ct of the chest
DESCRIPTION
CT of the Chest. Dorith Shaham, M.D. Department of Radiology Hadassah Medical Center. Indications for Chest CT. To evaluate abnormalities shown on CXR To demonstrate or exclude a suspected CXR abnormality To demonstrate an abnormality in a patient with a normal CXR. Types of Chest CT. - PowerPoint PPT PresentationTRANSCRIPT
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CT of the ChestCT of the Chest
Dorith Shaham, M.D.
Department of Radiology
Hadassah Medical Center
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Indications for Chest CTIndications for Chest CT
• To evaluate abnormalities shown on CXR
• To demonstrate or exclude a suspected CXR abnormality
• To demonstrate an abnormality in a patient with a normal CXR
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Types of Chest CTTypes of Chest CT
• Standard chest CT– Without IV contrast– With IV contrast
• CT-angiography– PCTA (r/o PE)– Coronary CTA
• HRCT• CT-guided intervention
– Biopsy– Pleural drainage
• Low-dose CT
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IV contrastIV contrast
• Not used for pulmonary parenchimal abnormalities– Inherent high contrast
• Always used for CT-angiography• May be used for evaluation of
– Mediastinum – Hilum– Pleura
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Metastatic Lung Ca Metastatic Lung Ca (Adenocarcinoma)(Adenocarcinoma)
Rt. Hilar mass and small pleural effusionRt. Hilar mass and small pleural effusion
Without IV contrast
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Anterior Mediastinal Mass : Anterior Mediastinal Mass : Germ cell tumorGerm cell tumor
Without IV contrast With IV contrast
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Chest CT Chest CT with IV contrastwith IV contrast
SVC syndrome
ThrombusVenous collaterals
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CT-AngiographyCT-Angiography
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Pulmonary Embolism:Pulmonary Embolism:Imaging ModalitiesImaging Modalities
• Chest X-ray
• V/Q scan
• Computed tomographyComputed tomography– Helical (spiral) CTHelical (spiral) CT
• MRI
• Pulmonary angiography: the “gold standard”
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69- year old female with 69- year old female with shortness of breathshortness of breath
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Ventilation-perfusion (V/Q) scanVentilation-perfusion (V/Q) scan
• Perfusion scan: distribution of blood flow– Macroaggregated human serum albumin (10-100
micron) labeled with Tc-99m
• Ventilation scan: distribution of alveolar ventilation– Radioactive inert gas: X-133
• V/Q mismatchV/Q mismatch: abnormal perfusion and normal ventilation
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Interpretation of V/Q scanningInterpretation of V/Q scanning
• Probability stratification approach (based on the assumption that the only reason for performing a V/Q scan is to diagnose PE):– High probability– Intermediate probability/ indeterminate– Low probability– Normal
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Prospective Investigation of Pulmonary Prospective Investigation of Pulmonary Embolism DiagnosisEmbolism Diagnosis (PIOPED) (PIOPED)
• Multi-institutional study conducted in the mid-80’s,
• Purpose: to determine the sensitivity and specificity of V/Q scan compared with pulmonary angiogram
• 933 patients with suspected PE – 931 had V/Q scan
– 755 had pulmonary angiography
• Study patients were followed clinically for 1 Y
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PIOPED STUDYPIOPED STUDY
• High sensitivity of V/Q scan:
98% of patients with PE had abnormal scans (low, intermediate or high probability)
• Low specificity: 10%
• Non-diagnostic V/Q scans: 72%
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CTPACTPA
• Direct visualization of clot
• Imaging of associated findings– Pulmonary infarction– Pleural effusion
• Imaging of alternative diagnosis
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Pulmonary EmbolismPulmonary Embolism
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Pulmonary Embolism Pulmonary Embolism with Infarctionwith Infarction
Atelectasis
Infarction
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Pulmonary EmbolismPulmonary Embolism
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Combined PCTA/CTVCombined PCTA/CTV
• No additional contrast injection
• Rapid examination
• Imaging of portions of the deep venous system that are inadequately imaged by Duplex (pelvic veins, adductor canal)
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HL: Massive PE
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HL: Bilateral DVT
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PIOPED IIPIOPED II
• To determine the sensitivity, specificity, positive/negative predictive value of spiral CT for the diagnosis of PE.
