Faculty Bibliography

Pulmonary and mediastinal masses represent a wide range of pathologic processes with very different treatment options. Although advances in imaging (such as PET and high-resolution CT) help in many cases with the differential diagnosis of thoracic pathology, tissue samples are frequently needed to determine the best management for patients presenting with thoracic masses. There are many options for obtaining tissue samples, each of which has its own set of benefits and drawbacks. The purposes of this report are to present the most current evidence regarding biopsies of thoracic nodules and masses and to present the most appropriate options for select common clinical scenarios. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

RATIONALE AND OBJECTIVES/OBJECTIVE:Providing evidence-based appropriate imaging potentially increases diagnostic yield and prevents unnecessary imaging. The American College of Radiology's (ACR) evidence-based Appropriateness Criteria(®) (ACR-AC) were developed to provide imaging guidelines given various clinical scenarios. The goal of this study was to evaluate the knowledge level of the appropriate thoracic imaging study to be performed, given a clinical scenario. METHODS:An online survey comprising 20 multiple-choice questions was developed on the basis of excerpts from the ACR-AC for thoracic imaging. The survey was piloted and invitations were sent out to resident trainees in radiology (n = 32), medicine (n = 119), and surgery (n = 40) and to pulmonary and critical medicine fellows (n = 16). RESULTS:Sixty-nine trainees (33%) completed the survey. The trainees among those who completed the survey included 14 (20%) in radiology, 32 (46%) in medicine, eight (12%) in surgery, and 15 (22%) in pulmonary and critical medicine. Of the 69 trainees, most were male (n = 47 [68%]), aged 25 to 35 years (n = 65 [94%]), and in postgraduate years 1 to 3 (n = 44 [64%]). The overall median and percentage number of correct responses were 13 (interquartile range [IQR], 11-15) and 65% (n = 44), respectively. As would be expected, radiology residents performed better, with a median number of correct responses of 15 (IQR, 11-16) compared to 10 (IQR, 9-12) for medicine trainees, nine (IQR, 9-12) for surgery trainees, and 13 (IQR, 12-15) for pulmonary and critical medicine trainees. There was an increase in the median number of correct responses with years of training, ranging from 10 for postgraduate year 1 to 12 for postgraduate year 6. CONCLUSIONS:This study shows an opportunity to increase the awareness of the ACR-AC. Increasing the awareness of the ACR-AC among trainees will likely increase their use in practice and ultimately improve patient care.

This manuscript is a review of the recently published ACR Appropriateness Criteria Radiologic Management of Thoracic Nodules and Masses. Presented are best practice guidelines for the imaging evaluation and biopsy recommendations for pulmonary nodules, mediastinal masses, and pleural abnormalities. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

BACKGROUND AND AIM/OBJECTIVE:Data on prevalence of portopulmonary shunts (PPS) are quite limited. Most studies have used cineportography or echocardiography for diagnosis. Only few recent case reports have reported the use of computed tomography (CT) for identification of PPS. This study tried to determine the prevalence of PPS in patients with cirrhosis using contrast-enhanced CT of the abdomen, and to determine their association with demographic and clinical characteristics. METHODS:A total of 150 subjects with cirrhosis who had previously undergone triple-phase CT were analyzed. PPS was diagnosed when at least one esophageal varix met all of the following criteria: (i) it could be followed cephalad into the chest to the level of the inferior pulmonary vein or left atrium; (ii) it abutted the wall of either of these structures; (iii) it had luminal continuity with one of these structures; and (iv) it was no longer seen one slice above the level of contact. RESULTS:Of 150 subjects, 18 were excluded for incomplete data. The prevalence of PPS was found to be 26/132 (19.7%). Of these, 14 (53.8%) patients had PPS draining into the left atrium and 12 (46.2%) had those draining into one of the pulmonary veins. Presence of PPS was associated with the presence of varices at endoscopy, ascites, thrombocytopenia and splenomegaly. CONCLUSION/CONCLUSIONS:In our study, the largest study on PPS to date, the prevalence of PPS in cirrhotic patients using triple phase CT was found to be 19.7%. CT may be a useful technique to study PPS and their clinical implications.

Lymphoma of the heart and pericardium is usually present as one aspect of disseminated disease and rarely occurs as a primary malignancy. It accounts for 1.3% of primary cardiac tumors and 0.5% of extranodal lymphomas. Cardiac lymphomas are most commonly diffuse large cell lymphomas and frequently manifest as an ill-defined, infiltrative mass. Atrial location is typical; the right atrium is most often affected. Pericardial thickening or effusion is often a common early feature of disease. Infiltration of atrial or ventricular walls with extension along epicardial surfaces is also a notable feature. At computed tomography, the attenuation of cardiac lymphoma may be similar to or lower than that of normal myocardium. At magnetic resonance imaging, it has variable signal intensity and contrast enhancement. Clinical manifestations may include pericardial effusion, cardiac arrhythmias, and a variety of nonspecific electrocardiographic abnormalities, notably first- to third-degree atrioventricular block. Treatment most commonly includes anthracycline-based chemotherapy and anti-CD20 treatment. Chemotherapy has been used alone or combined with radiation therapy. Palliative surgery has been performed, mainly for tumor debulking. The prognosis for patients with either primary or secondary lymphomatous heart involvement is usually poor; late diagnosis is one of the major factors affecting outcome.