Bartholmai, Brian J.

Abstract BACKGROUND: Splenectomy is performed for palliating symptoms in patients with primary myelofibrosis (PMF; as well as post essential thrombocythemia myelofibrosis/ post polycythemia myelofibrosis (Mesa et. al. Cancer2006;107(2):361–70). Pre-operative computed tomograms (CTs) of the spleen are frequently performed for estimating spleen size and anatomy, but sometimes raise concern over radiographic splenic masses. We performed a retrospective analysis of splenectomized PMF patients to determine the predictive value of CT in these patients. METHODS: Splenectomized patients, with confirmed PMF (and POST ET/PV MF), with an available pre-operative CT scan were included. Pre-operative CT scans were reviewed in a blinded fashion by a radiologist (B.B.), and histopathology was concurrently reviewed in a blinded fashion by a hematopathologist (C.Y.L.), with attention for radiographic evidence of splenic masses, splenic infarction and hemorrhage, evidence of extra-splenic masses. Additionally splenic volume was calculated by CT through an algorithm using maximal splenic length, width, and slice size (prorated ellipsoid where volume = (30+.58(XxYxZ)). Results from each review were compared and analyzed against clinical outcomes and documented splenic mass. RESULTS: Thirty-eight patients had concurrent CT and splenic pathology available underwent splenectomy for myelofibrosis (20 PMF; median age at diagnosis 64.6 years (range (46–79), 52% males). Splenic volume estimations by CT correlated well with splenic mass measurements. Splenic volume estimation by CT was 2365 CC (range 736–11355 CC), compared with a measured median splenic mass of 2000 mg (range 730–11750 mg) (bivariate analysis p<0.001). Splenic lesions were identified in a total of 33 patients (87%), 10 only by histopathology (30%), 3 only by CT (9%), and 20 by both (61%). Histopathologically 15 patients had localized hemorrhage, 13 had splenic infractions, and 8 had nodular foci of extramedullary hematopoiesis. Only 2 patients had evidence of an alternative malignancy (concurrent chronic lymphocytic leukemia (CLL, n =1) or systemic mast cell disease (n = 1). CT was very sensitive for detecting focal low density lesions (LDLs), which are roughly spherical regions of decreased contrast enhancement in the spleen, and detected the majority of macroscopic lesions. The presence of splenic infarctions histologically was associated with decreased post splenectomy survival (p=0.02; median 7.2 months vs. 15.0 months), however the sensitive (but not specific) presence of LDL lesions by CT did not have prognostic significance. The CT appearance of splenic hemorrhage was nonspecific, and since these areas of parenchymal hemorrhage were likely subacute/chronic, they could not be reliably distinguished from other LDLs. CONCLUSIONS: Pre-operative CT in patients whom undergo palliative splenectomy for myelofibrosis is a sensitive tool for determining the presence of small splenic lesions (hemorrhage, infarction and EMH). Additionally splenic volume estimation by CT, correlates well with measured splenic mass and may assist in operative planning. Splenic lesions in PMF (post ET/PV MF) by CT rarely represented an alternative malignant process, and should likely not be the sole indication for splenectomy. Splenic infarctions were associated with decreased survival after splenectomy, however CT is not always able to distinguish these lesions from EMH and hemorrhage.

Context.— Preanalytic errors, including specimen labeling errors and specimen loss, occur frequently during specimen collection, transit, and accessioning. Radio-frequency identification tags can decrease specimen identification and tracking errors through continuous and automated tracking of specimens. Objective.— To implement a specimen tracking infrastructure to reduce preanalytic errors (specimen mislabeling or loss) between specimen collection and laboratory accessioning. Specific goals were to decrease preanalytic errors by at least 70% and to simultaneously decrease employee effort dedicated to resolving preanalytic errors or investigating lost specimens. Design.— A radio-frequency identification specimen-tracking system was developed. Major features included integral radio-frequency identification labels (radio-frequency identification tags and traditional bar codes in a single printed label) printed by point-of-care printers in collection suites; dispersed radio-frequency identification readers at major transit points; and systems integration of the electronic health record, laboratory information system, and radio-frequency identification tracking system to allow for computerized physician order entry driven label generation, specimen transit time tracking, interval-based alarms, and automated accessioning. Results.— In the 6-month postimplementation period, 6 mislabeling events occurred in collection areas using the radio-frequency identification system, compared with 24 events in the 6-month preimplementation period (75% decrease; P = .001). In addition, the system led to the timely recovery of 3 lost specimens. Labeling expenses were decreased substantially in the transition from high-frequency to ultrahigh frequency radio-frequency identification tags. Conclusions.— Radio-frequency identification specimen tracking prevented several potential specimen-loss events, decreased specimen recovery time, and decreased specimen labeling errors. Increases in labeling/tracking expenses for the system were more than offset by time savings and loss avoidance through error mitigation.

