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Background e-Cigarette or vaping-induced lung injury (EVALI) causes a spectrum of CT lung injury patterns. Relative frequencies and associations with vaping behavior are unknown. Research Question What are the frequencies of imaging findings and CT patterns in EVALI and what is the relationship to vaping behavior? Study Design and Methods CT scans of 160 subjects with EVALI from 15 institutions were retrospectively reviewed. CT findings and patterns were defined and agreed on via consensus. The parenchymal organizing pneumonia (OP) pattern was defined as regional or diffuse ground-glass opacity (GGO) ± consolidation without centrilobular nodules (CNs). An airway-centered OP pattern was defined as diffuse CNs with little or no GGO, whereas a mixed OP pattern was a combination of the two. Other patterns included diffuse alveolar damage (DAD), acute eosinophilic-like pneumonia, and pulmonary hemorrhage. Cases were classified as atypical if they did not fit into a pattern. Imaging findings, pattern frequencies, and injury severity were correlated with substance vaped (marijuana derives [tetrahydrocannabinol] [THC] only, nicotine derivates only, and both), vaping frequency, regional geography, and state recreational THC legality. One-way analysis of variance, χ2 test, and multivariable analyses were used for statistical analysis. Results A total of 160 patients (79.4% men) with a mean age of 28.2 years (range, 15-68 years) with EVALI underwent CT scan. Seventy-seven (48.1%), 15 (9.4%), and 68 (42.5%) patients admitted to vaping THC, nicotine, or both, respectively. Common findings included diffuse or lower lobe GGO with subpleural (78.1%), lobular (59.4%), or peribronchovascular (PBV) sparing (40%). Septal thickening (50.6%), lymphadenopathy (63.1%), and CNs (36.3%) were common. PBV sparing was associated with younger age (P = .02). Of 160 subjects, 156 (97.5%) had one of six defined patterns. Parenchymal, airway-centered, and mixed OP patterns were seen in 89 (55.6%), 14 (8.8%), and 32 (20%) patients, respectively. Acute eosinophilic-like pneumonia (six of 160, 3.8%), DAD (nine of 160, 5.6%), pulmonary hemorrhage (six of 160, 3.8%), and atypical (four of 160, 2.5%) patterns were less common. Increased vaping frequency was associated with more severe injury (P = .008). Multivariable analysis showed a negative association between vaping for > 6 months and DAD pattern (P = .03). Two subjects (1.25%) with DAD pattern died. There was no relation between pattern and injury severity, geographic location, and state legality of recreational use of THC. Interpretation EVALI typically causes an OP pattern but exists on a spectrum of acute lung injury. Vaping habits do not correlate with CT patterns except for negative correlation between vaping > 6 months and DAD pattern. PBV sparing, not previously described in acute lung injury, is a common finding.

To establish the diagnostic performance of diffusion-weighted magnetic resonance imaging (DWI) in discriminating malignant from non-malignant thoracic lymph nodes.This was a meta-analysis involving systematic searches of the MEDLINE, EMBASE, and Web of Science databases up through April 2020. Studies reporting thoracic DWI and lymph node evaluation were included. The pooled sensitivity, specificity, diagnostic odds ratio, positive predictive value, negative predictive value, and area under the receiver operating characteristic curve (AUC) were calculated.We evaluated six studies, involving a collective total of 356 mediastinal lymph nodes in 214 patients. Thoracic DWI had a pooled sensitivity and specificity of 92% (95% confidence interval [95% CI]: 71-98%) and 93% (95% CI: 79-98%), respectively. The positive and negative likelihood ratios were 13.2 (95% CI: 4.0-43.8) and 0.09 (95% CI: 0.02-0.36), respectively. The diagnostic odds ratio was 149 (95% CI: 18-1,243), and the AUC was 0.97 (95% CI: 0.95-0.98).DWI is a reproducible technique and has demonstrated high accuracy for differentiating between malignant and benign states in thoracic lymph nodes.Uma meta-análise foi realizada para estabelecer o desempenho diagnóstico da ressonância magnética com imagem ponderada em difusão (DWI) na discriminação de linfonodos torácicos malignos de benignos.MEDLINE, EMBASE e Web of Science foram sistematicamente pesquisados até abril de 2020. Foram incluídos estudos que relatavam o uso de DWI na avaliação de linfonodos torácicos. Sensibilidade, especificidade, razão de chances de diagnóstico, valores preditivos positivos e negativos e área sob a curva (AUC) foram calculados.Foram encontrados 356 linfonodos mediastinais de 214 pacientes nos seis estudos incluídos. DWI produziu sensibilidade e especificidade combinadas de 92% (intervalo de confiança 95% [IC 95%]: 71-98%) e 93% (IC 95%: 79-98%), respectivamente. A razão de verossimilhança positiva foi de 13,2 (IC 95%: 4,0-43,8), a razão de verossimilhança negativa foi de 0,09 (IC 95%: 0,02-0,36); A razão de chances de diagnóstico foi de 149 (IC 95%: 18-1.243). A DWI teve uma AUC de 0,97 (IC 95%: 0,95-0,98).DWI é uma técnica reprodutível que demonstrou alta acurácia na diferenciação de estados malignos e benignos nos linfonodos torácicos.

