INTRODUCTION:We hypothesized that pneumonitis during Pacific protocol (PDP) contributes to poor outcomes in patients with locally advanced non-small cell lung cancer (LANSCLC) treated with chemoradiation (ChRT) and durvalumab. METHODS:We analysed cases with LANSCLC extracted from a single academic institution database to identify patient, tumour, and treatment characteristics predicting for development of PDP and its effect on oncologic outcomes. RESULTS:Our database review identified 119 patients with LANSCLC that were treated with ChRT and durvalumab. Sixty-five percent were male and had a mean age of 66 years (SD 8); 58% stage IIB-IIIA, and 51% adenocarcinoma. PDP occurred in 35 (29.4%) cases, at a mean 2.6 months from durvalumab initiation (range 0.3-11 months), and was mostly low grade: G1-12, G2-18, G3-3, G4-1, G5-1. PDP resulted in treatment interruption in 24 cases (20%) with treatment discontinuation in 17 cases (14.3%). Multivariate analysis (MVA) showed all-grades PDP correlated with tumour stage, ipsilateral lung V5 ≥ 70%, and mean heart dose (MHD) ≥ 6 Gy. Grades 2-5 PDP correlated with total lungs V20 ≥ 27% and MHD ≥ 6 Gy. PDP did not correlate with a history of prior radiation pneumonitis (RP) (9/119). PDP was associated with decreased 3-year local control (LC) and progression-free survival (PFS); LC 53% vs 75.5% (HR 2.15, P = 0.031); PFS 35.5% vs 56.5% (HR 1.8, P = 0.04); and a trend for shorter overall survival (OS; 66% vs 77.5%, HR 1.5, P = 0.27). CONCLUSION:PDP correlated with ipsilateral lung V5 ≥ 70%, lungs V20 ≥ 27% and MHD ≥ 6 Gy. PDP was associated with inferior LC and PFS and trended for shorter OS. ADVANCES IN KNOWLEDGE:PDP occurred in a third of patients resulting in treatment discontinuation in 14.3%. PDP grades 2-5 correlated with radiation dose to lungs V20 ≥ 27% and MHD ≥ 6 Gy. PDP was associated with inferior LC and PFS and trended for shorter OS.

Pulmonary embolism is commonly associated with deep vein thrombosis and the components of Virchow’s triad: hypercoagulability, stasis, and endothelial injury. High-risk patients are traditionally those with prolonged immobility and hypercoagulability. Recent findings of pulmonary thrombosis (PT) in healthy combat soldiers, found on CT performed for initial trauma assessment, challenge this assumption. The aim of this study was to investigate the prevalence and characteristics of PT detected in acute traumatic war injuries, and evaluate the effectiveness of an artificial intelligence (AI) algorithm in these settings. This retrospective study analyzed immediate post-trauma CT scans of war-injured patients aged 18–45, from two tertiary hospitals between October 7, 2023, and January 7, 2024. Thrombi were retrospectively detected using AI software and confirmed by two senior radiologists. Findings were compared to the original reports. Clinical and injury-related data were analyzed. Of 190 patients (median age 24, IQR (21.0–30.0), 183 males), AI identified 10 confirmed PT patients (5.6

Introduction Multi-disciplinary discussions (MDDs) improve diagnosis and management of interstitial lung disease (ILD). The value of a virtual multi-centre MDD (V-MCMDD) incorporating expertise from multiple institutions remains underexplored. This study aimed to evaluate the impact of a V-MCMDD on diagnosis and management in ILD.Methods We conducted a retrospective multi-centre cohort study involving tertiary and secondary hospital clinics, private practices and community outpatient centres, all participating via a virtual platform. Between August 2020 and June 2023, patient cases were reviewed through V-MCMDDs, which included clinical, radiological, pathological and laboratory data. Each case was discussed to reach a consensus diagnosis and management plan.Results Following the V-MCMDD review, the diagnosis was revised in 51% of patients (p=0.031), and management plans were modified in 41% of cases. A significant shift in treatment was observed in patients with changed diagnoses vs unchanged diagnoses (p value=0.002).Conclusions Our findings suggest that the implementation of V-MCMDDs can be valuable in the diagnostic and therapeutic process for ILD. Incorporating input from multiple centres via a virtual format can lead to significant changes in both diagnosis and management, potentially improving patient outcomes.

