Elsevier

Clinics in Chest Medicine

Volume 20, Issue 4, 1 December 1999, Pages 845-861
Clinics in Chest Medicine

RADIOLOGIC EVALUATION OF EMPHYSEMA FOR LUNG VOLUME REDUCTION SURGERY

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Lung volume reduction surgery (LVRS) is a recent addition to the treatment options for selected patients with pulmonary emphysema, a condition affecting approximately 1.65 million people in the United States.81 Emphysema, asthma, and chronic bronchitis are three forms of chronic obstructive pulmonary disease (COPD), each characterized to some degree by shortness of breath and airflow limitation. Whereas asthma is a reversible condition characterized by bronchospasm, and chronic bronchitis is accompanied by a productive cough, these three forms of obstructive lung disease often overlap in the same patient.81 Emphysema, specifically, is a chronic, slowly progressive disease, defined by the American Thoracic Society as “a condition of the lung characterized by abnormal, permanent enlargement of the air spaces distal to the terminal bronchiole, accompanied by destruction of their walls.”80 Some forms of emphysema, such as α1-antiprotease deficiency are inherited, but most pulmonary emphysema develops secondary to cigarette smoking. This chronic and irreversible illness is the source of considerable patient morbidity and medical expense, through medical therapy, supplemental oxygen therapy, pulmonary rehabilitation, and hospitalization for disease exacerbation and superimposed infections.

Approximately two thirds of the nearly 12,000 patients requiring daily mechanical ventilator support via tracheostomy for respiratory failure in the United States each year have COPD as the etiology, at a yearly cost of $2 billion.38 Once requiring mechanical ventilation, the prognosis for patients with COPD is significantly worse than that for patients with other causes of respiratory failure.94

Until the advent of LVRS, lung transplantation was the only treatment available to patients with severe emphysema failing medical therapy. Unfortunately, because of the limited availability of lung allografts and frequency of chronic allograft rejection, this is not a viable option for many patients. 32, 88

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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    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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