Lymphangitic carcinomatosis, the presence of tumor within the pulmonary lymphatics, occurs in the setting of malignant tumors and is associated with a poor prognosis. Here we describe a case of lymphangitic carcinomatosis in the setting of renal cell carcinoma and review the radiological manifestations of this disease.

Childhood interstitial lung disease (chILD) is a group of lung disorders characterized by lung remodeling leading to abnormal gas exchange. ChILD is classified differently from adult interstitial lung disease and encompasses 2 broad categories: "disorders more prevalent in infancy" (2 years) and "disorders not specific to infancy" (2 years). High-resolution computed tomography can play an important role in the evaluation of chILD by narrowing the differential diagnosis and preventing unnecessary invasive procedures if typical imaging patterns are recognized. Thus, the pediatric radiologist should consider chILD in children with respiratory distress and identify the imaging patterns to suggest the diagnosis.

Parasitoses are infectious diseases of global distribution, with predominance in areas of poor sanitation. Parasites cause damage through direct tissue injury and the inflammatory response generated by their migration and establishment in various organs. Thoracic involvement by parasitic disease can generate both specific and nonspecific clinical, laboratorial, and radiologic manifestations, which often makes their diagnosis challenging. The correct diagnosis is crucial for definition of treatment, which sometimes requires rapid intervention. Based on a literature review of the last few decades, this article aimed to characterize the main radiologic findings related to thoracic manifestations of parasitic diseases, correlating them with radiographic and tomographic images of patients with confirmed diagnosis of such pathologies. The included parasitic diseases are malaria, Chagas disease, toxoplasmosis, amoebiasis, ascariasis, toxocariasis, strongyloidiasis, dirofilariasis, cysticercosis, echinococcosis, schistosomiasis, and paragonimiasis.

To evaluate the diagnostic test accuracy of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT), whole-body magnetic resonance imaging (WB-MRI), and whole-body diffusion-weighted imaging (WB-DWI) for the detection of metastases in patients with non–small cell lung cancer (NSCLC). MEDLINE, Embase, and Cochrane Library databases were searched up to June 2019. Studies were selected if they reported data that could be used to construct contingency tables to compare 18F-FDG PET/CT, WB-MRI, and WB-DWI. Two authors independently extracted data on study characteristics and assessed methodological quality using the Quality Assessment of Diagnostic Accuracy Studies. Forest plots were generated for sensitivity and specificity of 18F-FDG PET/CT, WB-MRI, and whole-body diffusion-weighted imaging (WB-DWI). Summary receiver operating characteristic plots were created. The 4 studies meeting inclusion criteria had a total of 564 patients and 559 lesions, 233 of which were metastases. In studies of 18F-FDG PET/CT, the pooled estimates of sensitivity and specificity were 0.83 (95% confidence interval [CI], 0.54–0.95) and 0.93 (95% CI, 0.87–0.96), respectively. For WB-MRI, pooled sensitivity was 0.92 (95% CI, 0.18–1.00) and pooled specificity was 0.93 (95% CI, 0.85–0.95). Pooled sensitivity and specificity for WB-DWI were 0.78 (95% CI, 0.46–0.93) and 0.91 (95% CI, 0.79–0.96), respectively. There was no statistical difference between the diagnostic odds ratio of WB-MRI and WB-DWI compared with that of PET/CT (p = 0.186 for WB-DWI; p = 0.638 for WB-MRI). WB-MRI and DWI are radiation-free alternatives with comparable diagnostic performance to 18F-FDG PET/CT for M staging of NSCLC. • Whole-body MRI with or without diffusion-weighted imaging has a high accuracy for the diagnostic evaluation of metastases in patients with non–small cell lung cancer. • Whole-body MRI may be used as a non-invasive and radiation-free alternative to positron emission tomography with CT with similar diagnostic performance.

