategies are needed to mitigate the burden of distress, especially in younger, female, ever smoking, and minoritized patients, and those with larger nodules.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; No.: NCT02623712; URL: www.

CLINICALTRIALS

gov.

A Quick Reference Guide for Incidental Findings on Lung Cancer Screening CT Examinations

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.

Geographic access to lung cancer screening among eligible adults living in rural and urban environments in the United States

BACKGROUND

Although recommended lung cancer screening with low-dose computed tomography scanning (LDCT) reduces mortality among high-risk adults, annual screening rates remain low. This study complements a previous nationwide assessment of access to lung cancer screening within 40 miles by evaluating differences in accessibility across rural and urban settings for the population aged 50 to 80 years and a subset eligible population based on the 2021 US Preventive Services Task Force LDCT lung screening recommendations.

METHODS

Distances from population centers to screening facilities (American College of Radiology Lung Cancer Screening Registry) were calculated, and the number of individuals who had access within graduating distances, including 10, 20, 40, 50, and 100 miles, were estimated. Census tract results were aggregated to counties, and both geographies were classified with rural-urban schemas.

RESULTS

Approximately 5% of the eligible population did not have access to lung cancer screening facilities within 40 miles; however, different patterns of accessibility were observed at different distances, between regions, and across rural-urban environments. Across all distances and geographies, there was a larger percentage of the population in rural geographies with no access. Although the rural population represented approximately 8% of the eligible population, the larger percentage of the rural population with no access was noteworthy and translated into a larger number of individuals with no access at longer distance thresholds (≥40 miles).

CONCLUSIONS

Disparities in access should be examined as both percentages of the population and numbers of individuals with no access in order to tailor interventions to communities and increase access. Geospatial analysis at the census tract level is recommended to help to identify optimal focus areas and reach the most people.

LAY SUMMARY

As annual lung cancer screening rates remain low, this study examines access to lung cancer screening nationwide and across rural and urban settings. A geographic information system network analysis of census tract-level populations is used to estimate access at different distances, including 10, 20, 40, 50, and 100 miles, and the results are aggregated to counties. Approximately 5% of the eligible population does not have access to screening facilities within 40 miles; however, different patterns of accessibility are observed at different distances, between regions, and across rural-urban environments. Across all distances and geographies, there is a larger percentage of the population in rural geographies with no access.

Improvement in Stage of Lung Cancer Diagnosis with Incident Pulmonary Nodules followed with a Patient Tracking System and Computerized Registry

Introduction

Given that an incidental pulmonary nodule (IPN) on chest computed tomography (CT) may represent nascent lung cancer, timely follow-up imaging is critical to assess nodule growth and the need for tissue sampling. We previously reported our institution’s systematic process to identify and track patients with an IPN associated with improved CT on follow-up. We hypothesized that this improvement may have led to a higher frequency of early-stage lung cancer. To evaluate this, we performed a study to determine whether cases of early-stage lung cancer were more likely to have had our tracking system applied to suspicious findings.

Methods

An observational study was performed by identifying cases of lung cancer that were detected as IPNs on chest CT scans performed at our institution, from 2006 to 2016. A total of 314 cases were dichotomized into early-stage (stage 1) or late-stage (stages II to IV) disease. A multivariant regression analysis with modeling was used to determine factors associated with a diagnosis of early-stage disease. Factors included the use of the tracking system and nodule registry.

Results

The following factors were independently associated with early-stage lung cancer: index nodule diameter, (OR = 0.971, confidence interval [CI]: 0.948–0.995], p = 0.016), adenocarcinoma histology (OR = 2.930 [CI: 1.695–5.064], p = 0.0001) and use of tracker phrases on CT reports (OR = 1.939 [CI: 1.126–3.339], p = 0.016).

Conclusions

The application of a patient tracking system and computerized lung nodule registry lead to an increased frequency in the diagnosis of stage 1 NSCLC from IPNs. This is a meaningful outcome for patients and should be adapted for IPN management.