There is increased recognition that some lung cancers arise from or are associated with air-filled cystic spaces. Recognition of precursors is important because these are often overlooked and because some of these cancers progress rapidly once a solid component develops. A systematic review suggests that such precursors typically appear as irregular air cysts; these should be distinguished from bullae and smooth round cysts with paper-thin walls that are often seen incidentally with increasing age. Such irregular cysts usually enlarge slowly before developing a ground glass or small solid component or becoming multiloculated. Such change warrants careful surveillance; continued progression of a solid component justifies intervention. Early intervention is associated with good outcomes; survival markedly diminishes if resection occurs when a more substantial solid component has developed.

IntroductionIn 1996, the International Association for the Study of Lung Cancer (IASLC) launched a worldwide TNM staging project to inform the next edition (seventh) of the TNM lung cancer staging system. In this article, we describe the methods and validation approaches used and discuss the internal and external validity of the recommended changes.MethodsThe International Staging Committee agreed on a number of general principles that guided the decision-making process. Internal validity was addressed by visually assessing the consistency of Kaplan-Meier curves across database types, geographic regions and addressing external validity, by assessing the similarity of curves generated using the population-based Surveillance Epidemiology and End Results cancer registry data to those generated using the project database. Cox proportional hazards regression was used to calculate hazard ratios between the proposed stage groupings with adjustment for cell type, sex, age, and region.ResultsCalls for data by the International Staging Committee resulted in the creation of an international database containing information on more than 100,000 cases. The present work is based on analyses of the 67,725 cases of non-small cell lung cancer. Validation checks were robust, demonstrating that the suggested staging changes are stable within the data sources used and externally. For example, suggested changes based on tumor size were well supported, with statistically significant hazard ratios ranging from 1.14 to 1.51 between adjacent pairs in the Surveillance Epidemiology and End Results data.ConclusionsLung cancer stage definitions have never been subjected to such an intense validation process. We do accept, however, that this work is limited in ways that can only be addressed by a prospective database, which we intend to develop. In the meantime, we think that this new system will greatly improve the usefulness of TNM lung staging across all of its purposes.

Imaging plays a key role in clinical staging of lung cancer and guiding therapy. A thorough understanding of the staging system including the nomenclature and updates is necessary to tailor treatment plans and optimize patient care. The 9th edition of the Tumor, Node, Metastasis staging system for lung cancer has no changes for T classification and subdivides N2 and M1c categories. In nodal staging, N2 splits into N2a, ipsilateral mediastinal single station involvement and N2b, ipsilateral mediastinal multiple stations involvement. In the staging of multiple extrathoracic metastases, M1c splits into M1c1, multiple extrathoracic metastases in one organ system and M1c2, multiple extrathoracic metastases in multiple organ systems. Awareness of the proposed changes in TNM-9 staging classification is essential to provide methodical and accurate imaging interpretation.

IntroductionThis study analyzed all metastatic categories of the current tumor, node, and metastasis (TNM) classification of non-small cell lung cancer to propose modifications of the M component in the next edition (9th) of the classification.MethodsA database of 124,581 patients diagnosed between 2011 and 2019 was established; of these, 14,937 with NSCLC in stage IVA-IVB were available for this analysis. Overall survival was calculated using the Kaplan-Meier method, and prognosis assessed using multivariable-adjusted Cox proportional hazards regression.ResultsThe 8th edition M categories demonstrated good discrimination in the 9th edition dataset. Assessments demonstrated that an increasing number of metastatic lesions was associated with decreasing prognosis; because this appears to be a continuum and adjustment for confounders was not possible, no specific lesion number was deemed appropriate for stage classification. Among tumors involving multiple metastases, decreasing prognosis was seen with an increasing number of organ systems involved. Multiple assessments, including after adjustment for potential confounders, demonstrated that patients with M1c patients who had metastases to a single extrathoracic organ system were prognostically distinct from M1c patients who had involvement of multiple extrathoracic organ systems.ConclusionsThese data validate the 8th edition M1a and M1b categories, that are recommended to be maintained. We propose the M1c category be divided into M1c1 (involvement of a single extrathoracic organ system) and M1c2 (involvement of multiple extrathoracic organ systems).

