Dual-Layer Spectral CT Imaging of Upper Aerodigestive Tract Cancer: Analysis of Spectral Imaging Parameters and Impact on Tumor Staging

BACKGROUND AND PURPOSE

Dual-layer spectral CT is a novel technology that utilized conventional single-tube CT acquisition with a dual-layer detector for the separation of high and low-energy photons to create spectral data for material decomposition. We evaluated the spectral parameters of iodine density and Z-effective values in primary head and neck squamous cell carcinoma and determined its impact on local tumor staging.

MATERIALS AND METHODS

Twenty-one patients with primary head and neck squamous cell carcinoma and 15 healthy controls were retrospectively evaluated. Iodine density (milligram/milliliter) and Z-effective values were compared quantitatively between head and neck squamous cell carcinoma and normal neck mucosa. The receiver operating characteristic area under the curve determined the diagnostic performance of the spectral data for local staging. We compared conventional CT images without and with iodine density and Z-effective images to determine its impact on local tumor staging.

RESULTS

Primary head and neck squamous cell carcinoma showed higher mean iodine density (2.01 [SD, 0.26] mg/mL, P < .001) and Z-effective values (8.21 [SD, 0.36], P < .001). A high interobserver correlation was demonstrated for ROI measurements for both the control group (iodine density, κ = 0.71, and Z-effective values, κ = 0.78) and head and neck squamous cell carcinoma (iodine density, κ = 0.84, and Z-effective values, κ = 0.75) group. The area under the curve for iodine density and Z-effective values was 0.98 and 0.93, respectively. Optimal thresholds were identified as 1.58 mg/mL (95% CI, 1.45-1.71 mg/mL; P < .001; sensitivity = 1.0; specificity = .0.93) for iodine density and 8.08 (95% CI, 7.96-8.19; P < .001; sensitivity = 0.86; specificity = 0.93) for Z-effective values. Conventional CT with the addition of dual-layer spectral data (iodine density and Z-effective values) improved the accuracy of local tumor staging in 3 of 21 patients (14%) with head and neck squamous cell carcinoma compared with the criterion standard surgical staging/histopathology.

CONCLUSIONS

Dual-layer spectral iodine density and Z-effective values provided increased quantitative and qualitative differentiation between upper aerodigestive head and neck squamous cell carcinoma and normal mucosa. Increased tissue differentiation improved the local tumor staging accuracy.

Fiberoptic Bronchoscopic Submucosal Injection of Mitomycin C for Recurrent Bening Tracheal Stenosis: A Case Series

BACKGROUND

Benign tracheal stenosis has emerged as a therapeutic challenge for physicians involved in the care of survivors of critical care units. Although the traditional mainstay of open surgical reconstructive treatment is still considered the gold standard, endoscopic therapies such as laser re-canalization, balloon dilation, or stenting are commonly practiced in invasive bronchology. Recurrent obstructing granulomas pose a challenge for bronchoscopists. Mitomycin C (MyC) is a cytotoxic agent that is isolated from Streptomyces caespitosus and acts by inhibiting DNA and RNA synthesis through alkylation and cross-linkages. Topical MyC is commonly used in indirect laryngoscopies for the treatment of granulation tissue in the trachea by using saturated pledgets.

OBJECTIVES

To describe fiberoptic bronchoscopic submucosal injection of MyC as a treatment for recurrent bening tracheal stenosis.

METHODS

The authors report their successful experience with submucosal intralesional injection of MyC in the management of recurrent obstructing granulomas/stenosis using the flexible fiberoptic bronchoscope in a series of 10 patients between 2005 and 2019.

RESULTS

The results suggest that intralesional injection of MyC using the flexible bronchoscope after the endoscopic treatment of the stenotic lesion may reduce the rate of subsequent formation of granulation tissue and scarring without side effects.

CONCLUSIONS

The efficacy of MyC injection should be studied prospectively.

The yield of immediate post lung biopsy CT in predicting iatrogenic pneumothorax

BACKGROUND

The most prevalent complication of percutaneous lung biopsy is pneumothorax (PNX). A routine immediate post-procedure CT scan (ICT) to spot PNX is done in many centers. However, the diagnostic yield of this practice has not been studied broadly. We sought to evaluate whether an ICT could replace the routine follow-up chest X-ray (CXR) in detecting procedure related PNX.

METHODS

We examined case-records of 453 patients who underwent lung biopsy at our medical center. We analyzed findings from CXR performed 2-h after biopsy and from CT images at the site of biopsy acquired immediately after the procedure (ICT). Multivariate analysis was used to identify the risk factors for PNX, and we examined the concordance between ICT and CXR-2-h post-procedure.

RESULTS

A total of 87 patients (19%) were diagnosed with PNX on CXR-2-h post-procedure. ICT detected 80.5% of diagnosed PNX (p <  0.01). However, ICT demonstrated a negative predictive value of only 94%, meaning 17 patients (6%) with a negative ICT did eventually develop PNX seen on CXR. Furthermore, bleeding surrounding the puncture area spotted on ICT negatively predicted the development of PNX (OR = 0.4 95% CI; 0.2-0.7).

CONCLUSIONS

We conclude that a CT scan performed immediately after percutaneous lung biopsy cannot replace the routine follow-up CXR in predicting iatrogenic PNX. Bleeding in the needle's tract may lower the risk for procedure-related PNX.

P3514Gender differences in prognosis for total mortality among patients with ADHF: results of four-year follow-up

Aim

To obtain information on the effect of various predictors on the prognosis of a patient with acute decompensated heart failure (ADHF).