Objective: To evaluate the effect that transitioning from a model of general radiology reporting to one of subspecialized radiology reporting has on report turnaround times (TATs) and on productivity in the radiology department of a hospital in a middle-income country. Materials and Methods: The reporting workflow in our radiology department was changed from general reporting (any radiologist reporting imaging studies for any specialty) to subspecialized reporting (radiologists exclusively reporting imaging studies that fall within their subspecialty-abdominal, musculoskeletal, cardiothoracic, emergency, or neurological imaging). This was a retrospective study in which we compared general reporting with subspecialized reporting in terms of the following variables: the TAT; the proportions of reports completed within 2 h and within 24 h (TAT-2h and TAT- 24 h, respectively); and productivity. Data were collected over two 24-month periods (2015-2016 for general reporting and 2017-2018 for subspecialized reporting). Results: A total of 208,516 reports were generated. The median report TAT decreased from 49.1 h and 52.9 h in 2015 and 2016, respectively, to 16.1 h and 15.2 h in 2017 and 2018, respectively (p < 0.001). The TAT-2h also improved, increasing from 8.7% and 7.9% in 2015 and 2016, respectively, to 52.0% and 61.3% in 2017 and 2018, respectively (p < 0.001), as did the TAT- 24 h, which increased from 12.1% and 14.1% in 2015 and 2016, respectively, to 74.3% and 78.7% in 2017 and 2018, respectively (p < 0.001). Between the two periods, the total number of scans performed increased by 33% (p = 0.001). Conclusion: The implementation of a subspecialized reporting system significantly improved the median TAT for radiology reports, as well as increasing the TAT-2h and TAT- 24 h, during a time of increased productivity. Resumo Objetivo: Avaliar o efeito da transição de um modelo de laudos em radiologia realizados por radiologistas gerais para um modelo relatado por subespecialização no tempo de resposta de relatórios (TAT) em radiologia e produtividade em um departamento de radiologia em um país em desenvolvimento. Materiais e Métodos: O fluxo em nosso departamento foi modificado de um sistema de relatórios gerais (qualquer radiologista lauda exames de imagem de qualquer especialidade) para um sistema de subespecialização (radiologistas laudam exclusivamente exames de imagem pertencente a sua subespecialidade - abdominal, musculoesquelético, cardiotorácico, emergência e neurologia). Este estudo retrospectivo avaliou a TAT, TAT-2 horas e TAT-24 horas e a produtividade num período de 24 meses de relatórios gerais (2015-2016) comparado a um período de 24 meses do sistema de subespecialização (2017-2018). Resultados: No total, 208.516 laudos foram gerados. A TAT reportada reduziu de uma média de 49,1-52,9 horas durante o período geral para 15,2-16,1 horas durante o período de relatórios por subespecialidade (p < 0,001). TAT-2 horas e TAT- 24 horas aumentaram significativamente de 7,9-8,7% para 52,0-61,3% e de 12,1-14,1% para 74,3-78,7%, respectivamente (p < 0.001). O número total de exames aumentou em 33% (p = 0.001) comparando os dois períodos. Conclusão: A implementação de um sistema de laudos por subespecialidade aumentou o TAT em radiologia, incluindo benefícios no TAT-2 horas e TAT-24 horas durante um período de aumento da produtividade.

Florida red tides occur annually due to proliferation of the marine dinoflagellate Karenia brevis, which produces neurotoxins known as brevotoxins. Inhalational exposure to brevotoxins usually results in upper airway symptoms only. Rarely does exposure lead to lower respiratory tract symptoms as in our case. We report a case of a 50-year-old man who presented with a 4-week history of dyspnea after exposure to the red tide. Computed tomography (CT) of the chest showed diffuse bilateral ground glass opacities and interstitial thickening. Bronchoalveolar lavage cultures and cytology were negative. The patient was started on steroids. Over the next few weeks, the patient’s symptoms resolved. Repeat CT chest showed complete resolution of the ground glass opacities. Steroids were then tapered. Most patients who are exposed to algal blooms have self-limiting symptoms. Patients with asthma are particularly susceptible to worsening respiratory symptoms after exposure to brevotoxin aerosols. This case highlights that, in rare cases, exposure to red tide can results in severe lower respiratory tract symptoms.

The purpose of this study was to evaluate the appropriateness of ultrasound (US) and computed tomography (CT) examinations ordered in the emergency department (ED) for abdominal complaints.We reviewed 154 CTs and 154 US orders for appropriateness using evidence-based recommendations by the American College of Radiology. The sample was powered to show a prevalence of inappropriate orders of 25% with a margin of error of 7.5%. Findings in the final reports were compared to the initial clinical diagnosis classified in 4 categories: normal, compatible with initial diagnosis, alternative diagnosis, and inconclusive. We also evaluated the frequency in which a second imaging modality was ordered on the same visit.A total of 135 CT and 143 US examinations had complete clinical information to allow evaluation of order appropriateness. The rate of inappropriate orders was 36.3% for CT and 84.4% for US. The final report of appropriate orders was significantly more likely to demonstrate findings compatible with the initial diagnosis for both CT (76.7% vs 20.4%, P0.0001) and US (38.9% vs 14.4%, P = 0.0093). Inappropriately ordered CT scans were more likely to show no abnormalities (46.9 vs 16.3%, P = 0.0001). An additional imaging order with a secondary modality was requested in 20% of the inappropriate US orders, and 8.2% of the inappropriate CT orders.The prevalence of inappropriate examinations in the ED was 36.3% for CT and 84.4% for US. Appropriately ordered exams were more likely to yield imaging findings compatible with the initial diagnosis for both modalities.

