Perfusion Lung Scan Research Articles

Hepatopulmonary Syndrome in Children: A 20-Year Review of Presenting Symptoms, Clinical Progression, and Transplant Outcome.

Hepatopulmonary syndrome (HPS) in stable patients with cirrhosis can easily be overlooked. We report on the presenting symptoms, disease progression, and outcomes after liver transplantation (LT) in children with HPS. Twenty patients were diagnosed with HPS between 1996 and 2016. The etiologies were as follows: biliary atresia (n = 9); alpha-1-antitrypsin deficiency (n = 2); cryptogenic liver disease (n = 3); and others (n = 6). HPS presentations were as follows; dyspnea (n = 17) and pneumonia (n = 3). For diagnostic confirmation, the following techniques were used: technetium-99m-labeled macroaggregated albumin lung perfusion scan (n = 13) or contrast echocardiogram (n = 7). There were 16 patients listed for LT, with a median age at HPS diagnosis of 10 years and an average wait from listing to LT of 9 weeks. A marked rise in hemoglobin (Hb; median, 125-143.5 g/L) and modest decrease in oxygen saturation (SpO2 ; median 91% to 88% room air) were evident over this time. Patients' need for assisted ventilation (1 day), pediatric intensive care unit (PICU) stay (3 days), and total hospital stay (20 days) were similar to our general LT recipients-the key difference in the postoperative period was the duration of supplementary O2 requirement. Hb of ≥130 g/L on the day of LT correlated with a longer PICU stay (P value = 0.02), duration of supplementary O2 (P value = 0.005), and the need for the latter beyond 7 days after LT (P value = 0.01). Fifteen patients had resolution of their HPS after LT. The 5-, 10-, and 20-year survival rates were unchanged at 87.5%. None had a recurrence of HPS. In conclusion, HPS is a life-threatening complication of cirrhosis which usually develops insidiously. This combined with the often-stable nature of the liver disease leads to delays in diagnosis and listing for LT. Progressive polycythemia extends the need for supplementary O2 and PICU stay. We advocate screening for HPS with a combination of SpO2 and Hb monitoring to facilitate earlier recognition, timely LT, and shortened recovery periods.

Validation of the Predictive Model of the European Society of Cardiology for Early Mortality in Acute Pulmonary Embolism.

Background Acute pulmonary embolism (PE) is burdened by high mortality, especially within 30 days from the diagnosis. The development and the validation of predictive models for the risk of early mortality allow to differentiate patients who can undergo home treatment from those who need admission into intensive care units. Methods To validate the prognostic model for early mortality after PE diagnosis proposed by the European Society of Cardiology (ESC) in 2014, we analyzed data of a cohort of 272 consecutive patients with acute PE, observed in our hospital during a 10-year period. Moreover, we evaluated the additional contribution of D-dimer, measured at PE diagnosis, in improving the prognostic ability of the model. All cases of PE were objectively diagnosed by angiography chest CT scan or perfusion lung scan. Results The overall mortality rate within 30 days from PE diagnosis was 10% (95% confidence interval [CI]: 6.4–13.5%). According to the ESC prognostic model, the risk of death increased 3.23 times in the intermediate-low-risk category, 5.55 times in the intermediate-high-risk category, and 23.78 times in the high-risk category, as compared with the low-risk category. The receiver operating characteristic analysis showed a good discriminatory power of the model (area under the curve [AUC] = 0.77 [95% CI: 0.67–0.87]), which further increased when D-dimer was added (AUC = 0.85 [95% CI: 0.73–0.96]). Conclusion This study represents a good validation of the ESC predictive model whose performance can be further improved by adding D-dimer plasma levels measured at PE diagnosis.