Managing Incidental Findings on Thoracic CT: Lung Findings. A White Paper of the ACR Incidental Findings Committee

The ACR Incidental Findings Committee presents recommendations for managing incidentally detected lung findings on thoracic CT. The Chest Subcommittee is composed of thoracic radiologists who endorsed and developed the provided guidance. These recommendations represent a combination of current published evidence and expert opinion and were finalized by informal iterative consensus. The recommendations address commonly encountered incidental findings in the lungs and are not intended to be a comprehensive review of all pulmonary incidental findings. The goal is to improve the quality of care by providing guidance on management of incidentally detected thoracic findings.

Improvement in Follow-up Imaging With a Patient Tracking System and Computerized Registry for Lung Nodule Management

PURPOSE

Despite established guidelines, radiologists' recommendations and timely follow-up of incidental lung nodules remain variable. To improve follow-up of nodules, a system using standardized language (tracker phrases) recommending time-based follow-up in chest CT reports, coupled with a computerized registry, was created.

MATERIALS AND METHODS

Data were obtained from the electronic health record and a facility-built electronic lung nodule registry. We evaluated two randomly selected patient cohorts with incidental nodules on chest CT reports: before intervention (September 2008 to March 2011) and after intervention (August 2011 to December 2016). Multivariable logistic regression was used to compare the cohorts for the main outcome of timely follow-up, defined as a subsequent report within 13 months of the initial report.

RESULTS

In all, 410 patients were included in the pretracker cohort versus 626 in the tracker cohort. Before system inception, 30% of CT reports lacked an explicit time-based recommendation for nodule follow-up. The proportion of patients with timely follow-up increased from 46% to 55%, and the proportion of those with no documented follow-up or follow-up beyond 24 months decreased from 48% to 31%. The likelihood of timely follow-up increased 41%, adjusted for high risk for lung cancer and age 65 years or older. After system inception, reports missing a tracker phrase for nodule recommendation averaged 6%, without significant interyear variation.

CONCLUSIONS

Standardized language added to CT reports combined with a computerized registry designed to identify and track patients with incidental lung nodules was associated with improved likelihood of follow-up imaging.

Using Geospatial Analysis to Evaluate Access to Lung Cancer Screening in the United States

BACKGROUND

Screening current and former heavy smokers 55 to 80 years of age for lung cancer (LC) with low-dose chest CT scanning has been recommended by the United States Preventive Services Task Force since 2013. Although the number of screening facilities in the United States has increased, screening uptake has been slow.

RESEARCH QUESTION

To what extent is geographic access to screening facilities a barrier for screening uptake nationally?

STUDY DESIGN AND METHODS

Screening facilities were defined as American College of Radiology (ACR) Lung Cancer Screening Registry (LCSR) facilities. Analysis was performed at different geographic levels using a road network to calculate travel distances for the recommended age groups. Full access to screening was defined as the entire 55- to 79-year-old population being within 40 miles of an ACR LCSR facility. No access was defined as lack of access by the entire target population. Partial access was expressed in intervening quartiles. A geospatial approach then was used to integrate accessibility with smoking prevalence and LC mortality rates to identify potential focus areas visually.

RESULTS

Screening facilities addresses were geocoded to identify 3,592 unique locations. Analysis of census tracts and aggregation to counties revealed that among 3,142 counties, adults 55 to 79 years of age have full access to an LC screening registry facility in 1,988 (63%) counties, partial access in 587 (19%) counties, and no access in 567 (18%) counties. Overall, less than 6% of those 55 to 79 years of age do not have access to registry screening facilities. Variation in screening facility access was noted across the United States, between states, and within some states.

INTERPRETATION

It is recommended to calculate accessibility using subcounty geographies and to examine variation regionally and within states. A foundation geographic accessibility layer can be integrated with other variables to identify geographic disparities in access to screening and to focus on areas for interventions. Identifying areas of greatest need can inform state and local officials and healthcare organizations when planning and implementing LC screening programs.

