Radiological assessment of patients with chronic thromboembolic pulmonary hypertension (CTEPH) is critical to decide whether patients should be treated with pulmonary endarterectomy (PEA). Although ...computed tomography pulmonary angiography (CTPA) is increasingly used for decision making in CTEPH, the value of CTPA to predict surgical findings and outcome has never been explored.
We retrospectively reviewed 100 consecutive patients with high-quality CTPA undergoing PEA for CTEPH between May 2015 and December 2017. The most proximal level of disease in the pulmonary artery on CTPA was classified by two blinded radiologists as level 1 (main pulmonary artery), 2a (lobar pulmonary artery), 2b (origin of basal segmental pulmonary artery), 3 (segmental pulmonary artery) or 4 (predominantly subsegmental pulmonary artery).
CTPA demonstrated level 1 in 20%, level 2a in 43%, level 2b in 11%, level 3 in 23% and level 4 in 3%. A majority of males presented with level 1 (55%) and level 2 (57%), and a majority of females (83%) with level 3 (p=0.01). Levels 3 and 4 were associated with longer duration of circulatory arrest (p=0.03) and higher frequency of Jamieson type III disease at surgery (p<0.0001). Requirement for targeted pulmonary hypertension therapy after PEA was 28% at 3 years in level 2b/3/4 compared with 6% in level 2a and 13% in level 1 (p=0.002). Level 2b/3/4 was an independent predictor for targeted pulmonary hypertension therapy after PEA (hazard ratio 4.23, 95% CI 1.24-14.39; p=0.02).
High-quality CTPA provides accurate evaluation of CTEPH patients. The level of disease on CTPA can help guide peri-operative planning and post-operative monitoring.
Chronic thromboembolic pulmonary hypertension (CTEPH) is an under recognized complication of pulmonary embolism with significant morbidity and mortality when left untreated. There have been ongoing ...advances in the treatment of CTEPH with potentially excellent outcomes for patients when diagnosed and treated in a timely fashion. Although ventilation-perfusion scintigraphy remains critical in screening for CTEPH, the radiologic diagnosis involves multiple modalities from digital subtraction angiography to high quality computed tomography pulmonary angiography. State of the art imaging in CTEPH now also includes dual energy computed tomography, lung subtraction iodine mapping, and magnetic resonance imaging.
Background
Sarcopenia indicates poor prognosis in various malignancies. We evaluated the association of sarcopenia with overall (OS) and progression-free survival (PFS) in metastatic esophageal ...cancer (MEC) patients, a population often presenting with poor nutritional status.
Methods
In newly diagnosed MEC patients managed at the Princess Margaret (PM) Cancer Centre (diagnosed 2006–2015), total muscle area, visceral adiposity (VA), and subcutaneous adiposity (SA) were quantified on abdominal computed tomography at L3. Sarcopenia was determined using published cutoffs, based on sex and height.
Results
Of 202 MEC patients, most were male (166/82%), < 65 years (116/57%), and had adenocarcinoma histology (141/70%); 110/54% had recurrent MEC after initial curative-intent treatment; 92/46% presented with de novo MEC. At stage IV diagnosis, 20/10% were underweight, 97/48% were normal-weight and 84/42% were overweight/obese; 103/51% were sarcopenic. Sarcopenia was associated with worse median OS (4.6 vs
.
7.9 months; log-rank
p
= 0.03) and 1-year survival, even after adjusting for other body composition variables (e.g., BMI, VA, and SA): adjusted-HR 1.51 95% CI 1.1–2.2, p = 0.02. In post hoc analysis, sarcopenia was highly prognostic in adenocarcinomas (
p
= 0.003), but not squamous cell carcinomas (SCC). In patients receiving palliative systemic treatment (104/51%), sarcopenia was associated with shorter PFS (
p
= 0.004) in adenocarcinoma patients (75/72%).