Hepatopulmonary syndrome

Hepatopulmonary syndrome

Repair of Ductus or Hemi-Truncus to One Lung and Major Aortopulmonary Collaterals to the Other Lung

There are patients born with pulmonary atresia and a ductus arteriosus or hemi-truncus to one lung and major aortopulmonary collateral arteries (MAPCAs) to the contralateral lung. The purpose of this study was to review our surgical results for this relatively rare subset of patients. This was a retrospective review of 35 patients with ductus/hemi-truncus in association with pulmonary atresia with ventricular septal defect and MAPCAs. Our surgical algorithm is bifurcated into two strategies: (1)patients with "favorable" MAPCAs are candidates for single stage complete repair, and (2) patients with "unfavorable"MAPCAs undergo a staged approach. The median age at surgery was 3 months (range, 1 to 7 months), and the mean number of MAPCAs was 3.1 ± 1.3. Twenty patients underwent a single stage complete repair. All 20 of these patients are alive with a right ventricle to aortic pressure ratio of 0.34 ± 0.07. The distribution of pulmonary blood flow by lung perfusion scan was 44% to the right and 56% to the left lung. Fifteen patients underwent a staged approach, including unifocalization of the MAPCAs to a central shunt. There were 2 interim deaths. Twelve patients have undergone complete repair with a right ventricle to aortic pressure ratio of 0.38 ± 0.07. There was 1 late death after complete repair. The distribution of pulmonary blood flow was 39% to the right and 61% to the left lung. The data demonstrate that 32 of 35 patients with ductus/hemi-truncus and MAPCAs ultimately achieved complete repair with relatively low pulmonary artery pressures.

Hepatopulmonary syndrome caused by hypothalamic obesity and nonalcoholic fatty liver disease after surgery for craniopharyngioma: a case report

Hypothalamic obesity is often complicated in patients with craniopharyngioma due to hypothalamic damage by the tumor itself, treatment modalities, and associated multiple pituitary hormone deficiency. Hypothalamic obesity causes secondary diseases such as nonalcoholic fatty liver disease (NAFLD) and diabetes mellitus (DM). We report a 19-year-old female who was diagnosed with craniopharyngioma, developed hypothalamic obesity after tumor resection, and progressed to hepatopulmonary syndrome. She manifested NAFLD 1 year after tumor resection. Two years later, the craniopharyngioma recurred, and she underwent a second resection. Three years after her second operation, she was diagnosed with type 2 DM, after which she did not visit the outpatient clinic for 2 years and then suddenly reappeared with a weight loss of 25.8 kg that had occurred over 21 months. One month later, she presented to the Emergency Department with dyspnea. Laboratory findings revealed liver dysfunction and hypoxia with increased alveolar artery oxygen gradient. Liver biopsy showed portal hypertension and micronodular cirrhosis. Echocardiography and a lung perfusion scan demonstrated a right to left shunt. She was finally diagnosed with hepatopulmonary syndrome and is currently awaiting a donor for liver transplantation. Patients surviving craniopharyngioma need to be followed up carefully to detect signs of hypothalamic obesity and monitored for the development of other comorbidities such as DM, NAFLD, and hepatopulmonary syndrome.

Clinical prediction score for identifying patients with pulmonary veno-occlusive disease/pulmonary capillary hemangiomatosis