Managing Incidental Findings on Thoracic CT: Mediastinal and Cardiovascular Findings. A White Paper of the ACR Incidental Findings Committee

The ACR Incidental Findings Committee presents recommendations for managing incidentally detected mediastinal and cardiovascular findings found on CT. The Chest Subcommittee was composed of thoracic radiologists who developed the provided guidance. These recommendations represent a combination of current published evidence and expert opinion and were finalized by informal iterative consensus. The recommendations address the most commonly encountered mediastinal and cardiovascular incidental findings and are not intended to be a comprehensive review of all incidental findings associated with these compartments. Our goal is to improve the quality of care by providing guidance on how to manage incidentally detected thoracic findings.

Radiologic diagnoses of patients who received imaging for venous thromboembolism despite negative D-dimer tests

OBJECTIVE

The literature supports a negative D-dimer (-DD) excluding venous thromboembolic disease (VTE) in low-risk patients. We determined the radiologic diagnoses in patients where imaging was ordered despite a -DD.

METHODS

This is a retrospective chart review of patients with a -DD (Tinaquant; Roche Diagnostics, Mannheim, Germany) and a radiologic study within 48 hours, sought to determine radiologic diagnosis (primary outcome), treatment of VTE, and consensus diagnosis of acute VTE.

RESULTS

Among 3462 DD tests, 1678 met the inclusion criteria. Of 1362 patients with DD values of 350 ng/mL or less, 166 (12.2%) had radiologic studies: 93.4% of the final radiologic diagnoses were negative for VTE, 3.6% were indeterminate, and 3.0% (1.0%-6.9%) were positive; 1.8% ultimately had a consensus diagnosis of acute VTE. In 316 patients with DD values between 351 and 500 ng/mL, 88 (27.8%) had radiologic studies: 95.5% were negative, 1.1% were indeterminate, and 3.4% (0.7%-9.6%) were positive.

CONCLUSIONS

Of patients who receive radiologic studies despite -DD tests, 3.0% have positive radiologic diagnoses for acute VTE; only 1.8% had acute VTE after the review of their hospital course.

Derivation of a Clinical Decision Rule to Exclude Thoracic Aortic Imaging in Patients With Blunt Chest Trauma After Motor Vehicle Collisions

BACKGROUND

Thoracic aortic injury (TAI) is associated with high mortality. It is not practical to evaluate all patients with blunt chest trauma with dedicated aortic imaging. The purpose of this study was to define a group of patients with blunt chest trauma after motor vehicle collision (MVC) that do not require aortic imaging based on information available in the emergency department.

METHODS

This was a secondary analysis of a prospectively-collected database. Consecutive patients with blunt chest trauma after MVC were included. Characteristics of mechanism, examination, and chest radiographic findings were collected for each patient. All patients underwent chest computed tomography (CT), aortography, or both for TAI evaluation. Binary recursive partitioning was used to derive and validate a clinical decision rule to predict exclusion of TAI.

RESULTS

During the study period, 1,096 patients were included, and 22 (2.0%) were diagnosed with TAI. The decision rule for exclusion of TAI included findings from the chest radiograph, incorporating left paraspinous line displacement, obscured aortic knob, and mediastinal widening. The rule resulted in a sensitivity of 86% (95% confidence interval [CI]: 65% to 97%), a specificity of 77% (95% CI: 75% to 80%), a positive predictive value of 7% (95% CI: 4% to 11%), a negative predictive value (NPV) of 99.6% (95% CI: 99.0% to 99.9%), a positive likelihood ratio of 3.8 (95% CI: 1.1-12.9), and a negative likelihood ratio of 0.18 (95% CI: 0.05-0.61). This would potentially reduce aortic imaging by 76% (95% CI: 74% to 79%).

CONCLUSION

We report a clinical decision rule with a high NPV for exclusion of TAI. This may standardize the approach to such patients and may reduce the need for CT.