Due to the COVID-19 pandemic, it is very likely that many radiology residency and fellowship programs will adopt interactive videoconference interviewing for the 2020-2021 residency match cycle. Although video interviewing has become a common part of the hiring process for business, experience with video interviewing for resident and fellow selection has been limited. Advantages of video interviews over traditional on-site interviews include cost-savings to both applicants and residency programs, less disruption to an applicant's educational activities, and potential for training programs to access a wider pool of candidates. The loss of the casual interactions that occur during an on-site interview and the inability of candidates to evaluate training facilities and their surrounding environments in-person are among the obstacles posed by video interviews, but training programs can mitigate these challenges with enhanced website content and creative media solutions. Through a review of the existing literature and internet resources, this article recommends specific measures medical schools, applicants, and radiology residency and fellowship programs can take to optimize the virtual interview experience for all involved parties.

Rationale and Objectives Implementation of low dose computed tomography (LDCT) lung cancer screening programs has followed the demonstration of reduced lung cancer mortality in the National Lung Screening Trial and subsequent consensus screening recommendations. Here we aim to assess the initial results of a screening program at an academic medical center, to discuss the challenges of implementing such a program, and suggest strategies for reducing patient dose. Materials and Methods Retrospective review of all patients who underwent LDCT lung cancer screening at our institution between March 2015 and July 2016 was performed to assess the lung cancer detection rate, the spectrum of imaging findings (nodule or mass characteristics, degree of emphysema, etc.), and patient radiation dose indices. Results A total of 272 patients were screened during the study period. Approximately 50% (n = 135) were women. The lung cancer detection rate was 2.2% (n = 6). One patient underwent chemoradiation therapy, whereas the remainder underwent uneventful thoracoscopic resection. Approximately, 80% of screened patients met United States Preventative Services Task Force criteria for LDCT screening. The median pack-years of smoking was 42 pack-years. The mean volume CT dose index for the screening CTs was 3.12 mGy. Utilizing tube current modulation and iterative reconstruction, where available, resulted in lower patient doses. Conclusion Initial LDCT lung cancer screening at our institution yielded results similar to those of the National Lung Screening Trial. Thorough prescreening evaluation, joint decision-making, centralized coordination of screening-related care, and patient size conscious scanning protocols are critical elements of a safe and successful lung cancer screening program.

Objectives To systematically review the effects of 3D-imaging virtual planning for nodule resection in the following solid organs: lung, liver, and kidney. Methods MEDLINE, EMBASE, and Cochrane Library were searched through September 31, 2020 to include randomized and non-randomized controlled studies that compared outcomes of surgical resection of lung, liver, or kidney nodule resection with and without 3D virtual planning with computed tomography. From each article, the mean operation time (OT), mean estimated blood loss (EBL), mean postoperative hospital stay (POHS), and the number of postoperative events (POE) were extracted. The effect size (ES) of 3D virtual planning vs. non-3D planning was extracted from each study to calculate the pooled measurements for continuous variables (OT, EBL, POHS). Data were pooled using a random-effects model. Results The literature search yielded 2397 studies and 10 met the inclusion criteria with a total of 897 patients. There was a significant difference in OT between groups with a moderate ES favoring the 3D group (ES,-0.56; 95%CI: 0.91,-0.29; I2 = 83.1%; p Conclusions 3D-imaging planning for surgical resection of lung, kidney, and liver nodules could reduce OT and EBL with no effects on immediate POHS and POE. Improvements in these perioperative variables could improve medium and long-term postoperative clinical outcomes.

