Imaging and measurement techniques in the evaluation of

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Imaging and measurement techniques in the evaluation of Powered By Docstoc
					E-Communication Session                                                                                                                  Room London 2 - 14:45-16:45

                                                               T UESDAY, O CTOBER 7 TH 2008

                                                                                       period.The indications were: cancer staging 26.3%, pneumonia 12.2%, pleurisy
                                                                                       8%, dyspnea 7.3%, hemoptysis 6.5%, thoracic pain 5.7% and other indications
                                                                                       Pulmonary embolism was detected in 11 of these patients (4.2%).
                                                                                       The most important findings of these cases concerned age and comorbidity.
                                                                                       6 patients out of 11(54.5%) were >70yrs and 7 patients out of 11(63.6%) had
                                                                                       The emboli in 6 of the positive scans were found to be at the segmental level, 4 at
                                                                                       the lobar level and only one embolus was found to be at one of the main branches
                                                                                       of the pulmonary artery.None of the cases was identified as positive by the original
                                                                                       interpretation except the one with the central embolus.
                                                                                       Conclusion: Unsuspected PE was detected in 4% of all patients who underwent
                                                                                       CT of the chest with a higher prevalence among older patients and patients with
                                                                                       an underlying malignancy.
                                                                                       The high mortality attributed to PE demands that all CT scans of the thorax
                                                                                       should be routinely investigated for emboli regardless of the indication for the

                                                                                       Prevalence of unsuspected pulmonary emboli in MDCT of the thorax being
                                                                                       carried out for staging of malignancy
                                                                                       Stuart Schembri 1 , Nicola Schembri 2 . 1 Chest Medicine, Mersey Deanery,
                                                                                       Liverpool, United Kingdom; 2 Radiology, Mersey Deanery, Liverpool, United

                                                                                       Background and Objectives: Pulmonary embolism (PE) is a common condition
                                                                                       that is often diagnosed on multi-detector computed tomography (MDCT) done
 420. Imaging and measurement techniques                                               for other indications. Other studies have shown a prevalence of unsuspected PE
                                                                                       of up to 6% in unselected populations. We aimed to establish the prevalence of
  in the evaluation of pulmonary embolism,                                             unsuspected PE in patients having a MDCT thorax for staging of malignancy.
                                                                                       Methods: A retrospective review of contrast-enhanced MDCT scans of the chest
          COPD and pleural diseases                                                    and abdomen performed for staging purposes over a two month period at a district
                                                                                       general hospital was carried out. We documented age, gender and the suspected
                                                                                       primary site together with the presence or absence of PE. All scans were carried out
                                                                                       on a four slice helical CT scanner after contrast injection with 5mm collimation.
E4283                                                                                  Results: 162 scans were carried out in the study period. 83 were females and 79
Evaluation of the resolution of thrombi with spiral CT at the end of treatment         males. Mean age was 66 years, (range 32-93yrs) Sites of primary were; colon (37),
for acute pulmonary thromboembolism                                                    breast (26), lung (23), oesaphagus (14) renal (8) and other (54). PE was noted in
Munire Gokirmak 1 , Ahmet Bircan 1 , Ahmet Ozden 2 , Orhan Oyar 2 ,                    3 (1.9%) scans. Table 1 shows the characteristics of the positive scans.
Ahmet Akkaya 1 . 1 Dept. of Pulmonary Diseases, Suleyman Demirel University,
Isparta, Turkey; 2 Dept. of Radiodiagnostics, Suleyman Demirel University,             Characteristics of patients with unsuspected PE
Isparta, Turkey                                                                                                 Age                  Gender            Primary site