Conclusions
In metastatic esophageal adenocarcinomas, sarcopenia is associated with worse PFS and OS. In metastatic esophageal SCC, there was a non-significant trend for worse PFS but no association with OS. In order to offset the poor prognosis associated with sarcopenia particularly in metastatic esophageal adenocarcinoma patients, future research should focus on possible countermeasures.
Correspondence to Dr Timothy Shun Him Kwok, timothysh.kwok@mail.utoronto.ca Description The prevalence of acupuncture use is increasing in the USA, as more patients seek out complementary medicine ...therapies in addition to conventional medicine.1 A specific form of acupuncture, known as Hari, involves the purposeful retention of acupuncture needles within a patient’s subcutaneous tissue in order to alleviate chronic musculoskeletal pain.1 This may subsequently lead to alarming imaging findings. Retained acupuncture needles have been noted in the literature; however, clinical consequences of this phenomena are not well documented.1 Migration of the needles has been reported from the subcutaneous tissues to intra-abdominal organs.1 The prevalence of retained acupuncture needles is unknown.1 To our knowledge, this case details the longest latency of retained acupuncture needles before clinical or radiographical detection. Non-ferromagnetic needles (eg, gold) are MR compatible.3 Other metal alloys, including those with a strongly ferromagnetic composition, may have more malicious consequences when exposed to magnetic gradients.3 In clinical practice, added attention is needed in obtaining a full history for retained metallic fragments, especially considering the increasing prevalence of acupuncture use.
Treatment options for chronic thromboembolic pulmonary hypertension (CTEPH) are rapidly expanding. The purpose of this study is to identify trends in CTEPH clinical trials and the publication of ...results. We performed a worldwide review of completed and ongoing clinical trials through searching the ClinicalTrials.gov database and the World Health Organization International Clinical Trials Registry Platform for “CTEPH” and related terms. Entries were classified as pharmaceutical/procedural interventions (Group 1), all other clinical trials (Group 2) and patient registries (Group 3). Trial characteristics and national affiliation were recorded. PubMed was searched for related publications. There were 117 clinical trials registry entries after removing duplicates and non-target records. Group 1 comprised 29 pharmaceutical, 15 procedural, and four combined interventions starting in 2005, 2010, and 2016, respectively. Riociguat and balloon pulmonary angioplasty were the most frequent pharmaceutical and procedural interventions, respectively. The proportion of procedural trials increased over time from 0% of those in 2005–2009 to 29% in 2010–2014 and 54% in 2015–2020. There were 56 entries in Group 2 and 13 in Group 3. Japan was the most frequent national affiliation and the most frequent participating country, present in 28% of all trials. The proportion of entries with published results was highest with Group 3 (62%) and lowest with Group 1 (27%). Thirty percent of all publications occurred in 2020. In conclusion, CTEPH clinical trials are increasingly procedural based, with growth largely attributable to Japan and balloon pulmonary angioplasty. Most trials have not published, but results from balloon pulmonary angioplasty clinical trials are anticipated soon.
Chronic thromboembolic pulmonary disease (CTEPD) is characterized by organized nonresolving thrombi in pulmonary arteries (PA). In CTEPD with pulmonary hypertension (PH), chronic thromboembolic PH ...(CTEPH), early wave reflection results in abnormalities of pulsatile afterload and augmented PA pressures. We hypothesized that exercise during right heart catheterization (RHC) would elicit more frequent elevations of pulsatile vascular afterload than resistive elevations in patients with CTEPD without PH. The interdependent physiology of pulmonary venous and PA hemodynamics was also evaluated. Consecutive patients with CTEPD without PH (resting mean PA pressure ≤20 mmHg) undergoing an exercise RHC were identified. Latent resistive and pulsatile abnormalities of pulmonary vascular afterload were defined as an exercise mean PA pressure/cardiac output >3 WU, and PA pulse pressure to PA wedge pressure (PA PP/PAWP) ratio >2.5, respectively. Forty‐five patients (29% female, 53 ± 14 years) with CTEPD without PH were analyzed. With exercise, 19 patients had no abnormalities (ExNOR), 26 patients had abnormalities (ExABN) of pulsatile (20), resistive (2), or both (4) elements of pulmonary vascular afterload. Exercise elicited elevations of pulsatile afterload (53%) more commonly than resistive afterload (13%) (p < 0.001). ExABN patients had lower PA compliance and higher pulmonary vascular resistance at rest and exercise and prolonged resistance‐compliance time product at rest. The physiological relationship between changes in PA pressures relative to PAWP was disrupted in the ExABN group. In CTEPD without PH, exercise RHC revealed latent pulmonary vascular afterload elevations in 58% of patients with more frequent augmentation of pulsatile than resistive pulmonary vascular afterload.