Pulmonary embolism (PE) remains a common and important clinical condition that cannot be accurately diagnosed on the basis of signs, symptoms, and history alone. The diagnosis of PE has been facilitated by technical advancements and multidetector CT pulmonary angiography, which is the major diagnostic modality currently used. Ventilation and perfusion scans remain largely accurate and useful in certain settings. Lower-extremity ultrasound can substitute by demonstrating deep vein thrombosis; however, if negative, further studies to exclude PE are indicated. In all cases, correlation with the clinical status, particularly with risk factors, improves not only the accuracy of diagnostic imaging but also overall utilization. Other diagnostic tests have limited roles. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Common variable immunodeficiency is the most common primary immunodeficiency and consists of impaired immunoglobulin production causing recurrent sinopulmonary infections. The most common cause of mortality for this disorder, however, is from the development of malignancy and autoimmune disorders. One common entity that develops is a systemic granulomatous and lymphoproliferative disorder that can cause an interstitial lung disease more formally referred to as granulomatous-lymphocytic interstitial lung disease (GL-ILD). We discuss a case of a 25-year-old woman with common variable immunodeficiency and GL-ILD and review the literature to summarize the most common radiological findings to raise the suspicion for GL-ILD on high-resolution computed tomography and delineate this from infection and other mimickers. We will also review key histopathological characteristics for diagnosis and the clinical approach and treatment options for this rare disease.

The immunocompromised patient with an acute respiratory illness (ARI) may present with fever, chills, weight loss, cough, shortness of breath, or chest pain. The number of immunocompromised patients continues to rise with medical advances including solid organ and stem cell transplantation, chemotherapy, and immunomodulatory therapy, along with the continued presence of human immunodeficiency virus and acquired immunodeficiency syndrome. Given the myriad of pathogens that can infect immunocompromised individuals, identifying the specific organism or organisms causing the lung disease can be elusive. Moreover, immunocompromised patients often receive prophylactic or empiric antimicrobial therapy, further complicating diagnostic evaluation. Noninfectious causes for ARI should also be considered, including pulmonary edema, drug-induced lung disease, atelectasis, malignancy, radiation-induced lung disease, pulmonary hemorrhage, diffuse alveolar damage, organizing pneumonia, lung transplant rejection, and pulmonary thromboembolic disease. As many immunocompromised patients with ARI progress along a rapid and potentially fatal course, timely selection of appropriate imaging is of great importance in this setting. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking, or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Pulmonary artery sarcoma is a rare malignancy with poor prognosis which can be misdiagnosed as pulmonary thromboembolism. We present a case of a middle age woman who initially diagnosed with presumptive pulmonary embolism that was later found to have pulmonary artery sarcoma. Symptoms, pathology, imaging characteristics and available treatments are discussed. Keywords: Pulmonary artery sarcoma, Pulmonary embolism

Chest imaging is often used as a complementary tool in the evaluation of coronavirus disease 2019 (COVID-19) patients, helping physicians to augment their clinical suspicion. Despite not being diagnostic for COVID-19, chest CT may help clinicians to isolate high suspicion patients with suggestive imaging findings. However, COVID-19 findings on CT are also common to other pulmonary infections and non-infectious diseases, and radiologists and point-of-care physicians should be aware of possible mimickers. This state-of-the-art review goal is to summarize and illustrate possible etiologies that may have a similar pattern on chest CT as COVID-19. The review encompasses both infectious etiologies, such as non-COVID viral pneumonia, Mycoplasma pneumoniae, Pneumocystis jiroveci, and pulmonary granulomatous infectious, and non-infectious disorders, such as pulmonary embolism, fat embolism, cryptogenic organizing pneumonia, non-specific interstitial pneumonia, desquamative interstitial pneumonia, and acute and chronic eosinophilic pneumonia.

Drug-induced lung disease has been described with over 300 different agents, some of which are asymptomatic and may first present on imaging. These pulmonary diseases may present with variable imaging manifestations, and often overlap with other etiologies such as rejection, lymphoproliferative disorders, and infection that may be suspected in this patient population. However, there are several drugs that have classic imaging appearances, and in the proper clinical context, the radiologist should include their toxicity in the differential diagnosis, potentially expediting withdrawal of the drug and avoiding irreversible lung injury such as fibrosis.

Modifications in recipient and donor criteria and innovations in donor management hold promise for increasing rates of lung transplantation, yet availability of donors remains a limiting resource. Imaging is critical in the work-up of donor and recipient including identification of conditions that may portend to poor posttransplant outcomes or necessitate modifications in surgical technique. This article describes the radiologic principles that guide selection of patients and surgical procedures in lung transplantation.

The thoracic cage provides the structural support that makes respiration possible, provides protection to vital organs such as the lungs, heart, liver, and spleen, and serves as an anchor point for the upper extremities. Neoplasms of the bony thorax are not an uncommon incidental finding at both radiography and cross-sectional imaging. Some tumors have a characteristic appearance and it is important that an accurate differential diagnosis be provided. Misidentification could lead to unnecessary imaging or procedures with associated cost, morbidity, and mortality. The purpose of this article is to serve as a quick review of bone tumors commonly encountered in the thorax and that every radiologist should know. Please note that there are also several non-neoplastic osseous lesions that may mimic bone tumors such as osteomyelitis and eosinophilic granuloma; however, these entities are beyond the scope of this review and would not be discussed.