Thoracic aortic injury: how predictive is mechanism and is chest computed tomography a reliable screening tool? A prospective study of 1,561 patients

BACKGROUND

Thoracic aortic injury (TAI) is a devastating condition in which prompt recognition can obviate morbidity and mortality. It is a long-held belief that TAI is more likely when there is a "major mechanism of injury." The purposes of this prospective study were to determine mechanism characteristics that are predictive of TAI and to evaluate chest computed tomography (CT) as a screening tool for TAI.

METHODS

Over a 5 1/2 year period, blunt chest trauma patients at two Level I trauma centers were evaluated for potential TAI. Patients were assigned mechanism and radiograph scores from 1 (low suspicion for TAI) to 5 (very high suspicion for TAI). Immediate aortography was obtained when suspicion for TAI was very high. The remaining patients were evaluated with contrast-enhanced chest CT. Confirmatory aortography was obtained on all positive chest CT scans and on all patients with mechanism scores of 4 or 5 even if the CT was negative. Mechanism and radiographic data were correlated with the results of aortic imaging.

RESULTS

Of the 1,561 patients evaluated for TAI, 30 aortic injuries were found. The assessment of mechanism was imperfect with a reliance on often incomplete and subjective data. The subjective mechanism score proved to be the most useful predictor of TAI. Radiographic scores were useful but insensitive for intimal injuries. Computed tomography was found to have 100% and 100% NPV for TAI.

CONCLUSION

Considering the inherent difficulties in identifying patients at risk for TAI and the effectiveness of chest CT as a screening tool for aortic injury, we recommend liberal use of chest CT in blunt chest trauma. Guidelines for determining the need for aortic imaging are outlined.

Can chest CT be used to exclude aortic injury?

PURPOSE

To determine whether chest computed tomography (CT) can be used to exclude aortic injury.

MATERIALS AND METHODS

Patients in whom there was very high suspicion of traumatic aortic injury were examined with aortography only. Other patients were examined with contrast material-enhanced CT. Follow-up aortography was performed in all patients with moderate to high suspicion of traumatic aortic injury and in all patients with CT scans that were positive for traumatic aortic injury. CT scans were regarded as positive when they showed mediastinal hematoma or direct findings of aortic injury. During a 4 1/2-year period, 1,009 patients (263 female, 746 male; age range, 3-90 years) were evaluated for possible traumatic aortic injury.

RESULTS

Of the 207 patients who underwent aortography directly without CT, 10 had traumatic aortic injury. Of the 802 patients who were examined with CT, 382 underwent follow-up aortography. In this group, there were 10 true-positive and no false-negative CT scans. CT had 100% sensitivity and a 100% negative predictive value for the detection of traumatic aortic injury.

Detection of diabetic macular edema: Nidek 3Dx stereophotography compared with fundus biomicroscopy

PURPOSE

To assess the use of the Nidek 3Dx simultaneous stereophotography camera in diabetic patients, comparing the detection of clinically significant macular edema by fundus biomicroscopy to detection by the Nidek 3Dx simultaneous fundus stereophotograph.

METHODS

Two hundred eight eyes of 123 diabetic patients at the Wilmer Retinal Vascular Center were examined for this prospective study between August 1993 and October 1993. Each patient was examined by one of three retina specialists by contact lens biomicroscopy for clinically significant macular edema and foveal center thickening. Nidek 3Dx fundus stereophotographs were obtained and graded independently for clinically significant macular edema and foveal center thickening by a fourth ophthalmologist masked from the clinical examination findings. Percent agreement, kappa statistic, and weighted kappa statistic were determined for the two diagnostic methods.

RESULTS

One hundred eighty-four (88%) of the 208 stereophotographs were of sufficient quality to detect clinically significant macular edema; 175 (84%) of the 208 stereophotographs detected foveal center thickening. The agreement between the clinician and the photographic grading, measured by weighted kappa, was 0.52 for clinically significant macular edema and 0.58 for foveal center thickening, representing fair to good agreement beyond chance. Agreement was improved when normal fundus Nidek stereophotographs were available as standards for comparison.