Background: Although several studies exist in literature optimizing the diagnosis      Patient 1                 42                  Female              Renal
of acute pulmonary thromboembolism (PTE), the data regarding the resolution of         Patient 2                 61                   Male              Melanoma
pulmonary thrombi is very limited. There is no study in literature evaluating the      Patient 3                 69                   Male               Gastric
resolution of thrombi by spiral CT, just at the end of treatment.
Aims: The aim of the current study was to evaluate the resolution of thrombi by        Conclusion and discussion: The prevalence of unsuspected PE in our study was
means of spiral CT, at the end of anticoagulant treatment for acute PTE.               1.9%, this is less than previously published data. It is possible that this is due to our
Methods: Forty-seven consecutive patients admitted for acute PTE between June          population being outpatient based. Furthermore unlike previous studies increasing
2005 and January 2008, were included in the study. The demographic features of         age was not associated with an increased prevalence of PE this could be due to
all patients as well as the predisposing factors for PTE were recorded. The spiral     our sample size or possibly because age is less of a factor in the presence of
CTs performed before and after treatment were compared by two radiologists             malignancy.
according to a predefined scoring system.
Results: Since 14 patients did not have follow-up spiral CTs due to several reasons,
the results are given for a total number of 33 patients. The patients (15 males,       E4286
18 females) had a mean age of 56.9±14.3 years. All patients have been treated          Unexpected diagnoses with CT pulmonary angiogram (CTPA)
by heparin and oral anticogulants, while 4 patients received fibrinolytic therapy.      Nanda Nalla, M. Thirumaran, S. Faruqi, S.P.L. Meghjee. Respiratory
The mean CT scores calculated before and after treatment were 14.66±6.45 and           Department, Pinderfields General Hospital, Wakefield, United Kingdom
1.36±2.91, respectively. At the end of treatment, 26 patients (78.8%) had complete
resolution, while 7 patients (21.2%) showed endovascular abnormalities.                Background: CTPA is a first line investigation for evaluation of suspected pul-
Conclusion: Complete resolution did not occur at completion of therapy in all          monary embolism (PE). Due to technological improvements CTPA tends to pick
patients with acute PTE. Performance of a control spiral CT at completion of           up abnormalities which would have otherwise gone undetected. We wanted to
therapy may help to differentiate acute from residual thrombus, when patients          analyze the incidental abnormalities diagnosed on patients undergoing CTPA for
return with complaints possibly due to recurrent PTE.                                  suspected PE. We retrospectively reviewed the CTPA results over a period of 12
                                                                                       Results: 714 patients (Female-60%) with a mean age of 59 years were investigated
E4284                                                                                  for a suspected PE. The diagnoses suggested by CTPA are listed in Table 1.
Incidence of unsuspected pulmonary embolism on routine MDCT of the chest
Christos Papakonstantinou 1 , Vasiliki Paschidou 1 , Maria Tziata 2 ,                  Table 1
Evagelos Alexiou 2 , Ioanna Petrou, Alex Tsomidis 1 , George Michalopoulos 2 ,         Diagnosis                            Number
Kostas Tsipelis 2 . 1 Pulmonary Department, Hospital of Chalkidiki, Polygyros,
Greece; 2 Radiology Department, Hospital of Chalkidiki, Polygyros, Greece              Consolidation                          140
                                                                                       PE                                     136
                                                                                       Pulmonary nodule                        14
The diagnosis of pulmonary embolism (PE) requires a high index of clinical
                                                                                       Lung Cancer                             11
suspicion and is sometimes missed because it imitates other diseases.
                                                                                       Lung metastasis                         7
Aim: To assess the prevalence of PE in patients undergoing routine multidetector       Small pneumothorax                      2
CT (MDCT) scanning of the chest for indications other than suspected PE.               Multiple Myeloma                        2
Methods: The files of all patients who underwent MDCT within the second                 Renal carcinoma                         1
semester of 2007 were retrospectively reviewed.Patients referred for CT an-            Lymphoma                                1
giogram with suspected PE were not considered.CT scans were independently
rereviewed by two radiologists.Cases of interpretational disagreement between the
radiologists were excluded.                                                            136 patients (19%) were diagnosed to have PE. Consolidation suggestive of an
Results: 262 patients (62% men 48% women) underwent MDCT over a 6-month                infective cause was seen in 140 patients (20%) who did not have a PE. In 22

                        Abstract printing supported by Nonin Medical, Inc. Visit Nonin Medical, Inc. at Hall 3.2 Stand 3.57
E-Communication Session                                                                                                               Room London 2 - 14:45-16:45