BackgroundPulmonary veno-occlusive disease (PVOD) and pulmonary capillary hemangiomatosis (PCH) are rare causes of pulmonary hypertension. Although diagnosis is based on pathological findings, an early diagnosis is crucial because of poor prognosis compared to other types of pulmonary hypertension. Furthermore, vasodilators may cause fatal pulmonary edema in patients with PVOD/PCH. This study aimed to identify specific characteristics for patients with PVOD/PCH to clinically diagnose PVOD/PCH. MethodsClinical data were obtained at baseline and were compared between 19 patients with PVOD/PCH and 55 patients with idiopathic/heritable pulmonary arterial hypertension. Receiver operating characteristic analyses were used to determine characteristics specific for patients with PVOD/PCH and a scoring system to diagnose PVOD/PCH was developed. ResultsPatients with PVOD/PCH had a smoking history and were predominantly male. Six-minute walk distance was significantly lower and oxygen desaturation was severe during the walk. Diffusion capacity of carbon monoxide was significantly low. Radiological findings included ground glass opacity on chest high-resolution computed tomography (CT) in all patients with PVOD/PCH, and thickened septal lines in 90% of the patients. Lung perfusion scintigraphy showed defect in >70% of the patients. Pulmonary edema after initiation of vasodilation therapy was frequently observed in PVOD/PCH patients. Based on these results, we identified nine important clinical characteristics and a novel scoring system was designed to clinically diagnose PVOD/PCH: male sex, smoking history, 6-minute walk distance<285m, minimum SpO2<92% during the 6-minute walk test, %DLco<34%, ground glass opacity and thickening of the interlobular septa in high-resolution CT, defects in the perfusion lung scan, and pulmonary edema due to vasodilators. Score≥5 points had 95% sensitivity and 98% specificity to predict PVOD/PCH (area under the curve: 0.991; 95% CI: 0.976–1.000). ConclusionsOur novel prediction rule for diagnosing PVOD/PCH may offer an early clinical diagnosis of these diseases.

Pulmonary hypertension in congenital diaphragmatic hernia patients: Prognostic markers and long-term outcomes.

A single center retrospective chart review was performed for CDH neonates from January 1, 2006, to December 31, 2015, (REB #1000053124) to include prenatal O/E LHR, liver position, first arterial blood gas, repair type, echocardiogram (ECHO), and lung perfusion scan (LPS) results up to 5years of age. Of 153 newborns, 123 survived (80.4%), 58 (37.9%) had prenatal O/E LHR, and 42 (27.5%) had postnatal ECHO results. High mortality risk neonates (O/E LHR ≤45%) correlated with higher right ventricular systolic pressure (RVsp) at birth. Generally PH resolved by age 5years. LPS results did not change over time (p>0.05) regardless of initial PH severity, suggesting that PH resolution did not correlate with increased ipsilateral lung perfusion to offload the right ventricle. Prenatal prognostic markers correlated with initial PH severity for CDH newborns, but PH resolved over time despite fixed perfusion bias to the lungs. These results suggest favorable PH outcomes for CDH patients who survive beyond infancy. Retrospective Cohort Study. 3b.

Development of early reperfusion after the first episode of acute pulmonary embolism

IntroductionFactors influencing the early reperfusion after pulmonary embolism (PE), with possible impact on development of chronic thromboembolic disease and chronic thromboembolic pulmonary hypertension (CTEPH), have not been completely identified yet. Study population and methodsThe total of 85 patients hospitalized with the first episode of acute PE underwent a ventilation–perfusion lung scan before hospital discharge. The reperfusion was evaluated based on clinical, echocardiographic and laboratory parameters. ResultsThe study population consisted of 37 men and 48 women, mean age 60 years. A high-risk PE was present in 9.4% of patients, medium-risk PE in 49.4% and low-risk PE in 41.2% of patients. 26 (30.5%) of patients were diagnosed with provoked pulmonary embolism. Prior to discharge, the residual perfusion defects were detectable in 66 patients, in 18 patients the perfusion was normal. The two groups did not significantly differ in clinical, echocardiographic or laboratory parameters. ConclusionThe analysis did not identify risk factors significantly associated with the absence of early reperfusion of the PE. This points toward the need of further follow-up of patients after a PE with the aim of identifying the patients with the high risk of developing the chronic thromboembolic disease and CTEPH.

Which is the optimal threshold for defining functional lung in single-photon emission computed tomography lung perfusion imaging of lung cancer patients?