Editor's Note.-RadioGraphics Update articles supplement or update information found in full-length articles previously published in RadioGraphics. These updates, written by at least one author of the previous article, provide a brief synopsis that emphasizes important new information such as technological advances, revised imaging protocols, new clinical guidelines involving imaging, or updated classification schemes.

Lung cancer continues to be the primary cause of cancer-related deaths globally. Precise staging is imperative for the development of successful treatment approaches and improvement of patient outcomes. Traditionally, lung cancer staging has depended on the TNM staging system, and the International Association for the Study of Lung Cancer (IASLC) has recently recommended modifications. The updated classification for the ninth edition of the TNM staging system (TNM-9), slated to take effect in January 2025, is derived from a thorough analysis of a newly established large international database of lung cancer cases compiled by the IASLC. Proposed changes in TNM-9 include the following: (a) The mediastinal nodal category (N2) was split into single-station (N2a) and multiple-station (N2b) subcategories, and (b) multiple extrathoracic metastatic lesions (M1c) were split into single organ system (M1c1) and multiple organ systems (M1c2) subcategories. Considering these revisions, adjustments have been made to the established stage groups. In terms of pathologic nodal staging, patients in the post-neoadjuvant ypN category demonstrated worse prognosis than those in the similar non-neoadjuvant pN category. Understanding the fundamental changes introduced in TNM-9 enables radiologists to precisely determine the clinical stage of lung cancer and enhance therapeutic approaches.

Thymic imaging is challenging because the imaging appearance of a variety of benign and malignant thymic conditions are similar. CT is the most commonly used modality for mediastinal imaging, while MRI and fluorine 18 fluorodeoxyglucose (FDG) PET/CT are helpful when they are tailored to the correct indication. Each of these imaging modalities has limitations and technical pitfalls that may lead to an incorrect diagnosis and mismanagement. CT may not be sufficient for the characterization of cystic thymic processes and differentiation between thymic hyperplasia and thymic tumors. MRI can be used to overcome these limitations but is subject to other potential pitfalls such as an equivocal decrease in signal intensity at chemical shift imaging, size limitations, unusual signal intensity for cysts, subtraction artifacts, pseudonodularity on T2-weighted MR images, early imaging misinterpretation, flow and spatial resolution issues hampering assessment of local invasion, and the overlap of apparent diffusion coefficients between malignant and benign thymic entities. FDG PET/CT is not routinely indicated due to some overlap in FDG uptake between thymomas and benign thymic processes. However, it is useful for staging and follow-up of aggressive tumors (eg, thymic carcinoma), particularly for detection of occult metastatic disease. Pitfalls in imaging after treatment of thymic malignancies relate to technical challenges such as postthymectomy sternotomy streak metal artifacts, differentiation of postsurgical thymic bed changes from tumor recurrence, or human error with typical "blind spots" for identification of metastatic disease. Understanding these pitfalls enables appropriate selection of imaging modalities, improves diagnostic accuracy, and guides patient treatment. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Neural image denoising has proven a powerful approach for both generic and medical image enhancement. In recent years, fully convolutional architectures, followed by GANs, and more recently visual transformers have consecutively defined the state of the art in the field. A critical component to the success of the neural approach is the loss under which the model is trained. In particular, the rich features generated by CNN-based perceptual loss methods have demonstrated strength in leading to a denoised image quality consistent with human perception. In this work, we present a natural evolution of the CNN-based loss wherein transformer-based features are used to define improved perceptual losses. The proposed perceptual transformer losses (PETEL) are validated qualitatively and quantitatively against CNN-based perceptual loss, as well as L 2 and L 1 losses for the training of state-of-the-art network architectures for an ultra-low dose Computed Tomography (CT) denoising task. A dataset of 37 real ultra-low dose - normal dose CT scan pairs is utilized for this purpose. The obtained results suggest that the proposed PETEL are promising losses for the challenging neural denoising of ultra-low dose CT images.

