RADIOLOGIC EVALUATION OF EMPHYSEMA FOR LUNG VOLUME REDUCTION SURGERY
Section snippets
EMPHYSEMA TYPES AND PATHOPHYSIOLOGY
Histologically, emphysema is characterized by abnormal and permanent enlargement of the air spaces distal to the terminal bronchioles, with destruction of the alveolar walls.69 There are several forms of pulmonary emphysema, including centrilobular (centriacinar or proximal acinar), panlobular (panacinar), paraseptal (distal acinar), and perifocal (paracicatricial) emphysema.69 The first two are the most commonly seen forms in clinical practice. Paraseptal emphysema occurs along the lung
IMPACT OF LUNG VOLUME REDUCTION SURGERY ON IMAGING OF EMPHYSEMA
The imaging of emphysema has received tremendous attention since the resurgence of LVRS. First performed in the 1950s by surgeon and anatomist Otto Brantigan, thissurgical treatment for emphysema was abandoned because of unacceptable patient morbidity and mortality (6 of 33 or 18%), and uncontrolled air leaks across the visceral pleural surface.10 Thoracic surgeon Joel Cooper revived the technique, reporting the first modern human case series of successful LVRS in 1994. 15, 16, 17, 18, 19 The
ROLE OF IMAGING IN PATIENT SELECTION FOR LUNG VOLUME REDUCTION SURGERY
Before the reintroduction of LVRS, the clinical imaging of emphysema was often limited to the chest radiograph. Most qualitative or semiquantitative chest radiographic scoring systems for emphysema use signs of lung destruction or hyperinflation on either the posteroanterior or lateral views. 68, 90 These signs include irregular radiolucency of the lungs, arterial deficiency or increased perivascular markings, flattening or depression of the diaphragm, enlargement of the retrosternal clear
COMPUTED TOMOGRAPHY OF EMPHYSEMA
CT, particularly HRCT of the chest, provides excellent anatomic detail for detecting, characterizing, and qualitatively or quantitatively determining the severity of emphysema. Not surprisingly, conventional CT is more accurate than chest radiography, and HRCT is more accurate than conventional CT in demonstrating the presence, severity, and distribution of emphysema. 8, 56 Emphysema appears as abnormal areas of low-attenuation lung, without definable walls (Figs. 1C, D; 2C; 3A, B; 4A, B). A
COMPUTED TOMOGRAPHY BEFORE AND AFTER LUNG VOLUME REDUCTION SURGERY
CT scans before and after LVRS can be used to evaluate the structural changes that occur in the lungs following surgery. Quantitative CT scan of lung volumes before and after video-assisted thoracoscopic unilateral LVRS in one series of 28 patients demonstrated a 22% decrease in the volume, 14% decrease in the percentage of emphysema, and 26 HU mean increase in lung attenuation in the lung that underwent resection, without significant changes in the contralateral lung.35 In this series, pixel
COMPUTED TOMOGRAPHY AND PATIENT SELECTION FOR LUNG VOLUME REDUCTION SURGERY
Several investigators have demonstrated that the morphologic distribution of emphysema within the lungs, as demonstrated on CT scan, is an excellent predictor of patient outcome following LVRS.* Although some studies have used qualitative emphysema scoring systems91, 97, 98 and others have used quantitative analysis, 3, 4, 31, 43, 78 the results have been similar. Specifically, the more homogeneous the emphysema from lung apices to bases, the
CHEST RADIOGRAPHY AND PATIENT SELECTION
Limited data are available on the use of chest radiographs (CXRs) to identify patients who will attain the greatest benefit from LVRS. One series of 47 LVRS survivors demonstrated that chest radiographic scores may be more strongly correlated with outcome than CT scores.78 The severity of emphysema was scored on both CXRs and CT scan using a five-point scale (0 = normal, 1 = mild, 2 = moderate, 3 = marked, 4 = severe) and the heterogeneity also scored on a five-point scale (0 = uniform
INCIDENTAL LUNG CANCER
Most patients with severe emphysema have a long history of cigarette smoking, placing them at increased risk for developing bronchogenic carcinoma. Three different series have reported a 5% incidence of bronchogenic carcinoma in emphysema patients being evaluated for LVRS or lung transplantation (Fig. 5). 71, 77, 81 These studies have similar results despite different scanning techniques, including HRCT with 1- to 1.5-mm collimation at 10-mm intervals in one series, 81 and 10-mm contiguous
VENTILATION AND PERFUSION SCINTIGRAPHY
Lung perfusion and ventilation scintigraphy may demonstrate focal or diffuse abnormality in patients with emphysema. When emphysema is mild, perfusion defects occur in the absence of ventilation defects; when emphysema becomes advanced, the defects are usually matched (see Fig. 1G, H; 4C, D).65 Lung perfusion scintigraphy has received the most attention. Some investigators have proposed that it is useful for the identification of target areas for resection during LVRS. 39, 53, 83, 84, 86, 87, 91
SUMMARY
Lung volume reduction surgery has created an opportunity for the advanced imaging of emphysema. Patients with CT or perfusion scintigraphy demonstrating an upper- or lower-lobe–predominant pattern of emphysema have better patient outcomes after LVRS than patients with emphysema diffusely or homogeneously distributed throughout the lungs. Some patients with diffuse or homogeneous emphysema may demonstrate improvement in function or dyspnea after surgery, but the magnitude of the improvement seen
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Quantitative <sup>1</sup>H and hyperpolarized <sup>3</sup>He magnetic resonance imaging: Comparison in chronic obstructive pulmonary disease and healthy never-smokers
2014, European Journal of RadiologyCitation Excerpt :While pulmonary function tests provide established measurements of global lung function that are widely accepted for the diagnosis and monitoring of COPD [4,5], high-resolution X-ray computer tomography (CT) imaging is often used to provide regional anatomical information. CT is used to evaluate COPD abnormalities of the airways [6–8], regional evaluation of gas trapping [9,10] and quantitative information about lung tissue structure alterations [11–17]. Conventional proton magnetic resonance imaging (1H MRI) is also readily available in most clinical care centers but has historically posed a number of major challenges for the evaluation of the respiratory system and in particular for COPD.
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2007, European Journal of RadiologyAssessment of the relationship between lung parenchymal destruction and impaired pulmonary perfusion on a lobar level in patients with emphysema
2007, European Journal of RadiologyCitation Excerpt :In our study the severity grading of emphysema, based on loss of structure and perfusion, showed no correlation with FEV1% predicted and poor correlation with TLCO% predicted. This is not surprising since the TLCO measurement is more reliable in homogeneous ventilation of the lung [40], which obviously was not the case in our patients as in other studies [41–43]. Local assessment of V/Q might already identify disease at early stages with better therapeutic options and a higher quality of life.
Patient selection for lung volume reduction surgery
2003, Chest Surgery Clinics of North AmericaGiant healed non-collapsed pulmonary cavities mimicking emphysematous bullae
2015, Neumologia y Cirugia de Torax(Mexico)High-resolution computed tomography in assessment of patients with emphysema
2013, Respiratory Care
Address reprint requests to Ella A. Kazerooni, MD, Department of Radiology/2910Q Taubman Center, University of Michigan Medical Center, 1500 E. Medical Center Drive, Ann Arbor, MI 48109–0326, e-mail: [email protected]
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Department of Radiology, University of Michigan Medical Center, Ann Arbor, Michigan