• Reference for PE: various combinations of– V/P scan– Venous U/S– Pulmonary angiography– Contrast venography
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PIOPED IIPIOPED II
• 824 patients with suspected PE
• CTPA alone:– Sensitivity: 83%– Specificity: 96%– PPV: 96% (concordant high/low clinical probability),
92% (intermediate clinical probability)
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PIOPED IIPIOPED II
• Combined CTPA + CTV:– Sensitivity: 90%– Specificity: 95%
• Additional testing is necessary when clinical probability is inconsistent with imaging results
N Engl J Med 2006;354:2317-27
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15-year old male with chest pain15-year old male with chest pain
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Intramural hematoma
Pericardial effusion
Small right pleural effusion
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Collateral blood flow
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Coarctation of the aorta with enlarged internal mammary arteries
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CT Coronary AngiographyCT Coronary Angiography
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High Resolution CT (HRCT)High Resolution CT (HRCT)
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HRCT: HRCT: TechniqueTechnique
• Narrow slice width
• “Bone” reconstruction algorithm
• Small field of view
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HRCT: Ground glass opacityHRCT: Ground glass opacity
HRCTChest CT
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HRCT: scanning protocolsHRCT: scanning protocols
• 1-mm slices every 10-mm/ Contiguous 1-mm slices
• Supine/ Prone
• Full inspiration/ Expiration
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HRCT: patterns of lung diseaseHRCT: patterns of lung disease
• Reticular and short linear
• Nodular
• Increased lung opacity (“ground glass”)
• Decreased lung density– Cysts– Emphysema– Bronchiectasis
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CT vs. HRCTCT vs. HRCT
Multiple tiny perilymphatic nodulesSarcoidosis
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HRCT: BronchiectasisHRCT: Bronchiectasis
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CT-guided Needle BiopsyCT-guided Needle Biopsy
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IndicationsIndications
• Evaluation of – Solitary pulmonary nodule– Multiple pulmonary nodules– Mediastinal/hilar masses/lymphadenopathy– Chest wall masses
• Retrieval of organisms from infectious lung lesions
• Staging of tumors (lung cancer, extrathoracic)
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ContraindicationsContraindications
• An uncooperative patient
• Bleeding diathesis– INR>1.3– Platelet count<50,000 mm3
• Severe underlying lung disease– emphysema
• Intractable cough
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Image GuidanceImage Guidance
• CT• Fluoroscopy
– visualization in 2 projections
• Ultrasound– chest wall– pleura– anterior mediastinum– lung periphery
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Advantages of CT-guided BiopsyAdvantages of CT-guided Biopsy
• Needle path that avoids– aerated lung– fissures– large vessels– bullae– vital cardiovascular structures
• Differentiation of necrotic vs. viable portions of tumor– I.V. contrast
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Biopsy NeedlesBiopsy Needles::Westcott and TurnerWestcott and Turner
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Biopsy Needles:Biopsy Needles: Cutting Spring-AcivatedCutting Spring-Acivated
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Lung Biopsy: SPNLung Biopsy: SPN(Squamous cell ca.)(Squamous cell ca.)
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Lung Biopsy: Lung Biopsy: Multiple nodulesMultiple nodules((Alveolar soft part sarcoma)Alveolar soft part sarcoma)
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Rib Biopsy: Multiple myelomaRib Biopsy: Multiple myeloma
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Cytologic SpecimenCytologic Specimen
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CT-guided biopsy: ComplicationsCT-guided biopsy: Complications
• Pneumothorax
• Hemorrhage
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Drainage of Intrathoracic Drainage of Intrathoracic CollectionsCollections
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IndicationsIndications
• Malignant pleural effusion
• Empyema/ parapneumonic effusions
• Lung abscess
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Contraindications (relative) Contraindications (relative)
• Clotting deficiency– INR < 1.5– Thrombocytopenia (< 50,000 cells/ml)– Anticoagulation therapy
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Catheter PlacementCatheter Placement
• One step (trocar)
• Seldinger technique
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Drainage Catheters: Drainage Catheters: One Step
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Drainage CathetersDrainage Catheters: Seldinger technique
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Drainage of Empyema: PostpartumDrainage of Empyema: Postpartum
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Low-dose CT: Lung cancer Low-dose CT: Lung cancer screeningscreening
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Baseline Findings- ELCAPBaseline Findings- ELCAP
• Low dose CT greatly increases the likelihood of detection of NCN and early lung cancer compared with chest radiography– NCN:NCN: 3 times as commonly– Malignant tumors:Malignant tumors: 4 times as commonly– Stage I tumors:Stage I tumors: 6 times as commonly
Henschke et al, Lancet 1999; 354:99-105
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Low-dose CTLow-dose CT
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Low-dose CT: Lung cancerLow-dose CT: Lung cancer
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Low-dose CT and HRCTLow-dose CT and HRCT
1 year later
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HRCT 3 months later: HRCT 3 months later: Lung cancerLung cancer
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I-ELCAP results I-ELCAP results ((N Engl J Med 2006;355:1763-71)N Engl J Med 2006;355:1763-71)
• 31,567 asymptomatic persons at risk for lung cancer screened using low-dose CT (1993-2005)
• Stage I lung cancer diagnosed in 412/484 (85%)
• 10-year survival in stage I lung cancer– Overall: 88%– Surgical resection in 1 month: 92%
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National Lung Screening Trial (NLST)National Lung Screening Trial (NLST) ( (N Engl J Med 2011;365:395-409)N Engl J Med 2011;365:395-409)
• Started in 2002• >53,000 current and former heavy smokers, ages 55
to 74• compared the effects of two screening procedures for
lung cancer – – low-dose helical computed tomography (CT) – standard chest X-ray
• 20% fewer lung cancer deaths among trial participants screened with low-dose helical CT– Lung cancer deaths in CT-screened: 354, in CXR
screened: 442 (p=0.0041)