The goal of surgical resection is to completely remove a cancer; it is useful to have a system to describe how well this was accomplished. This is captured by the residual tumor (R) classification, which is separate from the TNM classification that describes the anatomic extent of a cancer independent of treatment. The traditional R-classification designates as R0 a complete resection, as R1 a macroscopically complete resection but with microscopic tumor at the surgical margin, and as R2 a resection that leaves gross tumor behind. For lung cancer, an additional category encompasses situations in which the presence of residual tumor is uncertain. This paper represents a comprehensive review of evidence regarding these R categories and the descriptors thereof, focusing on studies published after the year 2000 and with adjustment for potential confounders. Consistent discrimination between complete, uncertain, and incomplete resection is demonstrated with respect to overall survival. Evidence regarding specific descriptors is generally somewhat limited and only partially consistent; nevertheless, the data suggests retaining all descriptors but with clarifications to address ambiguities. Based on this review, the R-classification for the 9th edition of stage classification of lung cancer is proposed to retain the same overall framework and descriptors, with more precise definitions of descriptors. These refinements should facilitate application as well as further research.

PURPOSE:High volumes of chest radiographs (CXR) remain uninterpreted due to severe shortage of radiologists. These CXRs may be informally reported by non-radiologist physicians, or not reviewed at all. Artificial intelligence (AI) software can aid lung nodule detection. Our aim was to assess evaluation and management by non-radiologists of uninterpreted CXRs with AI detected nodules, compared to retrospective radiology reports.MATERIALS AND METHODS:AI detected nodules on uninterpreted CXRs of adults, performed 30/6/2022-31/1/2023, were evaluated. Excluded were patients with known active malignancy and duplicate CXRs of the same patient. The electronic medical records (EMR) were reviewed, and the clinicians' notes on the CXR and AI detected nodule were documented. Dedicated thoracic radiologists retrospectively interpreted all CXRs, and similarly to the clinicians, they had access to the AI findings, prior imaging and EMR. The radiologists' interpretation served as the ground truth, and determined if the AI-detected nodule was a true lung nodule and if further workup was required.RESULTS:A total of 683 patients met the inclusion criteria. The clinicians commented on 386 (56.5%) CXRs, identified true nodules on 113 CXRs (16.5%), incorrectly mentioned 31 (4.5%) false nodules as real nodules, and did not mention the AI detected nodule on 242 (35%) CXRs, of which 68 (10%) patients were retrospectively referred for further workup by the radiologist. For 297 patients (43.5%) there were no comments regarding the CXR in the EMR. Of these, 77 nodules (11.3%) were retrospectively referred for further workup by the radiologist.CONCLUSION:AI software for lung nodule detection may be insufficient without a formal radiology report, and may lead to over diagnosis or misdiagnosis of nodules.

INTRODUCTION:Pathologists are staging thymic epithelial tumors (TET) according to the 8th UICC/AJCC TNM system. Within the French RYTHMIC network, dedicated to TET, agreement on pathologic tumor stage (pT) among the pathology panelists was difficult. The aim of our study was to determine the interobserver reproducibility of pT at an international level, to explore the source of discrepancies and potential interventions to address these. METHODS:An international panel of pathologists was recruited through the International Thymic Malignancy Interest Group (ITMIG). The study focused on invasion of mediastinal pleura, pericardium, and lung. From a cohort of cases identified as challenging within the RYTHMIC network, we chose a series of test and validation cases (n = 5 and 10, respectively). RESULTS:Reproducibility of the pT stage was also challenging at an international level as none of the 15 cases was classified as the same pT stage by all ITMIG pathologists. The agreement rose from slight (κ = 0.13) to moderate (κ = 0.48) between test and validation series. Discussion among the expert pathologists pinpointed two major reasons underlying discrepancies: 1) Thymomas growing with their "capsule" and adhering to the pleurae, pericardium, or lung were often misinterpreted as invading these structures. 2) Recognition of the mediastinal pleura was identified as challenging. CONCLUSION:Our study underlines that the evaluation of the pT stage of TET is problematic and needs to be addressed in more detail in an upcoming TNM classification. The publication of histopathologic images of landmarks, including ancillary tests could improve reproducibility for future TNM classifications.

