Faculty Bibliography

To determine if general radiologists can accurately measure breast density on low-dose chest computed tomographic (CT) scans, two board-certified radiologists with expertise in mammography and CT scan interpretation, and seven general radiologists performed retrospective review of 100 women's low-dose chest CT scans. CT breast density grade based on Breast Imaging Reporting and Data System grades was independently assigned for each case. Kappa statistic was used to compare agreement between the expert consensus grading and those of the general radiologists. Kappa statistics were 0.61-0.88 for the seven radiologists, showing substantial to excellent agreement and leading to the conclusion that general radiologists can be trained to determine breast density on chest CT.

RATIONALE/BACKGROUND:Sarcoidosis is an idiopathic granulomatous disorder with heterogeneous clinical manifestations and variable prognosis. Monitoring disease activity is important to identify patients requiring treatment. Several cytokines have previously been shown to be elevated in the serum of patients with sarcoidosis and may be useful biomarkers of disease activity. OBJECTIVES/OBJECTIVE:To identify novel biomarkers of sarcoidosis disease activity. To identify the relationship between plasma cytokines, disease severity and prognosis. METHODS:The study was approved by the institutional review board. Plasma concentration of 19 cytokines was measured in 112 subjects with chronic sarcoidosis and 52 matched controls, using the bead-based Milliplex xMAP multiplex technology. Plasma levels of individual cytokines were compared between the two groups, and between the groups with clinically active vs. inactive disease. Sensitivity, specificity and receiver operating characteristics curves were used to evaluate biomarker performance. Linear regression analyses were performed to identify associations between cytokine levels, pulmonary function tests and changes in pulmonary function. MEASUREMENTS AND MAIN RESULTS/RESULTS:Subjects with sarcoidosis had higher plasma levels of interferon gamma induced protein 10 (IP-10) and tumor necrosis factor α (TNFα). IP-10 had the highest sensitivity and specificity in identifying active disease. Higher levels of IP-10 and TNFα were associated with greater disease severity and better prognosis. CONCLUSIONS:IP-10 is a potentially useful biomarker of sarcoidosis and its severity.

We report a case of a 56-year-old man with traumatic aortic rupture (TAR) sustained in a motor vehicle accident diagnosed by helical computed tomography, aortography, and transesophageal echocardiography. A large majority of patients with TAR never make it to the hospital, and for those who do, a timely diagnosis is critical for survival. We discuss the merits and pitfalls of the three imaging modalities

OBJECTIVE: Concern for thoracolumbar spine (TLS) injuries after major trauma mandates immobilization pending radiographic evaluation. Current protocols use standard posteroanterior and lateral radiographs of the thoracolumbar spine (XR/TLS), but many patients also undergo abdominal or thoracic computed tomographic (CT) scanning. We sought to evaluate whether helical truncal CT scanning performed to evaluate visceral trauma images the spine as well as dedicated XR/TLS. METHODS: We prospectively studied 222 consecutive patients sustaining high-risk trauma requiring TLS screening because of clinical findings or altered mentation. The chest, abdomen, and pelvis were imaged with one intravenous contrast infusion. All patients had CT scan of the chest, abdomen, and pelvis (CT/CAP) and XR/TLS. Initial radiologic diagnoses were compared with the discharge diagnosis of acute fractures confirmed by thin-cut CT scan and/or clinical examination of the patient when alert. RESULTS: Of 222 patients studied, 215 were fully evaluated. Thirty-six (17%) had acute TLS fractures. The accuracy of CT/CAP for TLS fractures was 99% (95% confidence interval [CI], 96-100%). The accuracy of XR/TLS was 87% (95% CI, 82-92%). Sensitivity, specificity, and positive and negative predictive values were better for CT/CAP than for XR/TLS. CT/CAP found acute fractures XR/TLS missed, and correctly classified old fractures XR/TLS read as 'possibly' acute. The total XR/TLS misclassification rate was 12.6% (95% CI, 8.4-19%); for CT/CAP it was 1.4% (95% CI, 0.3-3.3%). No fractures were missed by CT/CAP. No unstable fracture was missed by either technique. CONCLUSION: CT/CAP diagnoses TLS fractures more accurately than XR/TLS. Neither misses unstable fractures, but CT scanning finds small fractures that benefit by treatment and identifies chronic disease better. CT screening is far faster and shortens time to removal of spine precautions. CT scan-based diagnosis does not result in greater radiation exposure and improves resource use. Screening the TLS on truncal helical CT scanning performed for the evaluation of visceral injuries is more accurate than TLS imaging by standard radiography. CT/CAP should replace plain radiographs in high-risk trauma patients who require screening

