0:01

Let's approach this case from the perspective

0:02

of incidental findings on the soft tissue windows.

0:06

While the soft tissues on a low dose screening CT are going

0:10

to be noisy, particularly above the shoulders

0:12

where there's a lot of bone tissue in the humeral heads,

0:15

the scapula and the clavicles,

0:17

you can still see the anatomy quite well.

0:20

You certainly don't have the detail of a standard dose exam,

0:25

but remember, this is a screening exam.

0:27

It's a public health tool to identify early evidence

0:30

of lung cancer for the purpose

0:31

of reducing lung cancer mortality.

0:34

It is not considered a full diagnostic chest CT examination.

0:38

One of the things that we readily see on the soft tissue

0:41

windows is looking for abnormal calcification

0:44

as individuals age the calcium, for example,

0:48

deposits in the rings of the trachea.

0:50

So we see calcium there.

0:52

As we're looking to the airway, we see this little kind

0:55

of smooth low density lump along the edge here.

0:58

This patient has a lot

0:59

of secretion sitting in their airway right here,

1:01

a big area of mucus.

1:03

This is common in patients who smoke cigarettes

1:06

who have chronic bronchitis

1:08

and evidence of small airway disease.

1:09

So whenever I see mucus plugging in the trachea

1:12

or in the small airways is common in individuals

1:14

who smoke cigarettes.

1:15

It often has this frothy appearance with air bubbles in it.

1:20

It's common in individuals who smoke cigarettes

1:22

because of the association with chronic bronchitis

1:25

and small airway disease.

1:26

So whenever I see it on cts, I'm going to report this type

1:30

of airway abnormality.

1:32

If airway findings are solid without this sort

1:35

of frothy air bubble appearance, if they're not linear

1:39

and if they are adherent to the non-dependent wall,

1:42

then we get concerned about them being endobronchial

1:45

malignancies such as carcinoid tumor.

1:48

These are relatively uncommon in lung cancer screening

1:51

compared to other incidental findings.

1:54

Going back to our soft tissue windows,

1:56

we can see a little bit of calcium in the thoracic UTA

1:59

on our chest CT reports.

2:01

Here at our institution, we not only report coronary calcium

2:06

as a non mild, moderate, severe score currently,

2:08

and we're investigating using an AGA

2:11

and score on all of our chest CT exams.

2:14

We also give a visual grading for

2:17

thoracic retic calcification.

2:20

Not sure what the scientific evidence is yet to prove

2:24

that its benefit, but you have to start somewhere in trying

2:26

to change practice and understanding what we see

2:28

and what its implications are.

2:30

Of course, the most common cardiovascular calcification

2:33

we're gonna find is coronary calcification.

2:36

As we're scrolling down here,

2:38

we can see calcification in the expected location

2:40

of the left main and proximal left anterior

2:43

descending coronary arteries.

2:45

Calcification and coronary disease,

2:47

particularly at those locations, makes a patient higher risk

2:51

of cardiovascular events than smaller calcification in the

2:54

more peripheral portion of the cardiovascular tree.

2:59

So not only is it important

3:00

to report coronary calcium using a non mild moderate visual

3:03

score, or potentially

3:05

to give it a quantitative score if you're using those sorts

3:07

of software tools, but particularly

3:09

to point out if it's in the left main

3:11

or proximal LAD in the radiology reports.

3:14

So here we have multifocal calcification

3:17

in the left circulation, the expected direction

3:20

of the LAD here coming down LAD,

3:23

we see some extending posteriorly here,

3:26

which is in the left circumflex coronary territory.

3:29

And we see some anteriorly here in the right AV groove

3:33

where the right coronary artery is.

3:35

So we have triple vessel coronary calcification.

3:38

It's somewhat scattered,

3:40

so this amount would fall into the moderate visual coronary

3:43

calcium scoring strata,

3:47

which would make this patient at intermediate

3:49

to moderate risk of future coronary events.

3:52

Moderate coronary calcification is important

3:55

to report on your lung cancer screening cts moderate

3:58

or severe because cardiovascular risk assessment

4:01

and risk management is particularly

4:03

important in these patients.

4:05

We have the opportunity

4:06

to see this patient's lung cancer screening cts

4:09

over several years.

4:10

We have 20, 24, 20 22, 20, 21, and 2019.

4:16

So this is not a new finding.

4:19

Tson scores can be used

4:21

to quantify changes in coronary calcium over time.

4:24

Visual scoring is a little bit less accurate at measuring

4:28

change going from say, mild to moderate to severe.

4:30

But atkisson scores are being applied serially in some

4:34

patients with high cardiovascular risk in clinical practice,

4:37

usually those being managed by cardiovascular specialists

4:41

or primary care physicians with particular expertise

4:44

of interest in cardiovascular disease risk mitigation.

4:47

So we can see this patient has had this coronary calcium

4:49

present for several years now that we have been, uh,

4:53

doing lung cancer screening.

4:54

cts. You'll notice this one exam in the middle doesn't look

4:57

quite as noisy because along the way,

5:00

the patient had a high resolution CT

5:02

to look at their lung disease findings.

5:05

And we'll take a look a little bit at emphysema

5:09

as we talk about this later.

5:12

But looking at emphysema, quantifying emphysema

5:15

and looking at progression

5:16

of emphysema is importantly recognized as something

5:19

that we should be doing in our patients

5:21

who have lung cancer screening

5:23

and it has significant impact on their patient, uh,

5:26

mortality and potentially morbidity.