Oscillometry is an emerging pulmonary function testing tool that is conducted during tidal breaths with minimal patient effort. It is highly sensitive to changes in lung mechanics. Oscillometry was ...recently shown to be highly associated with disease severity in idiopathic pulmonary fibrosis (IPF). The usefulness of oscillometry after single lung transplant in IPF patients is not well understood. Our study demonstrated that oscillometry can detect changes in the graft despite presence of a native fibrotic lung to provide useful information to complement spirometry.
We assessed the value of dual-energy CT pulmonary angiography (CTPA) for classification of the level of disease in chronic thromboembolic pulmonary hypertension (CTEPH) patients compared to the ...surgical Jamieson classification and prediction of hemodynamic changes after pulmonary endarterectomy. Forty-three CTEPH patients (mean age, 57 ± 16 years; 18 females) undergoing CTPA prior to surgery were retrospectively included. "Proximal" and "distal disease" were defined as L1 and 2a (main and lobar pulmonary artery PA) and L2b-4 (lower lobe basal trunk to subsegmental PA), respectively. Three radiologists had a moderate interobserver agreement for the radiological classification of disease (k = 0.55). Sensitivity was 92-100% and specificity was 24-53% to predict proximal disease according to the Jamieson classification. A median of 9 segments/patient had CTPA perfusion defects (range, 2-18 segments). L1 disease had a greater decrease in the mean pulmonary artery pressure (
= 0.029) and pulmonary vascular resistance (
= 0.011) after surgery compared to patients with L2a to L3 disease. The extent of perfusion defects was not associated with the level of disease or hemodynamic changes after surgery (
> 0.05 for all). CTPA is highly sensitive for predicting the level of disease in CTEPH patients with a moderate interobserver agreement. The radiological level of disease is associated with hemodynamic improvement after surgery.
Lung cancer screening programs generate a high volume of low-dose computed tomography (LDCT) reports that contain valuable information, typically in a free-text format. High-performance named-entity ...recognition (NER) models can extract relevant information from these reports automatically for inter-radiologist quality control.
Using LDCT report data from a longitudinal lung cancer screening program (8,305 reports; 3,124 participants; 2006-2019), we trained a rule-based model and two bidirectional long short-term memory (Bi-LSTM) NER neural network models to detect clinically relevant information from LDCT reports. Model performance was tested using F1 scores and compared with a published open-source radiology NER model (Stanza) in an independent evaluation set of 150 reports. The top performing model was applied to a data set of 6,948 reports for an inter-radiologist quality control assessment.
The best performing model, a Bi-LSTM NER recurrent neural network model, had an overall F1 score of 0.950, which outperformed Stanza (F1 score = 0.872) and a rule-based NER model (F1 score = 0.809). Recall (sensitivity) for the best Bi-LSTM model ranged from 0.916 to 0.991 for different entity types; precision (positive predictive value) ranged from 0.892 to 0.997. Test performance remained stable across time periods. There was an average of a 2.86-fold difference in the number of identified entities between the most and the least detailed radiologists.
We built an open-source Bi-LSTM NER model that outperformed other open-source or rule-based radiology NER models. This model can efficiently extract clinically relevant information from lung cancer screening computerized tomography reports with high accuracy, enabling efficient audit and feedback to improve quality of patient care.
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