Many lung diseases including interstitial lung disease (ILD) are associated with changes in the lung’s biomechanical properties. ILD comprises a number of serious diseases in which fibrosis stiffens and damages lung tissue. Most ILDs are typically distributed in the lung’s peripheral and subpleural regions. Pulmonary function test (PFT) and high-resolution computed tomography (HRCT) are used to assess ILD. Ultrasonography is not widely used for lung assessment because ultrasound cannot image deep lung tissue. We have developed lung ultrasound surface wave elastography (LUSWE) for measuring superficial lung wave speed. In LUSWE, a 0.1-s harmonic vibration is generated on the chest wall of a subject using a handheld vibrator. An ultrasound probe is aligned with the vibration excitation in the same intercostal space to measure the generated surface wave propagation on the lung. A human subject is examined in a sitting position. The lung is tested at the total lung volume and through six intercostal spaces. Significant differences of surface wave speed between patients and controls were found in 6 lung regions and for 3 excitation frequencies. A positive correlation between LUSWE and clinical tests including HRCT and PTF was found. LUSWE may complement the clinical standard HRCT for assessing ILD.

Objectives The aim of this study was to evaluate if a high-resolution photon-counting detector computed tomography (PCD-CT) system with a 1024×1024 matrix reconstruction can improve the visualization of fine structures in the lungs compared with conventional high-resolution CT (HRCT). Materials and Methods Twenty-two adult patients referred for clinical chest HRCT (mean CTDI vol, 13.58 mGy) underwent additional dose-matched PCD-CT (mean volume CT dose index, 13.37 mGy) after written informed consent. Computed tomography images were reconstructed at a slice thickness of 1.5 mm and an image increment of 1 mm with our routine HRCT reconstruction kernels (B46 and Bv49) at 512 and 1024 matrix sizes for conventional energy-integrating detector (EID) CT scans. For PCD-CT, routine B46 kernel and an additional sharp kernel (Q65, unavailable for EID) images were reconstructed at 1024 matrix size. Two thoracic radiologists compared images from EID and PCD-CT noting the highest level bronchus clearly identified in each lobe of the right lung, and rating bronchial wall conspicuity of third- and fourth-order bronchi. Lung nodules were also compared with the B46/EID/512 images using a 5-point Likert scale. Statistical analysis was performed using a Wilcoxon signed rank test with a P < 0.05 considered significant. Results Compared with B46/EID/512, readers detected higher-order bronchi using B46/PCD/1024 and Q65/PCD/1024 images for every lung lobe (P < 0.0015), but in only the right middle lobe for B46/EID/1024 (P = 0.007). Readers were able to better identify bronchial walls of the third- and fourth-order bronchi better using the Q65/PCD/1024 images (mean Likert scores of 1.1 and 1.5), which was significantly higher compared with B46/EID/1024 or B46/PCD/1024 images (mean difference, 0.8; P < 0.0001). The Q65/PCD/1024 images had a mean nodule score of 1 ± 1.3 for reader 1, and −0.1 (0.9) for reader 2, with one reader having improved nodule evaluation scores for both PCD kernels (P < 0.001), and the other reader not identifying any increased advantage over B46/EID/1024 (P = 1.0). Conclusions High-resolution lung PCD-CT with 1024 image matrix reconstruction increased radiologists' ability to visualize higher-order bronchi and bronchial walls without compromising nodule evaluation compared with current chest CT, creating an opportunity for radiologists to better evaluate airway pathology.