Benign metastasizing leiomyoma is a rare diagnosis in women with history of uterine leiomyomata. Distant metastasis may occur anywhere but is most commonly seen to the lungs. The age of presentation is often young to mid age, with patients often having a history of hysterectomy or myomectomy for uterine leiomyomata. The clinical course of these patients is most often indolent. However, the size and number of nodules can result in pulmonary symptoms. Differentiating benign metastasizing leiomyoma from malignant metastatic disease, including from leiomyosarcoma, is important to avoid unnecessary procedures or delayed treatment. The treatment with hormonal suppression is often successful for decreasing the size of lesions and alleviating pulmonary symptoms.

The respiratory system is often affected by complications of immunodeficiency, typically manifesting clinically as acute respiratory illness. Ongoing literature reviews regarding the appropriateness of imaging in these patients are critical, as advanced medical therapies including stem cell transplantation, chemotherapy, and immunosuppressive therapies for autoimmune disease continue to keep the population of immunosuppressed patients in our health care system high. This ACR Appropriateness Criteria topic describes clinical scenarios of acute respiratory illness in immunocompromised patients with cough, dyspnea, chest pain, and fever, in those with negative, equivocal, or nonspecific findings on chest radiography, in those with multiple, diffuse, or confluent opacities on chest radiography, and in those in whom noninfectious disease is suspected. The use of chest radiography, chest computed tomography, transthoracic needle biopsy, and nuclear medicine imaging is discussed in the context of these clinical scenarios. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 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 is not definitive, expert opinion may be used to recommend imaging or treatment.

Thoracic outlet syndrome is a clinical entity characterized by compression of the neurovascular bundle, and may be associated with additional findings such as venous thrombosis, arterial stenosis, or neurologic symptoms. The goal of imaging is to localize the site of compression, the compressing structure, and the compressed organ or vessel, while excluding common mimics. A literature review is provided of current indications for diagnostic imaging, with discussion of potential limitations and benefits of the respective modalities. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 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. In this document, we provided guidelines for use of various imaging modalities for assessment of thoracic outlet syndrome.

Pulmonary calcifications encompass a wide range of causes, both common and rare, such as calcified pulmonary nodules from chronic fungal infections and pulmonary alveolar microlithiasis. In this pictorial review, we categorize them based on etiology, which includes neoplastic calcifications, nonneoplastic calcified nodules, and iatrogenic- and exposure-related causes of pulmonary calcifications. We also illustrate the most characteristic imaging findings and outline the clinical implications for each of these entities to provide a sensible approach to pulmonary calcifications.

The results from the National Lung Screening Trial and the subsequent United States Preventative Services Task Force grade B recommendation in favor of using a screening low-dose chest computed tomography (S-LDCT) for early detection of lung cancer have generated a lot of excitement in the lung cancer community. Although that excitement has been tempered by the Medicare Evidence Development and Coverage Advisory Committee's recent decision not to recommend that Medicare cover S-LDCT, screening computed tomography remains a popular topic in medical imaging literature. As many practices are now considering implementing these S-LDCT programs, we review the challenges for establishing such a screening program and discuss some tips for successfully implementing a lung cancer screening program.

Left ventricular noncompaction cardiomyopathy is a very rare condition, yet believed to be often overlooked. It is thought to be caused by the developmental arrest in embryogenesis and characterized by an increase in the noncompacted, trabeculated myocardium adjacent to compacted myocardium in the left ventricular. The clinical presentations of this type of cardiomyopathy are of variable severity. Echocardiography used to be the diagnostic modality, but recent reports suggest that cardiac magnetic resonance imaging has higher sensitivity and specificity by showing a ratio of the noncompacted myocardium to compacted myocardium of >2.3.

Themaincauses of smoking-related deaths are lung cancer, chronicobstructive pulmonary disease (COPD), and ischemic heartdisease.Smokinghasalsobeenstronglyassociatedwithseveralinterstitiallungdiseases(ILDs),namelypulmonaryLangerhanscell histiocytosis (PLCH), respiratory bronchiolitis (RB), RB-associated ILD (RB-ILD), and desquamative interstitialpneumonia (DIP).This article reviews the major diffuse pulmonary diseasesaffectingsmokers,includingemphysemaandsmoking-relatedILDs. We describe the histologic and radiologic features of thedifferent forms of emphysema (centrilobular, panlobular, andparaseptal). Finally, we then discuss the clinical, histopatho-logic, and radiologic characteristics of smoking-related ILDs,including PLCH, RB, RB-ILD, and DIP. Bronchogenic carci-noma is not covered in this article.

