Thoracic imaging Meeting organised by the East of England Branch of The British Institute of Radiology Friday 15 May 2015 Robinson College, Cambridge 09:00
Registration and refreshments
09:30
Imaging in interstitial lung disease—what the clinician wants to know Dr Helen Parfrey, Consultant ILD Chest Physician, Papworth Hospital NHS Trust
10:00
HRCT in the idiopathic interstitial pneumonias Dr Arjun Nair, Consultant Radiologist, Guy’s & St Thomas’ NHS Foundation Trust
10:30
Imaging in small airway diseases Dr Judith Babar, Consultant Radiologist, Addenbrooke’s Hospital
11:00
Refreshments
11:20
Imaging work-up of incidentally detected lung nodules— new BTS guidelines Dr Nicholas Screaton, Consultant Radiologist, Addenbrooke’s and Papworth Hospitals NHS Trust
11:50
Image guided percutaneous ablative therapy in lung malignancy—how does it compare to the alternatives? Dr Paul Jennings, Consultant Radiologist, Ipswich Hospital
12:200
Current optimal lung cancer staging: tips and tricks Dr Nagmi Qureshi, Consultant Radiologist, Papworth Hospital NHS Trust
12:50
Lunch
Incorporated by Royal Charter Patron - Her Majesty The Queen
President Dr David Wilson MBBS BSc MFSEM FRCP FRCR Chief Executive Ms Jacqueline Fowler BA, MInstF(Cert)
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13:50
What a thoracic surgeon is looking at when you’re looking at the image! Mr Aman Coonar, Consultant Thoracic Surgeon, Papworth Hospital NHS Trust
14:20
Imaging postop chest Dr Angela Tasker, Consultant Radiologist, Papworth Hospital NHS Trust
14:50
Refreshments
15:20
Assessing the heart on thoracic imaging Dr John Curtin, Consultant Radiologist, Norfolk and Norwich University Hospital
15:50
State of the art imaging and controversies in suspected acute pulmonary embolism Dr Sylvia Worthy, Consultant Radiologist, Newcastle University Teaching Hospitals
16:20
Close of meeting
This meeting has been awarded 5 RCR category I CPD credits. Your certificate of attendance will be emailed to you within the next two weeks once you have completed the online survey at: https://www.surveymonkey.com/s/thoracicimaging2015
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Speaker profiles Mr Aman Coonar, Consultant Thoracic Surgeon, Papworth Hospital NHS Trust Appointed Consultant in 2006, Mr Aman S Coonar is Consultant Surgeon and Clinical Lead for Thoracic Surgery at Papworth Hospital. He also works at Addenbrooke’s and East and North Hertfordhsire NHS Trust. He is the Royal College of Surgeons Tutor and a University of Cambridge Senior Clinical Tutor. He is currently President of the Cardiothoracic Section, Royal Society of Medicine. Training included Guy's, St Thomas’, Kings, London Chest, Brompton & Hammersmith. Advanced training came in forms of senior fellowships in general thoracic surgery and lung transplant at Toronto General Hospital. Dr John Curtin, Consultant Radiologist, Norfolk and Norwich University Hospital Dr John Curtin trained in radiology at Northwick Park Hospital, Harrow. He also undertook a one year chest fellowship in USA. He is currently a Consultant Radiologist with an interest in chest and cardiac imaging at the Norfolk and Norwich Hospital. He is currently training programme director at the Norwich Radiology Academy. Dr Paul Jennings, Consultant Radiologist, Ipswich Hospital Dr Paul Jennings trained in radiology at the Middlesex and University College Hospitals, London and is currently a Consultant at Ipswich Hospital and Associate Lecturer, University of Cambridge. Dr Arjun Nair, Consultant Radiologist, Guy’s & St Thomas’ NHS Foundation Trust Dr Arjun Nair was appointed Consultant Radiologist with a sub-specialty interest in cardiothoracic imaging at Guy’s and St Thomas’ NHS Foundation Trust in 2013. Dr Nair qualified from the University of Edinburgh Medical School in 2001 and was awarded the MRCP in 2005. He undertook radiology training at St George’s Hospital between 2005 and 2011, passing the FRCR in 2008. Dr Nair was awarded the Thoracic Imaging Fellowship at the Royal Brompton Hospital between 2011 and 2013, and during this time completed his thesis on “Computed Tomography Reading Strategies in Lung Cancer Screening”, for which he was awarded an MD by the University of Edinburgh in 2014. In the course of his research, Dr Nair has been actively involved in the UK Lung Screen pilot trial. He has presented at various national and international meetings and has been awarded prizes for presentations at the Radiological Society of North America, European Society of Thoracic Imaging and World Congress of Thoracic Imaging. Dr Nair is the author/co-author of several peer-reviewed scientific papers and book chapters on cardiothoracic imaging.