Abstract Background Borderline resectable stage III non-small cell lung cancer (NSCLC) poses significant clinical challenges. This study evaluated the outcomes of patients receiving neoadjuvant chemoradiation (NA-CRT), durvalumab, and surgery. Materials and Methods A retrospective analysis of an institutional database identified patients with borderline resectable stage III NSCLC treated with NA-CRT, durvalumab, and completion surgery. The data collected included radiographic and pathologic responses, surgical and clinical outcomes, and adverse events (AEs). Results Between 2017 and2021, 11 patients received NA-CRT, durvalumab, and completion surgery. Patients received a median number of 6 durvalumab treatments. Preoperative imaging revealed partial response (n = 5) or stable disease (n = 6). Surgical procedures included lobectomy (n = 10) or pneumonectomy (n = 1), resulting in R0 resection in all patients. Eight patients (73%) had a pathologic complete response (pCR), and 9 (82%) had a major pathologic response (MPR). At a median follow-up of 27 months, two cases of metastatic recurrence occurred. The median, 1-year, and 2-year estimates of progression-free survival (PFS) and overall survival (OS) were: 23 months and 25 months, 82% and 100%, and 72% and 80% respectively. Univariate analysis revealed no factors associated with pCR, MPR, PFS, or OS. Six patients had immune-related AEs (irAEs), 6 had postoperative AEs, and none were grade 4 or 5. Conclusion This integrated approach of NA-CRT + durvalumab exhibited promising outcomes and tolerability in patients with borderline resectable stage III NSCLC. These results suggest a rationale for including radiation therapy in future trials examining neoadjuvant strategies for resectable NSCLC patients.

INTRODUCTION:An international database was created by the International Association for the Study of Lung Cancer to inform on the ninth edition of the TNM classification of lung cancer. The present analyses concern its T component. METHODS:Data on 124,581 patients diagnosed with lung cancer from January 1, 2011 to December 31, 2019 were submitted to the International Association for the Study of Lung Cancer database. Of these, 33,982 met the inclusion criteria for the clinical T analysis, and 30,715 met the inclusion criteria for the pathologic postsurgical analysis. Survival was measured from the date of diagnosis or operation for clinically and pathologically staged tumors, respectively. T descriptors were evaluated in univariate analysis and multivariable Cox regression analysis adjusted for age, sex, pathologic type, and geographic region. RESULTS:Comprehensive survival analysis revealed that the existing eighth edition T component criteria performed adequately in the ninth edition data set. Although pathologic chest wall or parietal pleura involvement (PL 3) yielded a worse survival compared with the other T3 descriptors, with a similar survival as T4 tumors, this difference was not observed for clinical chest wall or PL 3 tumors. Because of these inconsistent findings, no reallocation of chest wall or PL 3 tumors is advised. CONCLUSIONS:The T subcommittee members proposed not to implement any changes and keep the current eighth-edition T descriptors for the ninth edition.

We report 8 cases of persistent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia in patients previously treated with anti-CD20 monoclonal antibodies. Polymerase chain reaction of nasopharyngeal swabs for SARS-CoV-2 was negative in most cases; viral cell cultures confirmed that viable SARS-Co-2 virus was present. Four patients were treated with anti-SARS-CoV-2 hyperimmune globulins with rapid resolution of disease.

INTRODUCTION:R0 resection and radiation therapy have been associated with improved overall survival (OS) in patients with thymic carcinoma (TC). Here, we analyzed which subgroups of patients derive the greatest benefit from postoperative radiation therapy (PORT). METHODS:Clinical, pathologic, treatment, and survival information of 462 patients with TC from the International Thymic Malignancy Interest Group/European Society of Thoracic Surgeons database were analyzed. Variables included age, sex, continent of treatment, paraneoplastic syndrome, carcinoma subtype, tumor size, pathologic Masaoka stage, resection status, and use of chemotherapy. OS was the primary end point using the Kaplan-Meier method. Time to recurrence (TTR) was the secondary end point using a competing risk analysis. A 3-month landmark analysis was performed. RESULTS:PORT was associated with a significant OS benefit (5-y OS 68% versus 53%, p = 0.002). In patients with R0 resection, PORT was associated with increased OS for advanced (stages III-IV, p = 0.04), but not early (stages I-II, p = 0.14) stage TC. In patients with an R1/2 resection of advanced-stage TC, PORT was associated with significantly longer OS (5-y OS 53% versus 38%; p < 0.001). Subset analyses did not reveal clear associations of PORT with TTR. On multivariable analysis, lower pathologic stage, PORT, and R0 resection status were associated with an OS benefit, whereas only higher age and lower pathologic stage had an association with longer TTR. CONCLUSIONS:In the largest individual patient data set on patients with TC reported to date, PORT was associated with a meaningful OS benefit in patients with advanced-stage TC after an R0 or R1/2 resection.