The aim of this study was to investigate the optimal threshold for the functional lung (FL) definition of single-photon emission computed tomography (SPECT) lung perfusion imaging. Forty consecutive stage III non-small-cell lung cancer patients underwent SPECT lung perfusion scans and PET/CT scans for treatment planning, and the images were coregistered. Total lung and perfusion lung volumes corresponding to 10, 20, …, 60% of the maximum SPECT count were segmented automatically. The SPECT-weighted mean lung dose (SWMDx%) and the percentage of FL volume receiving more than 20 Gy (Fx%V20) of different thresholds were investigated using SPECT-weighted dose-volume histograms. Receiver-operator characteristic curves were used to identify SWMD and FV20 of different thresholds in predicting the incidence of radiation pneumonitis (RP). Eleven (27.5%) patients developed RP (grades 1, 2, 3, and 4 were 10.0, 7.5, 7.5, and 2.5%, respectively) after treatment. The largest area under the receiver-operator characteristic curve was 0.881 for the ability of SWMD to predict RP with 20% as the threshold and 0.928 for the ability of FV20 with 20% as the threshold. The SWMD20% and FV20 of FL using 20% of the maximum SPECT count as the threshold may be better predictors for the risk of RP.

Role of perfusion defects at follow-up lung scan in predicting recurrences after a first episode of symptomatic pulmonary embolism: a retrospective analysis.

: The optimal duration of anticoagulant therapy after a first episode of unprovoked pulmonary thromboembolism is not fully defined. The identification of patients more prone to recurrence would be useful in this context but is currently relatively unreliable. Perfusion lung scan (PLS) is an established approach for the follow-up of patients with pulmonary embolism to identify recurrences and to help in the diagnosis of chronic thromboembolic pulmonary hypertension. The aim of the study was to investigate the potential role of residual perfusion defects at follow-up perfusion scans in predicting pulmonary embolism recurrences. We retrospectively analyzed PLSs of 252 patients with a first episode of unprovoked, symptomatic pulmonary embolism. The agreement between two experienced readers, as assessed by the kappa test, was good, with kappa indices ranging from 0.84 (baseline scan) to 0.98 (last prerecurrence available scan). Sixteen patients developed a late (at least 1 month from the index episode) recurrence identified through the appearance of (a) new perfusion defect(s) not matching radiograph alterations. When patients were divided based on the presence or absence of at least two unperfused segments at the 6-month follow-up lung scan, the probability of recurrence was significantly higher in the latter (P = 0.03 by log-rank test). The use of persistent perfusion defects at follow-up PLS as a guide to determine optimal duration of anticoagulant therapy after a first, unprovoked episode of acute pulmonary thromboembolism is a viable strategy that should be further investigated.

Evaluation of differential pulmonary perfusion using 99mTc macroaggregated albumin after the Fontan procedure.

The Fontan procedure [total cavopulmonary connection (TCPC)] is the final palliation for patients with univentricular physiology. We studied differential perfusion ratio and percentage uptake of a radiotracer in different zones of each lung following TCPC. Between July 2015 and June 2017, 45 patients underwent 99mTc macroaggregated albumin lung perfusion scan at a mean follow-up period of 49.3 ± SD 26.1 days following TCPC. Differential perfusion ratio and percentage uptake of the radiotracer in the upper, middle and lower zones of each lung were calculated. Post-foot injection [inferior vena cava (IVC) injection], preferential flow to the lungs was as follows: left lung (n = 13, 30.2%), right lung (n = 13, 30.2%) and uniformly to both lungs (n= 17, 39.6%). Post-arm injection [superior vena cava (SVC) injection], preferential flow to the lungs was as follows: left lung (n = 13, 30.2%), right lung (n = 22, 51.2%) and uniformly to both lungs (n= 8, 18.6%). The middle zone was perfused the most in both lungs. Total lower zone mean perfusion was higher than the upper zone following both SVC injection and IVC injection (34.1 ± SD 5.3% vs 17. ± SD 4.1% and 33 ± SD 5.0% vs 17.5 ± SD 4.1%, respectively). In patients with bilateral SVC, post-IVC injection, 6 (75%) patients had preferential flow to the right lung, whereas post-SVC injection, preferential flow to the left lung was visualized in 7 (87.5%) patients. Following TCPC, IVC blood was distributed uniformly in both lungs. SVC blood preferentially perfused the right lung. The middle zone was perfused the most in both lungs.

