Chapters Transcript Video Oncologic Chest CT Imaging: Top Tips for the Cardio-Oncologist Penn Medicine radiologist, Ana Kolansky, MD, reviews what the cardio-oncology team can glean from oncology imaging of the chest. Related Links: Twitter @PennMDForum Dr. Kolansky’s physician profile What I want to do in the next 12 minutes or so is I'm just switch gears and talk to you a little bit about um what the cardio routine can glean from uncle logic ct imaging of the chest. Um And um you have to understand that the primary focus of the interpreting radiologists in these Uncle Logic studies is the evaluation of the oncological findings. Were looking for metastatic disease in the form of modularity or lymphocytic carcinoma, ketosis. We're evaluating potential pleural metastases, evaluating radiation change, whether it's a cute pneumonitis or fibrosis and then drug related pneumonitis, which in the era of immunotherapy uh is something to really look for. Um as these patients do get immune related pneumonitis, but there are concurrent diagnostic possibilities that sometimes we don't uh think of because we don't have the appropriate clinical history um with us and that is the diagnosis of concurrent pneumonia and of cardiovascular disease. And so when the cardiologist or the cardiology team is a evaluating these examinations, there is a component um that you can add uh to to the evaluation that the radiologist may not be aware of. Um And so in looking at these, you you wanted to go through the same uh exercise that we do as radiologist. You want to look at the pulmonary Perrin comma, assess the pleural effusions and then assess the cardiovascular system. And the first thing that I want to just share with you is that always image in people's face of inspiration, which is the best phase for evaluating the long peron comma and when we don't image in full inspiration. For example, in pulmonary embolus studies, CTP ES are obtained in quiet breathing in order to maximize even inflow of intravenous contrast into the pulmonary circulation. And as a result, the exploratory phase of respiration is a much longer face than the conspiratorial face. So most of the scan is obtained during expiration. Expiration is associated with a whole slew of artifacts in the lung because hyper ventilatory changes in the lung mimic infiltrated lung disease, especially at the lung basis. Um So the way that you figure out whether you're looking at a good scan for evaluating the lung Perrin comma is to look at the trachea. Um The trachea is nice and round in inspiration. That's what you want to see. If you're going to evaluate the lung peron coma and on expiration the member nous back wall of the trachea becomes concave in um in expiration. And as a result there are uh huh. I put the lottery changes in the lung that mimic disease and all they represent really are micro add elected. So you want to make sure you're looking at a good scan if you're going to evaluate belongs for pulmonary oedema or other infiltrated disease, What does pulmonary agree on see? Deep Yeah, pulmonary oedema. Um well resolved in inter lobular septal thickening and gorge. Men of the lymphatic. So everywhere in the longer run to automatics are rich, meaning that the pleural surfaces. Therefore, the official services become thickened, the interlocutor become the local development. Glass density, ground glass density, meaning infiltration of the lung at a level beyond our level level of resolution. So in the distal emerge judicial system and partial veal or filling, you will get vascular tension and thinking of the micro vascular bundles and a great capacity. The hydrostatic changes of preliminary oedema are evident on the sea tv where the ground glass density is more prevalent dependent, lung sense of bilateral pleural effusions will also be helpful. This appointment Kadima looks like Pulmonary edema can also be difficult to diagnose with all the things that we see in oncology patients. The most difficult one is lymphocytic carcinoma ketosis, which can have a pattern that is extremely similar to pulmonary oedema, namely thickening of the inter lobular 70 and ground glass density. But unlike pulmonary oedema, Linfen gitic carcinoma ketosis is often Nagy ular, the thickening is more irregular and beat it. The fishers um instead of being smoothly thickened are not regular and irregular. There are irregular interfaces when the bronco vascular bundles are thickened, they're irregular. And unlike pulmonary oedema lymphoma, carcinoma ketosis is often unilateral. This is an easy case because we haven't infiltrated lung cancer, but metastatic disease in the setting of breast cancer and other diseases that typically give you Linfen gitic tumor can can really mimic pulmonary oedema. The differential diagnosis of pulmonary oedema. There are a slew of other diseases that we see um In cancer patients, radiation change when it first appears, can be very diffused, very ground glass in appearance and be difficult to diagnose as it evolves. Um the lateral sharp margin nations of the radiation portal gives away the diagnosis that this is radiation human itis um rather than anything else, the paddock growth of adenocarcinoma and also grows along the pulmonary interstitial in without destroying the lung Perrin comma. And uh this tumor uses the lung as a scaffolding and on the infiltration along the inter lobular septa. Can also, and the ground glass density that is produced from it can also mimic pulmonary oedema or even infection. And it's a diagnosis that sometimes can be missed on the initial evaluation and mistaken for other diseases rather than lepidus growth of adenocarcinoma, immune related pneumonitis. Here are two patients um one with metastatic melanoma, the other with metastatic left lung cancer following lumpectomy, who are on immunotherapy and have immune related pneumonitis. And all the variety of um immune related drugs can give you uh pneumonitis and that sometimes can be difficult to differentiate from either infection or pulmonary oedema with what I want to say in in in summary of this section, is that sometimes it is important for that conversation with the radiologist. Um If