                                                                T UESDAY, O CTOBER 7 TH 2008

patients (3.1%) an unexpected diagnosis of a malignant pulmonary lesion was             E4289
made. The mean age of this group of patients was 69 years. 7 out of the 11 patients     Imaging in 100 patients of pulmonary hydatid disease; review of unusual
diagnosed with lung cancer could not have definitive treatment or investigations         imaging appearances
due to their poor performance status. Of the 7 patients diagnosed to have metastasis    Soheyla Zahirifard, Mehrdad Bakhshayeshkaram. Radiology, NRITLD, Tehran,
3 were known to have a primary neoplasm. 14 patients were found to have lung            Iran, Islamic Republic of; Radiology, NRITLD, Tehran, Iran, Islamic Republic of
nodules which were all benign on follow up
Conclusion: Significant numbers of CTPA yield unexpected findings, which                  Purpose: To evaluate the chest radiography and CT scan characteristics of pul-
though often provide an explanation for the clinical presentation. Consolidation        monary hydatid disease.
was seen in a significant proportion. Patients diagnosed to have malignancy were         Material and Methods: 100 patients with surgically proven pulmonary hydatid
older, had poor performance status and hence possibly they did not have any             cysts were enrolled for study. We reviewed clinical findings and imaging of pa-
symptoms related to the primary malignancy.                                             tients. The radiological features (localization, diameter, architecture, density and
                                                                                        other radiological signs and appearances) were determined.
                                                                                        Results: On CXR 124 cysts were determined. On 82 available CT scans a total
E4287                                                                                   of 112 cysts were detected. No discrete cyst was detected on 11 CXR. On CT
MDCT – angiography in diagnosis of PE masked by other pathological                      examination of 82 available CT, a total of 112 cysts were detected and in 5 CT
processes in lungs                                                                      scans no cyst was detected. 57 cysts were ruptured and 25 patients with ruptured
Olga Lukina 1 , Alexandra Speranskaja 1 , Victor Amosov 1 , Mary Vasilieva 1 ,          cysts had hemoptysis. Single cysts were in 63 patients while multiple cysts were
Olga Baranova 2 . 1 Radiology, Pavlov’s State Medical University, St.Petersburg,        in 37. Median CT density was 24HU. Respectively, it was seen on CT and CXR
Russian Federation; 2 Pulmonology, Scientific Research institute of Pulmonology,         waterlily sign in 18 and 22 patients, Air-fluid level in 12 and 17 patients and
St.Petersburg, Russian Federation                                                       cresent sign on 11 and 5 of patients. Inverse cresent sign and calcification were not
                                                                                        observed on CXR s but each one was recorded on 4 CT scans. On CT scan 90%
PE – the pathological process complicating many diseases, is frequently masked          of Cysts were smooth and 89% were uniloculated. 19% of cysts were infected.
by their main clinical and radiological features.                                       Conclusion: CT scan should be done to elucidate cystic nature of the lung masses
Differential diagnostics of this pathology includes all processes with breathless-      and for accurate localization in the preoperative period. In endemic regions like
ness, blood-spitting, pain in a thorax. The most frequent diseases with such clinical   Iran, atypical imaging presentation of complicated pulmonary hydatid disease
presentation are: tumors, interstitial lung diseases, COPD.                             such as solid masses should be considered in differential diagnosis of pulmonary
MDCT with contrast enhancement allows us to visualize direct features of PE –           lesions.
defects of filling of branches of pulmonary arteries, and thus, allows to put final
diagnosis of PE, that is important for definition of tactics of treatment.
Aim: The aim of our research was an estimate opportunities MDCT – angiography           E4290
of in revealing PE in patients with different pathology.                                Sex differences in phenotypes of COPD
Materials and methods: We analysed results MDCT – angiography of 153 pa-                Pat Camp 1 , Peter Paré 1 , Harvey Coxson 1 , Sreekumar Pillai 2 , Wayne Anderson 2 ,
tients, with radiological picture that did not exclude presence of PE, or clinical      Edwin Silverman 3 , David Lomas 4 . 1 James Hogg iCAPTURE Centre for
presentation appeared to be highly suspective.                                          Cardiovascular and Pulmonary Research, University of British Columbia,
Results of research: PE was confirmed with in 78 patients, in 16 of them other           Vancouver, BC, Canada; 2 GlaxoSmithKline R&D, GlaxoSmithKline, Research
pathological processes were initially supposed. In 9 patients PE was a complication     Triangle Park, NC, United States of America; 3 Channing Laboratory, Brigham
of other diseases which were also revealed on CT: in 4 patients – the central cancer,   and Women’s Hospital, Boston, MA, United States of America; 4 Department of
in 1 patient – a peripheral cancer in 1 – chronic lympholeucosis, in 2 – vasculitis,    Medicine, University of Cambridge, Cambridge Institute for Medical Research,
in 1 – sarcoidosis (III stage).                                                         Cambridge, United Kingdom
In 7 patients PE was clinically underestimated because of – COPD (2 patients),
sarcoidosis I and II stages (2 patients), idiopathic pulmonary fibrosis, bronchoec-      Sex differences in COPD could be due to differences in the relative contribution
tasis.                                                                                  of emphysema and small airway (AW) remodeling. We hypothesized that on
Conclusions: Thus, MDCT – angiography allows us to assist in differential di-           quantitative high resolution computed tomography (HRCT), male smokers would
agnostics of PE in difficult cases in patients with other pathological processes in      exhibit more emphysema and female smokers would have thicker AW walls.
lungs and in cases with complicated pathology.                                          Methods: 356 men and 332 women with ≥5 pack years smoking history underwent
                                                                                        thoracic HRCT as part of a multi-centre study investigating genetic susceptibility
                                                                                        for COPD. The % low attenuation area (%LAA) was calculated using a density
E4288                                                                                   mask of -950 Hounsfield units. AW wall thickness was estimated from the wall area
Frequency of incidental solitary pulmonary nodules on CT pulmonary                      (WA) % and √WA. All subjects completed spirometry and the ATS Epidemiology
angiograms and consequential additional radiological requirements                       Questionnaire.
Katrina McNulty 1 , Laura Massouh 2 , Nicholas Hughes 3 , Timothy Ho 1 .                Results: Women had similar FEV1 % predicted (women 65.5±31.9%; men
  Respiratory Medicine Department, Frimley Park Hospital NHS Foundation                 62.1±30.4%; p=0.16) as men but fewer pack years (women 37.8±19.7; men
Trust, Camberley, United Kingdom; 2 Medical School, University of Bristol,              47.8±27.4; p<0.0001). Men had a greater %LAA compared to women (24±0.12%
Bristol, United Kingdom; 3 Radiology Department, Frimley Park Hospital NHS              vs 20±0.11%; p < 0.0001). This difference persisted after adjusting for covari-
Foundation Trust, Camberley, United Kingdom                                             ates including weight, smoking and FEV1 % predicted (p=0.0006). Women had a
                                                                                        similar WA% (female 80.77±3.25%; male 80.83±3.72%; p=0.8139) but a smaller
Introduction: CT pulmonary angiogram is increasingly used as the primary                √WA (female 0.387±0.058 cm; male 0.430±0.064 cm; p<0.0001). However,
radiological investigation in suspected pulmonary emboli. Pulmonary nodules             women had a smaller WA% and WA after adjusting for age, pack years, current
measuring 1-2mm can now be detected on CT scanning. A small number of these             smoking status, BMI or height and weight, lumen perimeter and FEV1 % predicted
turn out to be malignant and guidelines for follow-up have been suggested [1].          (p<0.0001).
The follow up of these patients requires further CT scans and places demands on         Conclusion: men have more emphysema than women, but women do not show
chest physicians and radiology departments.                                             increased AW wall thickness compared to men. This may be due to an inability
Aims: We aimed to investigate the frequency of incidental solitary pulmonary            of HRCT to detect subtle differences between men and women in thickness at the
nodules (SPNs) on CT pulmonary angiogram carried out for suspected pulmonary            level of the smallest AW.
emboli. Using current guidelines we sought to estimate the impact of these findings
in terms of follow-up.
Methods: The reports of CT pulmonary angiograms carried out over 60 consecutive         E4291
days in our hospital were examined retrospectively.                                     Gender differences in emphysema phenotypes in non-COPD smokers
Results: 132 CT pulmonary angiograms were performed. Pulmonary emboli were              Nicola Sverzellati 1 , Elisa Calabrò 2 , Giorgia Randi 3 , Carlo La Vecchia 3 ,
found in 20 studies (15.2%). SPNs were found in 10 studies (7.6%). 6 patients           Alfonso Marchianò 4 , Jan-Martin Kuhnigk 5 , Paolo Spagnolo 6 ,
had SPNs measuring < 4 mm. Guidelines suggest minimum follow-up for these               Maurizio Zompatori 1 , Ugo Pastorino 2 . 1 Clinical Sciences, of Radiology,
patients is a repeat CT scan after 12 months. Four patients had SPNs measuring          University of Parma, Parma, Italy; 2 Thoracic Surgery, Istituto Nazionale Tumori,
> 8 mm. A further 3 CT scans over a 24 month period are suggested, in addition          Milano, Italy; 3 Epdemiology, Mario Negri, Milano, Italy; 4 Radiology, Istituto
to consideration of PET-CT scan or biopsy. For this cohort an additional 18 CT          Nazionale Tumori, Milano, Italy; 5 MeVis-Center for Medical Visualization and
scans would be required, equivalent to 14% of the original number of CT scans           Diagnostic Systems, Universitaetsallee 29, Bremen 28359, Bremen, Germany;
requested.                                                                                Respiratory Diseases, University of Modena & Reggio Emilia, Modena, Italy
Conclusions: The majority of CT pulmonary angiograms performed were negative
for pulmonary emboli. However additional co-pathology was identified which gen-          Background: Data on gender differences in the emphysema features are available
erated significant extra CT scan requirements. This may have important resource          only in patients with chronic obstructive pulmonary disease (COPD).
implications.                                                                           Aims and objectives: The purpose of this study was to weight how gender
Reference:                                                                              influences emphysema phenotype, using multi-detector CT (MDCT) derived mul-
1. MacMahon H et al. Radiology. 2005;237:395-400.                                       tiparametric objective measurements in non-COPD smokers.
                                                                                        Methods: We retrospectively evaluated both clinical and low-dose MDCT data on
                                                                                        957 heavy smokers (343 women) without clinical evidence of significant airflow
                                                                                        obstruction recruited by the Multicentric Italian Lung Detection trial (MILD trial).