CONCLUSIONS

The Nidek 3Dx camera is suitable for photographic detection of clinically significant macular edema and may have a potential advantage over conventional cameras by achieving good-quality, gradable stereophotographs in a large proportion of photographed eyes.

Developmental neural abnormalities and seizures in epidermal nevus syndrome

The epidermal nevus syndrome (ENS) is an unusual neurocutaneous disorder consisting of the combination of an epidermal nevus and a central nervous system (CNS), ophthalmological, and/or skeletal abnormality. The study reports four new patients with ENS. Each had a confirmatory biopsy of the epidermal nevus, abnormal neurological examination findings, and documented CNS anatomical studies by imaging or autopsy. The paper also reviews the literature in English to determine neurological abnormalities found in skin-biopsy-proven cases of ENS. Hemi-atrophy, hemimegalencephaly, migrational abnormalities and vascular anomalies were found to be the most frequent intracranial abnormalities associated with ENS. Seizures and/or disabling moderate to severe developmental delays were present in a majority of patients. Seizure onset during the neonatal period or early infancy was associated with major hemispheric malformations. Neuroectodermal-derived ocular lesions were often bilateral. No consistent relation between laterality of the nevus and laterality of CNS abnormalities was found, supporting the gene mosaicism theory of pathogenesis.

Angiographic features and outcome of questionable recurrent choroidal neovascularization

PURPOSE

We sought to identify specific fluorescein angiographic patterns that may have led to the diagnosis of questionable recurrent choroidal neovascularization. We evaluated follow-up information to determine whether any specific angiographic patterns could be used to identify patients at high risk for definite recurrence.

METHODS

We identified fluorescein angiograms graded as questionable for recurrent choroidal neovascularization that were taken from a previous prospective study involving 401 consecutive follow-up visits of patients treated with photocoagulation for choroidal neovascularization. We reviewed these angiograms to identify specific angiographic patterns that might have led to the classification of questionable recurrent choroidal neovascularization. Angiograms from visits subsequent to a questionable recurrence were reviewed to determine which patterns, if any, were associated with an increased risk for a definite recurrence to develop later.

RESULTS

Forty-four eyes (44 patients) with questionable recurrences (of which 40 had at least four months of follow-up) were categorized into six angiographic patterns. The three most common patterns included the following: (1) focal staining along the edge of the laser lesion (20 cases, 15 subsequently recurred); (2) blocked fluorescence from subretinal hemorrhage not documented at the previous visit (eight cases, five subsequently recurred); (3) speckled hyperfluorescence noted beyond the edge of the laser lesion (eight cases, six subsequently recurred).

CONCLUSIONS

Questionable recurrent choroidal neovascularization may be identified by specific angiographic patterns. Focal staining along the edge of the laser lesion and speckled hyperfluorescence were the patterns that were most likely to progress to definite recurrence.

The role of laser wavelength in the treatment of vitreoretinal diseases

Advances in laser technology have provided ophthalmologists with lasers spanning the visible and near-infrared spectrum. Recently, prospective, randomized clinical trials have compared laser wavelengths in the treatment of specific disorders. The Krypton Argon Regression Neovascularization Study found no difference between argon blue-green and krypton red laser when performing panretinal photocoagulation to manage proliferative diabetic retinopathy. The Macular Photocoagulation Study Group and the Canadian Ophthalmology Study Group have independently found no substantial difference in treatment outcome when using argon green versus krypton red laser to treat choroidal neovascularization in eyes with age-related macular degeneration. These recent trials and others that evaluate laser management of proliferative diabetic retinopathy, choroidal neovascularization, retinopathy of prematurity, and retinal breaks are reviewed. Multiple studies have failed to identify a moderate difference in treatment outcome between treatments performed with different laser wavelengths; however, small differences in outcome cannot be excluded without further study involving great numbers of patients. At the present time, ophthalmologists should be reassured that individual preferences for one wavelength over another in specific situations should not have a major effect on the visual outcome of the procedure.