Transitioning to a filmless department is no easy task, especially at a large academic medical center. At the University of Medicine and Dentistry of New Jersey-New Jersey Medical School, a phased modality integration schedule was implemented to allow the technical and clinical staff to gradually absorb all of the changes to workflow. One-on-one training sessions were designed to prepare radiologists and referring clinicians to access and navigate the in-house picture archiving and communication system (PACS) workstations as well as to view images over the Internet via the PACS Web server. An interdepartmental steering committee was formed to plan deployment of the in-house workstations. A planning committee met on a weekly basis to outline placement of workstations within the Radiology Department, and to redesign the reading room. A user group was created to discuss specific user problems. Of particular interest was the challenge of outfitting a dozen conference rooms with projection systems capable of displaying radiologic images. We distinguished between regular and working conferences. At regular conferences only a few cases are reviewed over the course of an hour and only after the diagnosis has been made at a PACS workstation. In contrast, the surgical and medical intensive care units conduct daily working conferences. At those sessions the images of 20 to 30 patients are reviewed, many of them for the first time, and for each case a definitive diagnosis is expected. During the implementation process, a range of issues came up that limited access of certain studies to radiologists and referring clinicians alike. Even after the initial PACS installation, many studies went unread because of a lack of worklists. Other problems included image ordering for head computed tomography and magnetic resonance imaging. A few of our modalities were not DICOM compliant and needed image capture devices in order to be integrated with the PACS. To our dismay, this was also true of one of our modalities that was supposed to be DICOM compliant. These problems, and the solutions we discovered, are discussed in this paper.

STUDY OBJECTIVES: To describe the clinical features of radiographically massive pulmonary embolism (MPE). DESIGN: Retrospective analysis. SETTING: A 1,368-bed teaching hospital. PATIENTS OR PARTICIPANTS: Patients with pulmonary embolism between June 1997 and December 1999. INTERVENTIONS: Radiographic reports of patients with a radiographic diagnosis of pulmonary embolism were reviewed to determine whether MPE (>50% vascular occlusion) was present. For patients with MPE, vital signs, respiratory and cardiac symptoms, medical history, arterial blood gases, electrocardiographic (ECG) and echocardiographic results, treatment, and hospital mortality were recorded. MEASUREMENTS AND RESULTS: Fifty-four patients with MPE were identified. Patient age range was 28-91 years (mean 71 years). Symptoms were: dyspnea in 38 (70%), chest pain in 21 (38%), syncope in 12 (22%), palpitations in 6 (11%), systolic blood pressure <90 mmHg in 12 (22%), tachycardia (>120 beats/min) in 15 (28%) and tachypnea (respiratory rate >30) in 15 (28%). Pa O(2) (arterial partial pressure of oxygen) was less than 60 mmHg in 28 (71%) and the alveolar-arterial oxygen gradient was always greater than 20. ECG had an S1Q3T3 pattern in 6 (12%). Echocardiography revealed right ventricular dilatation in 12/31 (38%). Forty-nine patients received anticoagulation treatment, 4 (7%) received thrombolytic therapy with anticoagulation, 5 had inferior vena cava filters (IVC) alone, 6 received IVC filters with anticoagulation, and 2 received thrombolytic therapy, anticoagulation, and IVC filters. Eighteen (33%) patients were treated in the intensive care unit, 3 (5.5%) with mechanical ventilation. Fifty (93%) patients were eventually discharged and 4 (7%) died. Two of the deaths were not attributable to MPE. CONCLUSIONS: Patients with MPE usually present with dyspnea and hypoxemia, and most survive without thrombolytic therapy.