                        Abstract printing supported by Nonin Medical, Inc. Visit Nonin Medical, Inc. at Hall 3.2 Stand 3.57
E-Communication Session                                                                                                             Room London 2 - 14:45-16:45

                                                                T UESDAY, O CTOBER 7 TH 2008

MDCT scans were analyzed with prototypical emphysema detection software                 of a multi-centre study investigating genetic susceptibility for COPD. Radiologists
(MeVis, Bremen) which provides a region-based assessment of the following               assigned an emphysema score of 0 (none) to 5 (severe) for each scan. The % low
measures: lung volumes, mean lung density, emphysema index and four classes of          attenuation area (%LAA) was calculated using a density mask of -950 Hounsfield
emphysema clusters with different volumes. For these measures, multiple regres-         units. A power law analysis was used to calculate the slope of the relationship
sion models were applied to assess the effect of gender, after allowance for age,       between emphysematous lesion number and size. FEV1 /FVC < 0.70 was the gold
FEV1 , body mass index, pack-years, and pulmonary volume.                               standard to differentiate COPD from non-COPD. We used an receiver operating
Results: Compared to males, female smokers showed less severe mean MDCT                 characteristic (ROC) curve analysis to calculate the area under the curve (AUC)
emphysema measurements (p<0.001). However, fitting multivariate regression               for the three emphysema measurements.
models, we observed that women, compared to men, exhibited an emphysema                 Results: The radiologists’ rating of emphysema had the largest AUC (0.847),
phenotype which was more extensive, more heterogeneous in distribution, and             followed by the power law estimate (0.786). The %LAA had the smallest AUC
characterized by bigger hole sizes in the lower lobes.                                  (0.674).
Conclusion: Men and women seem to respond differently in the type and location          Conclusions: These results suggest that the radiologists’ subjective scoring of em-
of lung damage due to tobacco exposure and this may provide an advance in               physema yields information related to COPD which is not captured by quantitative
understanding the pathophysiologic differences between genders.                         HRCT estimates of emphysema.