Does tranexamic acid increase the risk of thromboembolism after bilateral simultaneous total knee arthroplasties in Asian Population?

To ascertain whether tranexamic acid reduces the blood loss and transfusion rate and volumes; increase the prevalence of deep vein thrombosis (DVT); and investigate factors associated with DVT in patients undergoing primary bilateral total knee arthroplasties (TKAs) without use of chemical thromboprophylaxis. There were 874 patients (1748 knees) in the control group who did not receive tranexamic acid and 871 patients (1742 knees) in the study group who received tranexamic acid. Mechanical compression device was applied without any chemical thromboprophylaxis. Transfusion rates and volumes were recorded. DVT was diagnosed using both sonogram and venogram at 7 or 8day post-operatively. Intra- and post-operative blood loss and transfusion volumes were significantly lower in the tranexamic acid group. The prevalence of DVT was 14% (245 of 1748 knees) in the control group and 18% (314 of 1742 knees) in the tranexamic acid group. Pre- and post-operative perfusion lung scans revealed no evidence of PE in any patients in either group. Coagulation or thrombophilic data or molecular genetic testing was not significantly different between the two groups. The use of tranexamic acid reduces the volume of blood transfusion and does not increase the prevalence of DVT or PE in the patients who did not receive routine chemical thromboprophylaxis after primary bilateral simultaneous sequential TKAs in Asian patients.

Single Lung Transplant Complicated by Anastomotic Pulmonary Artery Stenosis

SESSION TITLE: Transplantation SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Anastomotic pulmonary artery stenosis after lung transplantation is a rare complication. Endovascular stenting appears to be a safe and efficacious treatment modality1. CASE PRESENTATION: A 43-year-old female with COPD underwent a single left lung transplant. Four months post-transplant, she presented with progressive hypoxic respiratory failure. CT chest showed a new ill-defined 2.2 x 2.1 cm nodular opacity in the left lower lobe graft shown in Figure 1. Transbronchial biopsy was negative for rejection. Bronchoalveolar lavage showed Aspergillus antigen index of 7.56 and culture grew 1 colony of non-sporulating filamentous fungus. CT-guided biopsy of the lesion showed necrotic lung parenchyma. She was treated empirically with intravenous and inhaled Amphotericin B. Despite treatment, her respiratory failure worsened and she became heated high flow oxygen dependent. Quantitative nuclear lung perfusion scan showed an overall perfusion to the right native lung was calculated to be 77.04% with overall perfusion to the left graft lung calculated to be 22.96%. Right heart angiography confirmed significant stenosis of the left pulmonary artery shown in Figure 2. Placement of a 26 mm x 12 mm LD Mega stent resulted in minimal residual stenosis. Repeated nuclear lung perfusion showed overall perfusion of left graft lung increased to 57.34%. She was eventually discharged home on room air. DISCUSSION: Pulmonary artery stenosis is a rare complication after lung transplantation. It requires a high index of suspicion especially after ruling out rejection and infection etiologies. Open repair carries high mortality and morbidity risk. To date, there have been a few case reports and retrospective studies to support the safety and efficacy of percutaneous endovascular stent placement2. Our patient tolerated the procedure well and had significant clinical improvement. CONCLUSIONS: Percutaneous endovascular stent placement is gaining acceptance as the first choice treatment for pulmonary artery stenosis following lung transplant since it is better tolerated than open repair. It appears to be safe and efficacious. However, long-term outcomes are not clear at this point. Reference #1: Grubstein A et al. Angioplasty using covered stents in five patients with symptomatic pulmonary artery stenosis after single-lung transplantation. Cardiovasc Intervent Radiol, 2014; 37: 686-690. Reference #2: Anaya-Ayala JE et al. Endovascular management of early lung transplant-related anastomotic pulmonary artery stenosis. J Vasc Interv Radiol, 2015; 26: 878-882. DISCLOSURE: The following authors have nothing to disclose: Van Le, Amy Pope-Harman No Product/Research Disclosure Information