Dr Helen Parfrey, Consultant ILD Chest Physician, Papworth Hospital NHS Trust Dr Helen Parfrey is the Lead for the Cambridge Interstitial Lung Disease Service. After qualifying in medicine from the University of Oxford, she completed her training in respiratory medicine in Cambridge. She was awarded MRC Clinical Training fellowship leading to her PhD at the University of Cambridge. This was followed by Wellcome Trust Intermediate Fellowship undertaken at National Jewish Health in Denver, Colorado, studying the role of TNF in lung injury. She has clinical and translational research interests in the role of innate immunity in pulmonary fibrosis, and the genetics of familial and idiopathic pulmonary fibrosis. Dr Nicholas Screaton, Consultant Radiologist, Addenbrooke’s and Papworth Hospitals Dr Nicholas Screaton is a Consultant Cardiothoracic Radiologist at Papworth Hospital, Cambridge. His special interests include pulmonary hypertension, interstitial and airways diseases, and lung cancer screening. He was Radiology Clinical Director in Papworth Hospital 2004-12 and President of the British Society of Thoracic Imaging 2009-13. He sits on the British Thoracic Society Bronchiectasis Guidelines Development Group, National Institute of Clinical Excellence Idiopathic Pulmonary Fibrosis Quality Standards Committee, National Institute of Clinical Excellence Guidelines Updates Standing Committee, and National Clinical Commissioning Group for Specialised Imaging (stakeholder representative). Dr Angela Tasker, Consultant Radiologist, Papworth Hospital NHS Trust Dr Angela Tasker is a Consultant Cardiothoracic Radiologist at Papworth Hospital, Cambridge. She has a special interest in thoracic oncology including PET/CT. She also has an interest in interstitial and airways diseases and cardiac imaging. She has published papers on cardiothoracic topics. She was Clinical Director at Papworth Hospital from 2001-2004. She has been a longstanding member of the BIR. Dr Sylvia Worthy, Consultant Radiologist, Newcastle University Teaching Hospitals Dr Sylvia Worthy learned the art of thoracic radiology with Professor Nestor Muller in Vancouver, Canada and brought the expertise back to Newcastle, to develop and lead the Thoracic Radiology service at Newcastle upon Tyne Hospitals since 1997. A particular interest has been training the thoracic radiologists of the future and revealing the mysteries of radiology to respiratory physicians, through developing the British Thoracic Society Chest Radiology Course in Newcastle. She has worked with the Royal College of Radiologists nationally on Lung Cancer, is involved in exam question setting for both respiratory medicine and thoracic radiology and leads nationally as a Committee Member of the British Society of thoracic imaging.