E4292                                                                                   E4294
Perfusion scintigraphy as a tool to predict development of severe COPD                  Variation in emphysema index measurement in 64 multi detector-row
Olga Lukina, Valentina Zolotnitskaja, Alexandra Speranskaia, Victor Amosov.             computed tomography
Radiology, Pavlov’s State Medical University, Saint Petersburg, Russian                 Klaus Irion 1 , Edson Marchiori 2 , Bruno Hochhegger 3 , Erik Irion 3 ,
Federation                                                                              John Holemans 1 . 1 Departament of Radiolgy, Cardiothoracic Centre, Liverpool,
                                                                                        United Kingdom; 2 Departament of Radiolgy, Federal Fluminense University, Rio
Aim: the study was supposed to determine the main predicting factors of quick           de Janeiro, Brazil; 3 Departament of Radiolgy, Santa Casa de Porto Alegre, Porto
development of COPD.During the study we examined 27 patients with severe                Alegre, Brazil
COPD by means of perfusion scintigraphy, SPECT and MDCT. At the first anal-
ysis of microcirculation we divided patients in three groups with prevailing type       Purpose: To retrospectively assess the minimum increase in emphysema index
of disturbances of perfusion (upper lobes, lower lobes, diffuse). At the next visit     (EI) required for detection of real increased extent of emphysema in real setting.
(after 1 year) significant negative changes were revealed at patients with mainly        Materials and Methods: We review 951 CTs of the patients with diagnosis of lung
lower lobes type. At the subsequent study these patients developed increase of          cancer and incipient emphysema. One hundred multi–detector row CT (240 mAs,
zones with decreased perfusion, new sites with the decreased blood flow were also        64 detector rows, 0.75-mm section thickness) from fifty patients that had under-
revealed. Parameters of lung function (FOV1) in this group of patients significantly     went repeat multi–detector row CT with the same scanner after 2 months because
decreased. Computed tomography revealed enlargement of regions with panlobular          of an pulmonary nodule were included. Extent of emphysema was considered to
emphysema.In group of patients with mainly upper lobes localization of changes          remain stable in this short period. Extent of low-attenuation areas representing
no evidence of enlargement of regions with decreased perfusion was founded. CT          emphysema was computed for repeat and baseline scans as percentage of lung
picture also remained constant in this patients. FOV 1 in this group of patients        volume below two attenuation threshold values (–970 HU –950 HU). The measure
remained unchanged. Patients with diffuse changes of perfusion appeared to have         was realized in the contra lateral lung of the lesion. Upper limits were used to
more regions with mosaic perfusion. CT scans revealed regions of panlobular and         deduce the minimum increase in EI required for detecting increased extent of
centryacinar emphysema without any increasement. Changes of parameters of lung          emphysema with 95% probability. Factors influencing the limits of agreement
function (FOV1) in this group of patients were not significant.                          were determined.
Thus we can suppose that vascular abnormalities are developing quicker in patients      Results: In total, 50 patients (28 male, 22 female; mean age, 70 years) were
with lower lobe, and diffuse types of disturbances of microcirculation. These two       included in the study. Limits of agreement for differences in emphysema index
groups also appear to have rapidly decreasing FOV1. So we suppose that main             between repeat and baseline scans were 0% to +1.86% at –970 HU, –0 to +1.92%
type of disturbances of perfusion can be used to predict development of COPD,           at –950 HU. The correlation between CT1 and CT2 was r2 =0,93 (p<0,0001).
and these patients should have more aggressive treatment.                               Scanner calibration could be excluded as a factor contributing to variation in EI.
                                                                                        The mean of variation in total lung volume was 6.2%(SD=/-5.7%)
                                                                                        Conclusion: Increase in ES required to detect increased extent of smoking-related
E4293                                                                                   emphysema with 95% probability varies between 1.04% of total lung volume at
Differences in subjective and objective estimates of emphysema on HRCT                  –950 HU and 0.68% at –970 HU for 64 multi–detector row CT, in a real setting.
Pat Camp 1 , Harvey Coxson 1 , Sreekumar Pillai 2 , Wayne Anderson 2 ,
Edwin Silverman 3 , David Lomas 4 , Peter Paré 1 . 1 James Hogg iCAPTURE Centre
for Cardiovascular and Pulmonary Research, University of British Columbia,              E4295
Vancouver, BC, Canada; 2 GlaxoSmithKline R&D, GlaxoSmithKline, Research                 Fully automatic detection and quantification of emphysema on computed
Triangle Park, NC, United States of America; 3 Channing Laboratory, Brigham             tomography of the chest by a new software – comparison with lung functional
and Women’s Hospital, Boston, MA, United States of America; 4 Department of             criteria
Medicine, University of Cambridge, Cambridge Institute for Medical Research,            Stefan Krueger 1 , Tobias Merk 2 , Thomas Wibmer 2 , Christian Schumann 2 ,
Cambridge, United Kingdom                                                               Hans-Juergen Brambs 3 , Sandra Pauls 3 . 1 Medical Clinic I, University Clinic,
                                                                                        Aachen, Germany; 2 Department of Internal Medicine II, University Hospital,
Quantitative analysis of emphysema using HRCT is commonly utilized in COPD              Ulm, Germany; 3 Department of Diagnostic and Interventional Radiology,
research but the lack of a strong association with radiologists’ ratings of emphysema   University Hospital, Ulm, Germany
is poorly understood.
Objectives: To compare the ability of quantitative HRCT emphysema measures              Background: Aim of the study was fully automatic detection and quantification
and radiologist ratings of emphysema to differentiate COPD from non-COPD.               of emphysema on chest CT by a new software and to correlate the results with
Methods: 333 male and 301 female smokers underwent thoracic HRCT as part                lung function criteria of emphysema.
                                                                                        Methods: Chest MDCT (16-sclice) and bodyplethysmography were performed in
                                                                                        474 pts (60±15 y.). Bodyplethysmography was used as “gold standard" for the
                                                                                        diagnosis of emphysema according to GOLD criteria. Emphysema was quantified
                                                                                        on CT with a new fully automatic detection software ("lung emphysema", Extended
                                                                                        Brilliance Workspace, Philips Medical Systems, Cleveland, Ohio). Lung volume
                                                                                        (LV) and emphysema volume (EV) as well as emphysema-index (EI=EV/LV) were
                                                                                        calculated on CT. These results were correlated with total lung capacity (TLC),
                                                                                        intrathoracic gas volume (ITGV), residual volume (RV), vital capacity (VC) and
                                                                                        FEV1. Airway obstruction was defined as FEV1/VC < 70%.
                                                                                        Results: LV measured by CT showed a very good correlation with TLC (r = 0.86,
                                                                                        p < 0.001). EV calculated by CT correlated with TLC (r = 0.58, p < 0.001), ITGV
                                                                                        (r = 0.62, p < 0.001), RV (r = 0.55, p < 0.001), RV/TLC % (r = 0.21, p < 0.001),
                                                                                        VC (r = 0.24, p < 0.01), FEV1/VC % (r = -0.46, p < 0.001), but not with FEV1
                                                                                        (r = -0.07, n.s.). In pts with an airway obstruction (n=145) CT detected a higher
                                                                                        EV (369±587 vs. 39±98 cm3 , p < 0.001) and EI (5.3±7.8% vs. 0.7±1.6%, p <
                                                                                        0.001) compared to pts without obstruction (n=329).
                                                                                        Conclusions: Automatic detection and quantification of emphysema on chest CT
                                                                                        with a new software shows a good correlation with lung function parameters. It
                                                                                        can be used as an additional device for a better and more objective detection of
                                                                                        COPD on CT.