Impact of residual pulmonary obstruction on the long-term outcome of patients with pulmonary embolism

The impact of residual pulmonary obstruction on the outcome of patients with pulmonary embolism is uncertain.We recruited 647 consecutive symptomatic patients with a first episode of pulmonary embolism, with or without concomitant deep venous thrombosis. They received conventional anticoagulation, were assessed for residual pulmonary obstruction through perfusion lung scanning after 6 months and then were followed up for up to 3 years. Recurrent venous thromboembolism and chronic thromboembolic pulmonary hypertension were assessed according to widely accepted criteria.Residual pulmonary obstruction was detected in 324 patients (50.1%, 95% CI 46.2-54.0%). Patients with residual pulmonary obstruction were more likely to be older and to have an unprovoked episode. After a 3-year follow-up, recurrent venous thromboembolism and/or chronic thromboembolic pulmonary hypertension developed in 34 out of the 324 patients (10.5%) with residual pulmonary obstruction and in 15 out of the 323 patients (4.6%) without residual pulmonary obstruction, leading to an adjusted hazard ratio of 2.26 (95% CI 1.23-4.16).Residual pulmonary obstruction, as detected with perfusion lung scanning at 6 months after a first episode of pulmonary embolism, is an independent predictor of recurrent venous thromboembolism and/or chronic thromboembolic pulmonary hypertension.

Changes in Patterns of 99mTc-Macroaggregated Albumin Use Between 2000 and 2015.

Since the early 2000s, the method of evaluating pulmonary embolism has shifted from 99mTc-macroaggregated albumin (MAA) perfusion lung scans to CT angiography. 99mTc-MAA continues to be applied for patients with contraindications to CT angiography and for other uses. A reduced number of 99mTc-MAA particles is administered to patients with pulmonary hypertension or other risk factors. This study assessed the changing patterns of 99mTc-MAA use between 2000 and 2015 at a single institution by comparing snapshots of the procedures performed in those two years. Methods: Records for all patients receiving 99mTc-MAA in 2000 and 2015 were reviewed, making note of the type of imaging procedure, whether there was any contraindication to CT angiography, and whether a reduced number of 99mTc-MAA particles was administered. Results: In 2000, 99mTc-MAA was used for 489 lung scans for pulmonary embolism, 2 for peritoneovenous shunts, and 1 for a cardiac shunt. Of the lung scan patients, 46 (9%) had pulmonary hypertension. A reduced number of particles was administered to the pulmonary hypertension and cardiac shunt patients (47/492, or 9%). In 2015, 99mTc-MAA was used for 263 lung scans for pulmonary embolism, 33 for presurgical planning, 33 for patients with a lung transplant, 16 for pulmonary artery stenosis, 5 to determine hepatic artery microsphere eligibility, and 1 for a peritoneovenous shunt. Of the lung scans for pulmonary embolism, 256 of the 263 patients (97%) had a contraindication to CT angiography or a nondiagnostic CT angiogram, including 99 (38%) with pulmonary hypertension. A reduced number of particles was administered to the pulmonary hypertension patients, presurgical patients, and lung-transplant patients (165/351, or 47%). Conclusion: Comparing 2015 with 2000, lung scans for pulmonary embolism decreased 46%, from 489 to 263, apparently because of a shift to CT angiography, whereas other uses rose from 3 to 88. Administration of a reduced number of particles rose significantly from 9% to 47% of 99mTc-MAA doses. Although the total number of 99mTc-MAA doses dropped 29%, from 492 to 351, 99mTc-MAA remains an important radiopharmaceutical for both pulmonary embolism and other uses.