OBJECTIVE:To describe the characteristics and outcomes of HIV-infected patients with biopsy-proven cytomegalovirus (CMV) pneumonia. DESIGN/METHODS:Retrospective study. SETTING/METHODS:A 900-bed acute facility in New York City. PATIENTS/METHODS:Eighteen HIV-infected patients with pathologically confirmed CMV inclusions in lung tissue without other pathogens and 36 control patients with biopsy-proven Pneumocystis carinii pneumonia (PCP) selected for comparisons by computer-generated random sequential numbers. MAIN OUTCOME MEASURES/METHODS:Demographic, clinical, laboratory, radiological findings, and in-hospital mortality. RESULTS:Eighteen HIV-infected patients were found to have CMV lung infection alone. Pathologic findings were pneumonitis (n = 11); pneumonitis and pulmonary vasculitis (n = 1); and CMV inclusions alone (n = 6). All presented with respiratory symptoms (cough or dyspnea), 89% had fever, 83% had radiological abnormalities, and 56% had severe hypoxemia. The pulmonary presentation was similar except for higher lactate dehydrogenase (median, 449 versus 329 IU/l; P = 0.03) and presence of pleural effusions (33 versus 0%; P = 0.001) in CMV patients. Multivariate analysis showed that CD4 counts < or = 12 x 10(6)/l (odds ratio; 9.2; P = 0.029) and extrapulmonary CMV (odds ratio, 20.4; P = 0.039) were independently associated with CMV pneumonia. Seventeen patients received specific anti-CMV therapy for a mean of 22 +/- 13 days. In-hospital mortality was higher in patients with CMV pneumonia (odds ratio, 11.9; P = 0.002). The median time from admission to death was 31 days. CONCLUSIONS:CMV lung infection was seen in severely immunosuppressed HIV-positive patients and associated with clinical pneumonitis with high early mortality. Although the clinical features resemble PCP, the presence of extrapulmonary CMV disease should suggest the diagnosis of CMV pneumonia.

Cavernous hemangiomas of the mediastinum, though unusual, have typically been described in the anterior or posterior mediastinum. We report such a tumor in the subcarinal region and describe the potential contribution of CT scanning in the work-up of these rare space-occupying lesions.

Primary mesenchymal intrathoracic tumors are unusual. They can originate from the lung, the pleura, or the mediastinal structures. These sarcomas have protean, nonspecific imaging features. This pictorial essay illustrates a large number of these tumors, describes the plain film findings, and emphasizes the contribution of the new imaging modalities. The cross-sectional display and the high contrast resolution computed tomography (CT) and the ability to image vascular structures and chest wall with magnetic resonance (MR) allow excellent delineation of tumor extent and assessment of chest wall or vascular invasion. Early recognition of recurrence or metastases can be facilitated. In rare instances, the intrinsic characteristics of the tumor allow a specific diagnosis.

OBJECTIVE:Bronchiolitis obliterans, when not associated with organizing intraalveolar pneumonia or extensive peribronchiolar fibrosis, is often difficult to distinguish clinically and radiographically from other forms of chronic obstructive pulmonary disease. The aim of this study was to demonstrate a pattern on high-resolution CT (HRCT) that could suggest this diagnosis. MATERIALS AND METHODS/METHODS:Two patients with a clinical diagnosis of bronchiolitis obliterans, moderate-to-severe obstruction on pulmonary function tests, and normal chest radiography were studied with HRCT. RESULTS:High-resolution CT of the patients with chronic bronchiolitis demonstrated a mosaic pattern of low attenuation probably corresponding to secondary lobules. CONCLUSION/CONCLUSIONS:We conclude that the low attenuation areas represent either air trapping or hypoxic vasoconstriction in secondary pulmonary lobules from obstruction of small airways. This pattern of mosaic oligemia was, until recently, only recognized with occlusive vascular disease and may suggest obstructive disease in the small airways.