                        Abstract printing supported by Nonin Medical, Inc. Visit Nonin Medical, Inc. at Hall 3.2 Stand 3.57
E-Communication Session                                                                                                                Room London 2 - 14:45-16:45

                                                                 T UESDAY, O CTOBER 7 TH 2008

E4296                                                                                     images.The domain started at the soft palate and extended down to the diaphram.
Variation in the bronchial tree dimension predicts airflow limitation in                   The flow inside the computer models was determined using computational fluid
smokers                                                                                   dynamics (CFD). To solve the turbulence, the high tech Large Eddy Simulation
Michel Montaudon 1,2,3 , Francois Laurent 1,2,3 , Mathieu Lederlin 1,2,3 ,                (LES) model was used. On top of the flow, mono-disperse particles were injected
Pascal Desbarats 4 , Roger Marthan 1,2,5 , J.-Manuel Tunon-de-Lara 1,2,6 ,                into the models with diameters of 1.5, 3 and 6 microns. The deposition on the
Patrick Berger 1,2,5 . 1 Laboratoire de Physiologie Cellulaire Respiratoire,              airway wall in the oropharyngeal region was determined and compared to results
Universite Bordeaux 2, Bordeaux, France; 2 U885, INSERM, Bordeaux, France;                from literature (Usmani AJRCCM 2005).
  Unite d’Imagerie Thoracique, CHU de Bordeaux, Pessac, France; 4 Laboratoire
Bordelais de Recherche en Informatique, Universite Bordeaux 1, Talence, France;
  Service d’Exploration Fonctionnelle Respiratoire, CHU de Bordeaux, Pessac,
France; 6 Service des Maladies Respiratoires, CHU de Bordeaux, Pessac,