Chest radiographs are sometimes taken before surgeries and interventional procedures on hospital admissions and outpatients. This manuscript summarizes the American College of Radiology review of the literature and recommendations on routinely performed chest radiographies in these settings. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 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.

Occupational lung disease is a category of disease entities characterized by a reaction of the lung parenchyma to inhaled aerosolized particles found in the environment. This document summarizes the imaging appropriateness data for silicosis, coal worker pneumoconiosis, and asbestosis. The main points of the document are that computed tomography is more sensitive than radiography, computed tomography without contrast generally suffices for evaluation, and fluorodeoxyglucose-positron emission tomography may have utility in patients with mesothelioma. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review includes 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.

Within a radiology team, members individually lean toward being givers or takers. Radiology leadership must recognize this characteristic and leverage the strengths of givers and takers to best assist the team and to provide effective motivation. Understanding the importance of balancing these qualities within a team improves productivity and morale and reduces burnout.

Sickle cell disease is an inherited hemolytic disease with systemic complications. These complications significantly impact the patients' quality of life. There are characteristic radiological findings that can aid in the diagnosis and management of common sequelae of sickle cell disease. In this review, we will discuss the thoracic imaging findings of common complications of sickle cell disease in an organ-based approach and provide imaging examples of them.

To illustrate and describe computed tomographic large airway pathology and correlate with fiberoptic bronchoscopy findings. Commonly encountered diseases of the large airway include tracheobronchial amyloidosis, tracheobronchopathia osteochondroplastica, tracheobronchomegaly, laryngotracheobronchial papillomatosis, relapsing polychondritis, Wegener granulomatosis, sarcoidosis, and tracheal stenosis. Computed tomography manifestations and bronchoscopic findings of these selected large airway diseases are discussed.

Eponyms serve the purpose of honoring individuals who have made important observations and discoveries. As with other fields of medicine, eponyms are frequently encountered in radiology, particularly in chest radiology. However, inappropriate use of an eponym may lead to potentially dangerous miscommunication. Moreover, an eponym may honor the incorrect person or a person who falls into disrepute. Despite their limitations, eponyms are still widespread in the medical literature. Furthermore, in some circumstances, more than one individual may have contributed to the description or discovery of a particular anatomical structure or disease, whereas in others, an eponym may have been incorrectly applied initially and propagated for years in the medical literature. Nevertheless, radiologic eponyms are a means of honoring those who have made lasting contributions to the field of radiology, and familiarity with these eponyms is critical for proper reporting and accurate communication. In addition, the acquisition of some historical knowledge about those whose names are associated with various structures or pathologic conditions conveys a sense of humanity in the science of medicine. In this third installment of this series, the authors discuss a number of chest radiology eponyms as they relate to the pulmonary interstitium, including relevant clinical and imaging features, as well biographical information of the respective eponym's namesake.

Imaging is paramount in the setting of blunt trauma and is now the standard of care at any trauma center. Although anteroposterior radiography has inherent limitations, the ability to acquire a radiograph in the trauma bay with little interruption in clinical survey, monitoring, and treatment, as well as radiography's accepted role in screening for traumatic aortic injury, supports the routine use of chest radiography. Chest CT or CT angiography is the gold-standard routine imaging modality for detecting thoracic injuries caused by blunt trauma. There is disagreement on whether routine chest CT is necessary in all patients with histories of blunt trauma. Ultimately, the frequency and timing of CT chest imaging should be site specific and should depend on the local resources of the trauma center as well as patient status. Ultrasound may be beneficial in the detection of pneumothorax, hemothorax, and pericardial hemorrhage; transesophageal echocardiography is a first-line imaging tool in the setting of suspected cardiac injury. In the blunt trauma setting, MRI and nuclear medicine likely play no role in the acute setting, although these modalities may be helpful as problem-solving tools after initial assessment. 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.

Eponyms serve the purpose of honoring individuals who have made important observations and discoveries. As with other fields of medicine, eponyms are frequently encountered in radiology, particularly in chest radiology. However, inappropriate use of an eponym may lead to potentially dangerous miscommunication. Moreover, an eponym may honor the incorrect person or a person who falls into disrepute. Despite their limitations, eponyms are still widespread in medical literature. Furthermore, in some circumstances, more than one individual may have contributed to the description or discovery of a particular anatomical structure or disease, whereas in others, an eponym may have been incorrectly applied initially and propagated for years in medical literature. Nevertheless, radiologic eponyms are a means of honoring those who have made lasting contributions to the field of radiology, and familiarity with these eponyms is critical for proper reporting and accurate communication. In addition, the acquisition of some historical knowledge about those whose names are associated with various structures or pathologic conditions conveys a sense of humanity in the field of medicine. In this article, the first of a multipart series, the authors discuss a number of chest radiology eponyms as they relate to neoplasms, including relevant clinical and imaging features, as well biographic information of the respective eponym׳s namesake.