Methods

We investigated a sample of patients (n=719) hospitalized due to ADHF for 4 years (average observation duration was 2.3 years). 27 predictors were included in the model (clinical conditions and clinical signs of ADHF). We used regression tree method with CHAID algorithm with 10-fold cross-validation to determine the most important predictors of the prognosis.

Results

The most significant predictor for total mortality at the first branching was the gender of the patient. Mortality rate was 65.0% among males vs 47.9% among females (p<0.001). In the subgroup of males, the next most significant predictor for the prognosis was the level of systolic blood pressure (SBP): mortality rates was 79.6% with SBP ≤125 mm Hg vs. 57.2% with SBP >125 mm Hg (p=0.001). In the subgroup of males with SBP >125 mm Hg mortality rates differed depending on the presence of X-ray signs of congestion; when present, the total mortality was 65.7% vs. 47.8 in the absence (p=0.01). In the subgroup of females, the first most significant predictor of prognosis was diabetes mellitus (DM): mortality rates was 60.1% with DM vs. 41.2% without DM (p<0.001). The worst prognosis was found among those who are over 78 years old (55.8%) compared with younger (32.4%, p=0.001) for females with DM.

The model has high sensitivity (74.9%) but low specificity (50.3%). In the ROC analysis, AUC was 0.673 (95% CI: 0.634–0.712).

Regression tree for total mortality rate

Conclusion

The 4-year survival rate for patients with ADHF varies by gender. Among men, the most important predictors of prognosis were the level of SBP and the presence of congestion in the lungs at the hospital admission. Among women, DM and age had the greatest influence on the prognosis.

Chest wall shrapnel-induced beryllium-sensitization and associated pulmonary disease

Chronic beryllium disease (CBD) is an exposure-related granulomatous disease mimicking sarcoidosis. Beryllium exposure-associated disease occurs mainly via inhalation, but skin may also be a source of sensitization. A 65-year-old male with a history of war-related shrapnel wounds was initially diagnosed with pulmonary sarcoidosis. Twenty years later, the possibility of a metal-related etiology for the lung disease was raised. A beryllium lymphocyte proliferation test, elemental analysis of removed shrapnel, and genetic studies were consistent with a diagnosis of CBD. This case demonstrates that retained beryllium-containing foreign bodies can be linked to a pathophysiologic response in the lung consistent with CBD.

Continued progression of asbestos-related respiratory disease after more than 15 years of non-exposure

BACKGROUND

Most studies on asbestos-related diseases describe the associations between exposure and disease and the factors influencing that association. It is recognized that there is a long latency period between exposure and disease, but the health status of affected individuals after long-term non-exposure is uncertain.

OBJECTIVES

To describe the changes in pulmonary function tests (PFTs) and computed tomographic imaging of the thorax over a 15 year period after cessation of exposure to asbestos in a cohort of Israeli power plant workers.

METHODS

Israeli power plant workers whose PFTs and thoracic CT imaging between 1993 and 1998 revealed asbestos-related disease underwent a second clinical, functional and imaging evaluation up to 15 years later. The two sets of results were compared.

RESULTS

Of the original cohort of 59 males, 35 were still alive and 18 of them agreed to take part in the current study. The mean length of their exposure was 30 +/- 10.06 years (range 7-43 years). Comparison of the initial and follow-up examination findings revealed a significant increase in calcification of the pleural plaques (from 37% to 66%, P = 0.008) and a deterioration in PFT results (P= 0.04). Of the 24 men who died, malignant disease was the cause of death in 53%, mostly in sites other than the respiratory system.

CONCLUSIONS

PFTs declined and CT findings worsened in subjects who were formerly exposed to asbestos and had not been exposed to it for over a decade. Continued monitoring of individuals exposed to asbestos, even decades after the cessation of exposure, is recommended.

Vaccination against influenza in rheumatoid arthritis: the effect of disease modifying drugs, including TNF alpha blockers

OBJECTIVE

To assess the efficacy and safety of vaccination against influenza virus in patients with rheumatoid arthritis, with special emphasis on the effect of disease modifying antirheumatic drugs (DMARDs), including tumour necrosis factor alpha (TNFalpha) blockers.

METHODS

82 rheumatoid patients and 30 healthy controls were vaccinated with a split-virion inactivated vaccine containing 15 mug haemagglutinin (HA) per dose of each of B/Hong Kong/330/2001 (HK), A/Panama/2007/99 (PAN), and A/New Caledonian/20/99 (NC). Disease activity was assessed by tender and swollen joint count, morning stiffness, evaluation of pain, Health Assessment Questionnaire, ESR, and C reactive protein on the day of vaccination and six weeks later. Haemagglutination inhibiting (HI) antibodies were tested by a standard WHO procedure. Response was defined as a fourfold or more rise in HI antibodies six weeks after vaccination, or seroconversion in patients with a non-protective baseline level of antibodies (<1/40). Geometric mean titres (GMT) were calculated to assess the immunity of the whole group.

RESULTS

Six weeks after vaccination, a significant increase in GMT for each antigen was observed in both groups, this being higher in the healthy group for HK (p=0.004). The percentage of responders was lower in rheumatoid patients than healthy controls (significant for HK). The percentage of responders was not affected by prednisone or any DMARD, including methotrexate, infliximab, and etanercept. Indices of disease activity remained unchanged.

CONCLUSIONS

Influenza virus vaccine generated a good humoral response in rheumatoid patients, although lower than in healthy controls. The response was not affected by the use of prednisone or DMARDs.