Background: In chronic obstructive pulmonary disease (COPD), the assessment
of airway dimensions by computed tomography (CT) has been limited by the
obliquity of bronchi, the ability to identify the bronchial generation, and the
limited number of bronchial measurements. The objectives were (i) analyze cross-
sectional bronchial dimensions after automatic orthogonal reconstruction of all
visible bronchi on CT images, and, (ii) define new 3D parameters able to predict
airflow limitation.
Methods: CT and pulmonary function test (PFT) were performed in 7 healthy
non-smokers, 9 smokers with normal lung function, and 8 smokers with clinically
stable COPD. Bronchial dimensions were assessed using dedicated 3D software
able to provide accurate cross-sectional measurements of all visible bronchus on
CT. Results were compared by means of repeated ANOVA, MANOVA or one way
Results: Wall area (WA) and Lumen area (LA) were measured in a mean number
of 252±5, 242±49 and 252±88 bronchi for healthy non-smokers, healthy smokers              A good agreement was found between the CFD results and the Usmani data with an
and smokers with COPD respectively. Bronchial heterogeneity at each generation            average difference of 2.1% and a maximum of 4.4%.These data show that particle
was reflected by high coefficients of variation, which was up to 46% for WA. 3D             deposition studies using CFD and LES can provide accurate results making it a
analysis of all visible bronchi on CT images enables to define 3D parameters such          powerful tool in the development of inhalation medication and the accompanying
as WA/ LA ratio at each bronchial generation. This parameter discriminates                systems.
between healthy non-smokers, healthy smokers with normal function and COPD
patients. The maximal derivative of this parameter along bronchial generations
(i.e. Dmax WA/ LA) predicts airflow limitation assessed by FEV1 (r=-0.81,                  E4299
p<0.001).                                                                                 The importance of radiological findings to distinguish benign and malignant
Conclusions: Dmax WA/ LA could represent a novel CT-derived individual                    pleural diseases
biomarker predicting airflow limitation in chronic bronchial diseases.                     Guntulu Ak 1 , Muzaffer Metintas 1 , Huseyin Yildirim 1 , Sertac Arslan 1 ,
                                                                                          Sinan Erginel 1 , Fusun Alatas 1 , Selma Metintas 2 . 1 Department of Chest Diseases,
                                                                                          Eskisehir Osmangazi University Medical Faculty, Eskisehir, Turkey; 2 Department
E4297                                                                                     of Public Health, Eskisehir Osmangazi University Medical Faculty, Eskisehir,
Detection of lobar gas trapping by high resolution CT (HRCT) scanning                     Turkey
Caterina Salito 1 , Aleksandar Grgic 2 , Heinrike Wilkens 3 , Peter T. Macklem 4 ,
Gerhard Sybrecht 3 , Andrea Aliverti 1 . 1 Dip. Bioingegneria, Politecnico di Milano,     Computed tomography is a radiological method which is frequently used at diag-
Milano, Italy; 2 Klinik fur Nuklearmedizin, Universitatsklinikum des Saarlandes,          nosis and follow-up of pleural diseases. But there are no frequently used criteria
Homburg/Saar, Germany; 3 Innere Medizin V, Universitatsklinikum des                       to distinguish benign and malignant diseases of pleura with this method. We have
Saarlandes, Homburg/Saar, Germany; 4 Dept. Medicine, McGill University,                   found that pleural rind, pleural nodularity, pleural thickness >1 cm and mediasti-
Montreal, Canada                                                                          nal pleural involvement were useful to distinguish benign and malignant pleural
                                                                                          diseases in a retrospective study. The aim of this study is to verify same finding in
Lung specific gas volume (SgV) is the volume of gas per unit lung mass =                   a prospective study.
mlgas /gtissue . For whole lungs this varies linearly with total gas volume (Vg) in the   We collected patients with pleural diseases who administered our clinic between
lung assuming constant lung mass. A line connecting SgV at any lung volume to             February 2006 and February 2008. Chest x-ray and computed tomography of
the origin describes the locus of all values of SgV at all other lung volumes. This       patients with pleural diseases were evaluated before the diagnosis and the possible
is not the case with heterogeneous regions of lung emptying in emphysema. In a            diagnoses were reported according to four criteria which have been mentioned
gas-trapping region (Vtr), the change in regional SgV per unit Vg ( SgVtr/ Vg)            above. After that we matched the final diagnoses with possible diagnoses.
will be less than that for the whole lung, while a freely emptying region (Vem)           154 patients were evaluated; in which 66 of them were benign, 88 of them were
will be greater: SgVtr/ Vg < SgVg/ Vg < SgVem/ Vg. The within lung                        malignant. The specificity and sensitivity of these criteria for distinguishing benign
variation in slope is an index of heterogeneity of emptying. We measured lobar and        and malignant pleural diseases can be seen below, respectively: 24%, 97% for
overall SgV by HRCT scanning at high and low Vg in 9 patients with emphysema              pleural rind, 32%, 97% for pleural nodularity, 40%, 88% for pleural thickness
(E) that was judged to be homogenous and 2 age-matched controls (N). In N SgV’s           >1 cm and 65%, 79% for mediastinal pleural involvement. Consequently, pleural
were ∼6ml/g and ∼4 ml/g at high and low Vg respectively. SgV in upper was >               nodularity and pleural rind are not seen frequently but they have high specificity
SgV in lower lobes but emptying was nearly homogeneous. In E, lobar SgV ranged            for malignancy when they have been detected. Pleural thickness >1 cm and
from 56.2 ml/g to 10.0 ml/g at high and 58.1ml/g to 7.1 ml/g at low volumes. In           mediastinal pleural involvement are also important findings to indicate malignant
all lungs there were lobes where SgVtr/ Vg < SgVg/ Vg < SgVem/ Vg.                        pleural diseases.
Trapping was identified often in upper and rarely in lower lobes; within lung vari-
ation in slope was very different between subjects. We conclude that: 1) interlobar
heterogeneity in lung emptying is highly variable between patients with E; 2) thus        E4300
in E there are patients with large inter- and intralobar regions of gas trapping that     Sonographic echogenic swirling pattern in patients with malignancies: a
act like bullae; 3) HRCT scanning is useful in detecting regions that might be            useful diagnostic predictor for malignant pleural effusions
amenable to treatment.                                                                    Nancy Abdelaty, Mahmoud Elprince. Chest, Suez Canal University, Ismailia,
Funded by: Broncus Technologies.                                                          Egypt