(1240) - Value of Portable Perfusion Scans in the Immediate Post-Operative Period Following Lung Transplantation

The lung allograft is dependent on the vascular supply to the transplanted lung which may be compromised during the surgical procedure. Arterial blood gases and portable chest x-rays may be poor predictors of the vascular supply in the immediate post-operative period. Perfusion lung scans may non-invasively assess the perfusion and physiological function in the immediate post-operative period and detect reversible vascular problems. The aim of this study was to illustrate the use and impact of the perfusion scan in the immediate post-operative period.

(368) - Lessons Learned from the First Clinical Trial to Compare Outcomes of Lungs Transplanted from Uncontrolled Donation After Circulatory Determination of Death Donors (uDCDDs) Assessed by Ex-Vivo Lung Perfusion (EVLP) and CT Scan and Lungs Transplanted from Conventional Donors (CONV)

We obtained an Investigational Device Exemption (IDE) from the FDA and IRB approval to conduct a Phase II clinical trial to compare outcomes of lungs transplanted from uDCDDs to lungs transplanted from CONV donors.

Morbidity, Mortality and Costs Associated with Venous Thromboembolism in Hospitalized Patients with Cancer

Background: Venous thromboembolism (VTE) represents a leading cause of morbidity and mortality among hospitalized patients with cancer. Methods: Hospitalization data reported on adult cancer patients at US academic medical centers and affiliated hospitals between 1995 and 2012 were analyzed. Cancer diagnosis, presence of VTE, comorbidities and complications were based on ICD-9-CM codes. Major comorbidities considered were diabetes, and cerebrovascular, peripheral-vascular, heart, liver, and lung renal disease. In patients with multiple hospitalizations during the time period, a randomly selected hospitalization was utilized in the analysis. Hospitalization cost estimates were inflation adjusted to 2015 US dollars. Results: Nearly 6 million hospitalizations of 3,146,388 individual patients with cancer from more than 200 institutions were evaluated. VTE was reported in 8.4% of patients when all admissions are considered during the time period. When a single selected hospitalization is considered for each patient, VTE was reported in 166,547 (5.3%) of individual patients including 56,125 (1.8%) with pulmonary embolism (PE). The annual rate of VTE increased progressively from 3.5% in 1995 to over 6.5% in 2012 with the rate of PE nearly tripling from 0.8% in 1995 to 2.3% in 2012. For hospitalized patients receiving cancer chemotherapy, the annual rate of VTE more than doubled from 3.6% in 1995 to 8.3% in 2012. VTE was reported in 5.2%, 5.8% and 5.4% of patients with solid tumors, lymphoma, and leukemia, respectively (Table). Rates of VTE were greatest among patients with pancreatic (10.2%), gastric (7.1%) or other abdominal malignancies except colorectal cancer (9.2%) as well as those with ovarian (7.1%), lung (6.8%) and esophageal cancers (6.3%). The risk of VTE increased progressively from 2.3% in those with no comorbidities to over 11% for patients with 4 or more comorbid conditions. The strongest risk factors for VTE were infectious complications including sepsis (14%), invasive candidiasis (16%), pneumonia (11%) and IV line infections (14%).During this same time period, imaging related to VTE actually decreased with significantly lower rates of CT, vascular ultrasound and ventilation perfusion lung scans reported. In-hospital mortality was reported in 5.5% of cancer patients without VTE and in 15.0% of those with VTE including 19.4% of those with pulmonary embolism. In-hospital mortality during this time period decreased by approximately one-third in cancer patients both with and without VTE. While reported rates of VTE increased, the length of hospital stay shortened for patients with as well as without VTE during this period. Average costs per hospitalization adjusted to 2015 dollars for patients with and without VTE were $37,352 and $19,994, respectively. The estimated average inflation adjusted daily cost of hospitalization for patients with cancer and VTE increased nearly 50% between 1995 ($2,256) and 2012 ($3,297). Conclusions: VTE reported among hospitalized patients with cancer has increased significantly during the period of observation along with the cost of hospitalization while in-hospital mortality and imaging rates have decreased. However, patients with additional major medical comorbidities are at exceptionally high risk of serious complications including in-hospital mortality. Disclosures Lyman: Amgen: Research Funding. Kuderer:Janssen Scientific Affairs, LLC: Consultancy, Honoraria.

Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope

BackgroundThe prevalence of pulmonary embolism among patients hospitalized for syncope is not well documented, and current guidelines pay little attention to a diagnostic workup for pulmonary embolism in these patients.MethodsWe performed a systematic workup for pulmonary embolism in patients admitted to 11 hospitals in Italy for a first episode of syncope, regardless of whether there were alternative explanations for the syncope. The diagnosis of pulmonary embolism was ruled out in patients who had a low pretest clinical probability, which was defined according to the Wells score, in combination with a negative d-dimer assay. In all other patients, computed tomographic pulmonary angiography or ventilation–perfusion lung scanning was performed.ResultsA total of 560 patients (mean age, 76 years) were included in the study. A diagnosis of pulmonary embolism was ruled out in 330 of the 560 patients (58.9%) on the basis of the combination of a low pretest clinical probability of pulmonary embolism and negative d-dimer assay. Among the remaining 230 patients, pulmonary embolism was identified in 97 (42.2%). In the entire cohort, the prevalence of pulmonary embolism was 17.3% (95% confidence interval, 14.2 to 20.5). Evidence of an embolus in a main pulmonary or lobar artery or evidence of perfusion defects larger than 25% of the total area of both lungs was found in 61 patients. Pulmonary embolism was identified in 45 of the 355 patients (12.7%) who had an alternative explanation for syncope and in 52 of the 205 patients (25.4%) who did not.ConclusionsPulmonary embolism was identified in nearly one of every six patients hospitalized for a first episode of syncope. (Funded by the University of Padua; PESIT ClinicalTrials.gov number, NCT01797289.)

Decreased Lung Perfusion After Breast/Chest Wall Irradiation: Quantitative Results From a Prospective Clinical Trial

To quantify lung perfusion changes after breast/chest wall radiation therapy (RT) using pre- and post-RT single photon emission computed tomography/computed tomography (SPECT/CT) attenuation-corrected perfusion scans; and correlate decreased perfusion with adjuvant RT dose for breast cancer in a prospective clinical trial. As part of an institutional review board-approved trial studying the impact of RT technique on lung function in node-positive breast cancer, patients received breast/chest wall and regional nodal irradiation including superior internal mammary node RT to 50 to 52.2Gy with a boost to the tumor bed/mastectomy scar. All patients underwent quantitative SPECT/CT lung perfusion scanning before RT and 1year after RT. The SPECT/CT scans were co-registered, and the ratio of decreased perfusion after RT relative to the pre-RT perfusion scan was calculated to allow for direct comparison of SPECT/CT perfusion changes with delivered RT dose. The average ratio of decreased perfusion was calculated in 10-Gy dose increments from 0 to 60Gy. Fifty patients had complete lung SPECT/CT perfusion data available. No patient developed symptoms consistent with pulmonary toxicity. Nearly all patients demonstrated decreased perfusion in the left lung according to voxel-based analyses. The average ratio of lung perfusion deficits increased for each 10-Gy increment in radiation dose to the lung, with the largest changes in regions of lung that received 50 to 60Gy (ratio 0.72 [95% confidence interval 0.64-0.79], P<.001) compared with the 0- to 10-Gy region. For each increase in 10Gy to the left lung, the lung perfusion ratio decreased by 0.06 (P<.001). In the assessment of 50 patients with node-positive breast cancer treated with RT in a prospective clinical trial, decreased lung perfusion by SPECT/CT was demonstrated. Our study allowed for quantification of lung perfusion defects in a prospective cohort of breast cancer patients for whom attenuation-corrected SPECT/CT scans could be registered directly to RT treatment fields for precise dose estimates.