Abstracts (where supplied) What a thoracic surgeon is looking at when you’re looking at the image! Mr Aman Coonar Much contemplation has gone on the topic, 'What your surgeon is looking at when you're talking about the radiology'. As part of the preparation he married a radiologist and had a few children. He is therefore well used to all parties looking at the same thing, simultaneously expressing widely different opinions, that sometimes share elements of the truth. Assessing the heart on thoracic imaging Dr John Curtin With faster CT scanners producing thinner slices and better quality images the heart has come into focus over the last decade. It is no longer a blurry blob which we can ignore: routine CT now provides copious anatomical and physiological data on the heart. As a result of these advances, all radiologists are faced with the need to assess the heart on general body CT scans. The heart, however, can present a greater challenge than most organs. I will suggest a system for reviewing it and present a pictorial review of many of the abnormalities readily identifiable on standard, nonECG-gated, CT. We will look at the question of when we should report an abnormality – for example, should we always report the presence of aortic valve calcification, or mitral valve calcification, or coronary artery calcification, or a mid-ascending aorta of more than 4.3 cm in diameter? In addition we will explore the potential value of using incidental findings in the heart as risk predictors for future adverse cardiovascular events. The take home message is simple: Look at the heart! It does require time and energy, but you can detect abnormalities that will make a real difference to patient outcomes. Image guided percutaneous ablative therapy in lung malignancy—how does it compare to the alternatives? Dr Paul Jennings Thermal lung ablation can be used to treat both primary and secondary thoracic malignancies. These techniques offer minimally invasive percutaneous alternatives to traditional surgery and/or radiotherapy, with the potential for less morbidity. Evidence to support their use, particularly for metastases from colorectal tumours, is now strong, with survival data in selected cases approaching that seen after surgery. The Royal College of Radiologists predict that the number of patients who could benefit from such treatment may exceed 5000 per year in the UK. In recent years newer surgical techniques such as thoracoscopic resection have been introduced and technological advances in robotics and linear accelerators with image guidance have led to stereotactic ablative radiotherapy (SABR).
This presentation aims to compare and contrast thermal ablation with these newer methods and discuss the advantages and disadvantages of each. There are no published randomised trials comparing thermal ablation with surgery or SABR, however the results of many series of patients have been published and these will be summarised. Our experience of treating over 300 lesions in 200 patients over a five year period in the Radiology department at Ipswich will be briefly presented and the factors likely to influence the success of ablation will be discussed. Aims: • To provide an overview of percutaneous thermal ablation in lung malignancy and how it compares to the current alternatives Learning outcomes: • Understand the alternatives treatments available for small primary bronchogenic carcinomas and pulmonary oligo-metastatic disease • Understand the practical challenges that may determine the most suitable of the available techniques for individual patients HRCT in the idiopathic interstitial pneumonias Dr Arjun Nair High-resolution CT (HRCT) remains critical to the evaluation of the idiopathic interstitial pneumonias (IIPs), but its role has evolved over the past two decades. An earlier era saw an exhaustive correlation of radiological patterns on HRCT to pathological findings in the IIPs. Consequently, the classification of IIPs has increasingly cemented the role of HRCT as one of the three pillars in the multidisciplinary diagnosis of IIPs, integrating it with clinical and pathological data. Despite this, however, challenges in HRCT interpretation remain, due to variability in interpretation, arising particularly in the context of confounding factors such as age and emphysema. More recently HRCT has also been studied in the longitudinal evaluation and prognostication of these entities. In this session, the role of HRCT in diagnosing IIPs and detecting associated complications is reviewed. Observer variability in interpretation and a suggested approach for tackling cases are described. The principle changes within the updated classification of IIPs, and their implications for imaging are also discussed. Finally, the potential role for HRCT in aiding prognostication is reviewed. Aims: • Provide a summary of the role of HRCT in evaluating IIPs • Discuss the variability in HRCT interpretation of IIPs and the factors that contribute to them • Describe the recently updated classification of IIPs and their implications for imaging Learning outcomes: • Recognise the correlations between HRCT patterns and pathological diagnosis • Develop a systematic approach to the evaluation of IIPs
•
Appreciate the extent of inter- and intra-observer variability that can be encountered in HRCT interpretation.