                                                                                          Study objective: To assess the accuracy of chest ultrasonography in predicting ma-
E4298                                                                                     lignant pleural effusions in patients with malignancies by identifying the echogenic
Study of mono-disperse particle deposition in asthmatics using computational              swirling pattern.
fluid dynamics                                                                             Methods: Sixty-five patients(32 male:33 female) were enrolled in the study.The
Jan De Backer 1 , Wim Vos 1 , Catherine Gorle 2 , Rodrigo Salgado 3 ,                     subjects were between 30 and 60 years of age,with biopsy-proven malignancies
Paul Germonpre 4 , Wilfried De Backer 4 . 1 Physics, University of Antwerp,               and presented with pleural effusion (PE).All patients underwent thoracentesis and
Antwerp, Belgium; 2 EMAT, University of Antwerp, Antwerp, Belgium;                        pleural biopsy.Pleural fluid analysis was performed in all patients.Real-time chest
  Radiology, University Hospital Antwerp, Antwerp, Belgium; 4 Respiratory                 sonograms were performed before drainage to identify the echogenic swirling
Medicine, University Hospital Antwerp, Antwerp, Belgium                                   pattern.Malignant pleural effusions were defined by the presence of malignant
                                                                                          cells in the pleural fluid.The echogenic swirling pattern was defined as numerous
This study describes the findings of a particle deposition study in 4 patient specific      echogenic floating particles within the pleural effusion,which swirled in response to
computer models derived from low dose HRCT scans of asthmatic patients. The               respiratory movement or heartbeat.Correlation between malignant pleural effusions
computer models were reconstructed in 3D through segmentation of the HRCT                 and the echogenic swirling pattern was done.

                         Abstract printing supported by Nonin Medical, Inc. Visit Nonin Medical, Inc. at Hall 3.2 Stand 3.57
E-Communication Session                                                                                        Room London 2 - 14:45-16:45

                                                               T UESDAY, O CTOBER 7 TH 2008

Results: In patients with underlying malignancies,malignant pleural effusions
were diagnosed in{35/65(53.8%)of patients, a positive echogenic swirling pattern
was found in{28/35(80%)of those with cytologically positive pleural effusions for
malignancy.While a positive echogenic swirling pattern was found in only 30% of
those with cytologically negative pleural effusions for malignancy.The presence of
echogenic swirling was significantly more predictive of malignant pleural effusions
than was the absence of echogenic swirling(p < 0.01).
Conclusions: The echogenic swirling pattern is a useful predictor of and may
be a good marker for malignant pleural effusions in patients with underlying

Ultrasound in evaluation of chest pain
Marija Zdraveska, Deska Dimitrievska, Dejan Todevski, Angelko Gjorcev,
Tome Stefanovski. Department for Interventional bronhology, Pneumology and
Allergy Clinic Skopje, Skopje, Fyrom (Macedonia)

US is establishing its sensitivity and specificity in detection of pleural effusions
versus X-ray, and shifting the quantity border to very small detectable changes. In
order to estimate whether US has a role in evaluating the etiology of chest pain in
out-patient setting, we evaluated 54 patients, who were referred to our Clinic. All
of the patients were subject to a diagnostic protocol with history of the disease,
X-ray, ECG, biochemistry, and US (with or without real time, US-guided diagnos-
tic thoracentesis). Patients with coronary artery disease were excluded from this
number. 26 (48.1%) had evident pleural effusion visible on X-ray. From the rest
28 (51.9%) patients, 15 (53%) had small amount of pleural fluid ipsilateral to the
chest pain, 2 (7.1%) of them had billateral effusions, and 11 (39.2%) had no sign of
effusion at initial evaluation. Diagnostics revealed that 22 (40.7%) of the patients
had para-pneumonic effusions (including TB), 7 (12.9%) were transudates due to
heart failure, 5 (9.2%)were associated to pulmonary embolism, 1(1.8%) Dressler
syndrome, 16(29.6%)were malignant effusions and 3 (5.5%) subjects had myalgia.
US control was performed after 10 days, showing that 3 more patients developed
small effusions, not confirmed with control X-ray. US follow up continued once
in 15 days, until resolution of disease. Control X-ray was performed to confirm
the US results, showing that US was superior to X-ray in detection of pleural fluid
(overall 76.9% of false negative results with X-ray), as well as in determining the
exact location of thoracentesis in small effusions.
Conclusion: we recommend US guidance, as a low-cost, non-invasive, low-
radiation, reproducible method for triage of chest pain and follow up of pleural

                        Abstract printing supported by Nonin Medical, Inc. Visit Nonin Medical, Inc. at Hall 3.2 Stand 3.57