Acute fibrinous organizing pneumonia (AFOP) is a distinct histopathologic pattern of lung injury with the hallmark feature of intra-alveolar fibrin deposits with associated organizing pneumonia, type II pneumocyte hyperplasia, and a patchy lymphohistiocytic proliferation. We describe the case of a previously healthy 47-year-old man who presented with a 4-day history of worsening dyspnea, cough, and nocturnal fevers and miliary nodules on chest imaging. Subsequently, there was an indication of AFOP when he underwent open lung biopsy. AFOP has been associated with a variety of underlying conditions including rheumatologic diseases, medications, and infections, and several cases were idiopathic. This case highlights the importance for radiologists to be aware of this uncommon pattern of lung injury and to consider it in the differential when encountering bilateral miliary infiltrates on chest imaging.

Hermansky-Pudlak syndrome (HPS) is a rare autosomal recessive disorder characterized by platelet dysfunction, oculocutaneous albinism, and life-threatening pulmonary fibrosis. There are 7 HPS genotypes, with type 1 being the most severe. Pulmonary involvement usually begins during the third or fourth decades of life, with fibrosis being the most common cause of death. We present imaging and histopathologic findings of a 16-year-old Saudi adolescent girl with HPS-related pulmonary fibrosis, emphasizing on the role of imaging in assessment of disease severity and prognosis.

Daily routine chest radiographs in the intensive care unit (ICU) have been a tradition for many years. Anecdotal reports of misplacement of life support items, acute lung processes, and extra pulmonary air collections in a small number of patients served as a justification for routine chest radiographs in the ICU. Having analyzed this practice, the ACR Appropriateness Criteria Expert Panel on Thoracic Imaging has made the following recommendations: • When monitoring a stable patient or a patient on mechanical ventilation in the ICU, a portable chest radiograph is appropriate for clinical indications only. • It is appropriate to obtain a chest radiograph after placement of an endotracheal tube, central venous line, Swan-Ganz catheter, nasogastric tube, feeding tube, or chest tube. 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 where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. The strongest data contributing to these recommendations were derived from a meta-analysis of 8 trials comprising 7,078 ICU patients by Oba and Zaza [1].

Imaging plays a key role in the diagnosis and management of complications following lung transplantation. This article outlines the imaging modalities available for evaluation of posttransplant complications with a focus on major indications and key strengths and weaknesses of each modality. A brief description of surgical technique and relevant anatomy is included. Descriptions of some of the more commonly encountered complications are outlined with a focus on imaging findings. Complications are grouped by anatomic or imaging-based findings and subcategorized chronologically to help order the differential diagnosis.

Background and Aim: 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 identifi- cation 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, thrombocytope- nia and splenomegaly. Conclusion: 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.

Melanoma is a common neoplasm with a propensity to metastasize to the heart. Although cardiac metastasis is rarely diagnosed ante mortem, using a multimodality approach, several imaging findings may be seen. Echocardiography is often the initial imaging method used to detect cardiac metastases and their complications. On computed tomography, intraluminal filling defects and myocardial/pericardial nodules may be seen. On magnetic resonance imaging, metastatic melanoma is classically hyperintense on T1 images and hypointense on T2 images, a result of the T1 shortening of melanin; however, this is seen in a minority of cases. As melanoma metastases are fluorine-18-fluorodeoxyglucose avid, fluorine-18-fluorodeoxyglucose positron emission tomography may also be used to detect cardiac metastases.

Rationale and Objectives 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.

Rib fracture is the most common thoracic injury, present in 10% of all traumatic injuries and almost 40% of patients who sustain severe nonpenetrating trauma. Although rib fractures can produce significant morbidity, the diagnosis of associated complications (such as pneumothorax, hemothorax, pulmonary contusion, atelectasis, flail chest, cardiovascular injury, and injuries to solid and hollow abdominal organs) may have a more significant clinical impact. When isolated, rib fractures have a relatively low morbidity and mortality, and failure to detect isolated rib fractures does not necessarily alter patient management or outcome in uncomplicated cases. A standard posteroanterior chest radiograph should be the initial, and often the only, imaging test required in patients with suspected rib fracture after minor trauma. Detailed radiographs of the ribs rarely add additional information that would change treatment, and, although other imaging tests (eg, computed tomography, bone scan) have increased sensitivity for detection of rib fractures, there are little data to support their use. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review process 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.