you're thinking that perhaps some of the findings may be due to pulmonary oedema and not to a variety of other things that we are looking for and focused on evaluate the pleural effusions were very quick to say plural effusions are malignant, but executive pleural effusions enhance and those usually mean tumor or infection, as is nicely seen in this case with parietal pleura and the visceral pleura are both enhancing plural effusions that are transferred, dated do not enhance, and those are the pleural effusions that we see with cardiac disease. Second, the third aspect besides the long Perrin comma and the plural is you want to assess the cardio vascular structures in the chest um with an eye towards cardiovascular disease and chamber enlargement and hypertrophy. On actual imaging is very inaccurate because we're not we're not slicing the chest throughout the long or short axis of the heart. Um But all of our scans have multi planar imaging. We have corona and saddle imaging. We can which can give you a very good idea of what the chambers look like and what the wall thickness looks like, especially in contrast enhanced studies. So all you have to do is go to the sagittal and corona reconstructions. Put that in media style windows and and take a look. You should evaluate or into cardiac thrombosis, something that we sometimes overlook because our attention is in other parts of the media steinem looking for a Ganapathy, infiltration of adjacent cancers. And we forget that we got to look inside the heart, pericardial effusion and thickening may have um aerodynamic implications. Look for incidental thrombosis embolism. It's uh not an insignificant observation in oncological patients and then look for classification. It's either coronary valvular or pericardial. And let's look at a couple of examples. Here's a patient with um pancreatic cancer and on his staging cT he has a incidental pulmonary thrombosis embolism. So incidental pe occurs in a significant proportion of oncological patients and we should always be looking for it. In contrast, enhanced studies here's a patient who carried a diagnosis of chronic pulmonary thrombosis embolism, in fact, has a study from uh several, several months ago with um pulmonary emboli and he's becomes referred to our center or pulmonary from back to me And you can see in his studies that he has extensive pulmonary thrombosis level. I kind of irregular looking thrown by. It involves all the lobes and in fact this patient also had thrombosis in the spc and a large intra cardiac clot kind of irregular that is prolapse ng through the troika spit valve along with the pericardial effusion and pulmonary capacities, some which look typical of um metastases. Others look like pulmonary and fortunes. And this patient with extensive bilateral thrown by was taken to the operating room for thrown back to me and what he had was metastatic disease from colon cancer and all these. This was metastatic tumor thrown by. So this is obviously um extreme case. Um but look at the pulmonary vascular charity on contrast enhanced studies and look for those occult um Empoli that we may have not seen examine the heart for coronary artery calcification as coronary calcifications. As you know our reliable by a marker for the presence of atherosclerosis and uh predictor of cardiovascular events. Everyone is familiar with calcium scoring ct which uses the Agatston score. Uh The Agatston score is a semi automated tool for calculating the extent of coronary calcifications um and allows for early risk stratification. But we don't need a dedicated calcium score C. T two c calcium in the heart. And on non contrast not non gated cts of the chest as we do for um staging. We can see the presence of coronary artery calcifications. And this correlates with the Agatston Score. Um and underestimated by about 20%. So if we see coronary artery calcium on these studies, you know the patients have um significant calcifications in their coronary arteries and we rate these as mild, moderate and severe and this is how they correlate with the score. Here's a patient 71 year old with renal cell carcinoma and onset of Dysosmia. This patient has interstitial lung disease that is longstanding but it is not typical of pulmonary oedema. This is drug toxicity from remote chemotherapy. What you can glean from the C. T. Is that there are extensive coronary artery calcifications in the lady distribution and in the right coronary artery and that there is also marked classification of the aortic valve and on this corona reconstruction you can see the calcified aortic valve and get a glimpse of the coronary artery calcifications in the left coronary artery. In addition to um valvular and coronary artery calcifications, evaluate the pericardium for pericardial effusion, thickening or calcification. Here is a patient who has um head and neck carcinoma and has pericardial calcifications. And these can be due to remote radiation um in patients who have had media sternal radiation. But in this case this extensive pericardial classification was due to remote granulomas disease evidence by the multiple granuloma to seen in the spleen. So in summary there are five takeaways that I can leave you with um when evaluating these C. T. Scans on your own. Um make sure that the images are inspired story. If you want to assess the lung Perrin comma and be careful to not make a diagnosis of pulmonary oedema on exploratory scans, remember that the radiologist may not be thinking of pulmonary oedema or cardiovascular disease when you are and it may be necessary to have that discussion with the radiologist pulmonary oedema, radiation pneumonitis, um Linfen, genetic carcinoma, ketosis and drug induced pneumonitis as well as infection, have all overlapping imaging characteristics and it's important to bring in that clinical history in order to arrive at the right diagnosis. Remember that enhancing pleural effusions are not cardiac related. There you are infection and look at the media steinem for calcifications and cardio vascular thrombosis that may be clues to the diagnosis. Published April 9, 2021 Created by
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