Imaging in interstitial lung disease – what the clinician wants to know Dr Helen Parfrey The idiopathic interstitial pneumonias (IIP) represent a group of interstitial lung diseases (ILD) typically characterised by inflammation and/or progressive scarring of the alveolar interstitium. This can lead to significant morbidity and mortality due to hypoxaemic respiratory failure. Although some forms of pulmonary fibrosis are associated with occupational and environmental exposures, collagen vascular disease and drug toxicity, many have no known aetiology. The commonest of the IIPs is idiopathic pulmonary fibrosis (IPF), which has by far the worst prognosis with a median survival of 3 years from diagnosis. It is defined by a radiological and/or pathological pattern of usual interstitial pneumonia (UIP). However, UIP is not synonymous with IPF as other conditions may be associated with UIP, including chronic hypersensitivity pneumonitis, collagen vascular disease, amiodarone toxicity, asbestosis, familial IPF and Hermansky–Pudlak syndrome. Determining the likely cause or association of the IIP presents a diagnostic challenge to the physician since their clinical, radiological and histological characteristics may be non-specific. This is particularly relevant for IPF as over 40% of cases do not have pathognomonic radiological features. In addition, radiological and histological clues may help to distinguish IPF from other conditions with UIP pattern of pulmonary fibrosis. However, their appreciation requires expertise in interstitial lung disease provided by an integrated multidisciplinary approach involving pulmonologists, radiologists and pathologists. Given the diversity in disease behaviour, determining the likely cause of the ILD is critical for therapeutic decision making and being able to provide accurate prognostic information. Learning objectives • •
Understanding the key role of the multidisciplinary team approach in the assessment of a patient with interstitial lung disease, particularly suspected IPF and cases with discordant radiological and histological features. How to differentiate IPF from other causes of UIP pattern pulmonary fibrosis.
Imaging work-up of incidentally detected lung nodules – new BTS guidelines Dr Nicholas Screaton Incidental detection of lung nodules is an increasingly frequent occurrence with the proliferation of MDCT. Our understanding of both clinical and imaging risk factors for lung cancer have been enhanced in recent years largely from the lung cancer screening literature. There is need to have clear guidelines for management of incidentally detected lung nodules to standardise care and limit over investigation. The Fleischner Society issued guidelines for the management of solid lung nodules in 2005. More recently following the reclassification of lung adenocarcinoma in 2011 the Fleischner Society released recommendations for the management of subsolid pulmonary nodules detected at CT in 2013.
Given the rapid developments in our understanding of this area (including clinical risk model development), benign imaging characteristics, and in technology (volumetric nodule evaluation) the British Thoracic Society will in June 2015 release evidence based UK guidelines for the assessment of incidentally detected lung nodules. These are likely to have significant implications for years to come both within radiology and chest medicine. An outline of these guidelines will be presented. Broadly as in previous guidelines nodules are broken down by characteristics into 3 categories – one benign to be ignored; one low to intermediate risk to be followed; and finally a high risk group for which active work-up is required. The guidelines include several new features. Firstly a clear definition of intrapulmonary lymph node characteristics as benign nodule features. For the assessment of nodule growth evaluation of volume doubling time with nodule volumetry software packages is recommended though not mandated given its greater objectivity and sensitivity to change. Volume doubling time helps direct further management whether this be discharge, follow-up, or active work-up. Additionally 2 validated risk prediction models are recommended. The Brock model is recommended for initial risk assessment of pulmonary nodules (≥5mm or ≥80mm3) and if the risk of lung cancer is >10% on this basis active work-up is followed. Within the active work-up process use of the Herder tool which incorporates PET-CT characteristics is recommended to stratify patients towards either observation/biopsy or radical treatment. State of the art imaging and controversies in suspected acute pulmonary embolism Dr Sylvia Worthy The presentation covers some of the current controversies in imaging suspected acute PE, and considers factors important in investigation pathways, image reporting and patient management. Learning outcomes To understand current knowledge of: • Guidelines • Risk stratification • Are all clots equally important? • Too many CTPAs? • State of the art imaging • What’s new in patient management? • PE in pregnancy
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