Mehmet Aslan 1 , Murat Tuncel 1 , Ebru Yalçın 2 , Berna Oğuz 3 , Mehmet Köse 2 ,
description
Transcript of Mehmet Aslan 1 , Murat Tuncel 1 , Ebru Yalçın 2 , Berna Oğuz 3 , Mehmet Köse 2 ,
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ASSESSMENT OF RELATION BETWEEN RESPIRATORY FUNCTION TESTS,
VENTILATION/PERFUSION SCINTIGRAPHY AND HIGH RESOLUTION COMPUTED TOMOGRAPHY
FINDINGS IN PATIENTS WITH CYSTIC FIBROSIS
Mehmet Aslan1, Murat Tuncel1, Ebru Yalçın2, Berna Oğuz3, Mehmet Köse2,
Deniz Doğru2, Mithat Haliloğlu3, Nural Kiper2, Uğur Özçelik2, Pınar Kıratlı1
Hacettepe University Faculty of Medicine, Ankara, 2008
Nuclear Medicine Department1
Pediatric Chest Diseases Department2
Radiology Deptartment3
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INTRODUCTION
CYSTIC FIBROSIS :
• CF was previously known as “a pediatric disease that ens with death in first year of life”.
• Today we still dont have cure for the disease.
• Knowledge about CF accumulating comparably great improvement in survival and quality of life
• Chronic lung involvement
• Management: Symptom-sign control and preventive-prophylactic treatments.
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INTRODUCTION
Lung involvement in CF:
– A large portion of morbidity and mortality.
– Characterized with mucus plugs, infection and inflammation cycles.
– Most widely used standard study in clinical follow-up is respiratory function test.
• FEV1• %FEF 25-75
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PURPOSE
To compare the findings of
Pletismography – Respiratory function tests (pRFT), Ventilation-perfusion scintigraphy (VPS) and Thoracal high resolution computed tomography (tHRCT)
İn pediatric patients with CF.
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METHODS
• A prospective study– Hacettepe University ethical commitee– İnforming and approval of patient and parents
• CF patients selection criteria– Age 6-16 – Clinically mild-moderate lung disease– No active respiratory infection
• pRFT, VPS and low dose tHRCT was done in same visit to clinics.
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METHODS
• RFT-Pletismography
– Physical examination at Pediatric Chest Diseases Dept. policlinics
– Pediatric Chest Diseases Dept. Respiratory laboratory unit.
– Quantitative values of parameters FEV1, %FEF25-75, VC, TLC, RV/TLC ve Raw
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METHODS
• Ventilation and Perfusion Scintigraphy:– Tc99m-MAA used for perfusion scintigraphy,
ultrasounically nebulized aerosol Tc99m-DTPA used for ventilation scintigraphy. Radiation dose: V: 0.15 mSv, P: 0,5 mSv
– Gamma kamera, imaging done for 6 standard planes (anterior, posterior, both lateral, her both posterolateral views)
• Scoring: (0-162) (Donnelly et al, 1997)
visual defect scoring system, for each segment• Defect intensity: 1= <%25, 2= %25-75, 3= >%75• Segment area: 1= <%25, 2= %25-75, 3= >%75
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METHODS
• Thoracal HRCT :– Lowered dose, without contrast – Additional expirium slides– Radiation dose: 0.5-1.1 mSv
• Scoring : (0-102) (Donnelly et al, 1997)
• For each lobe, degree of:– Bronchiektasis (B)– Peribronchial thickening (PK)– Mucus plug (MT)– Air trapment (HH)– Bul (Bul) ve – Atelectasis/consolidation (A/K)
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METHODS• tHRCT scoring (Donnelly et al, 1997)
PARAMETRE score
0 1 2 3
Bronchiectasis none Lumen > neighboring vessel
Lumen 2-3x> vessel
Lumen > 3x vessel
Peribronchial thickening
none Bronchial wall ≥ neighboring vessel
Bronchial wall ≥ up to 2xneighboring vessel
Bronchial wall > 2xneighboring vessel
Mucus plug none mild obvious -
Hyperlucency none < 1/3 zone 1/3-2/3 zone >2/3 zone
Bul none < 1/3 zone 1/3-2/3 zone >2/3 zone
Atelectasis/ consolidation
none < 1/3 zone 1/3-2/3 zone >2/3 zone
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FINDINGS
• n = 17
• Age mean: 12 (st.dev.=2.3)• Age : min 8 – max 16
• Female : 5, Male: 12
• 1 patient couldn’t mange to do diffusion test, 1 patient’s tHRCT scoring couldn’t be done because expirium slices couldn’t be taken.
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FINDINGS• Normal perfusion
scintigraphy score in 8, normal ventilation scintigraphy score in 6 patients.
• 9 patients had abnormal ventilation and perfusion scintigraphy scores.
• Statistically no difference between ventilation scintigraphy scores and perfusion scintigraphy scores (Mann Whitney U p: 0,980).
Patient No
Age VS score
PS score
tHRCT total score
1 13 0 0 0
2 16 35 35 28
3* 13 23 14 25
4* 13 58 61 30
5 14 0 0 14
6 14 0 0 3
7 10 0 0 4
8 14 10 10 11
9 11 7 7 11
10* 9 3 0 2
11* 12 6 0 11
12 11 72 72 51
13* 15 2 3 13
14 8 2 2 22
15 13 0 0 7
16 10 0 0 2
17* 9 33 38 -
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FINDINGS “VPS and tHRCT”
• A good correlation is detected between ventilation and perfusion scores and tHRCT scores (Table: Spearman correlation coefficient)
• VS and PS scores have high correlation. (Spearman kk: 0.912**)
** correlation significant at 0.01 value (2-tailed)* correlation significant at 0.05 value (2-tailed)
Thoracal HRCT Scores / Parameter
TotalScor
Bronchiektasis
Peribronchial thickening
Mucus plug
Air trapment
Atelectasis/ consolidation
VS score
0.742** 0.762** 0.791** 0.727** 0.575* 0.532*
PS score
0.826** 0.886** 0.857** 0.755** 0.578* 0.579*
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FINDINGS ”VPS and tHRCT”Patient No VS
scorePS
scoreTotal tHRCT score
B.ect score
Pbr thick
score
MucPlug
score
Air trap
score
Atl / con
score
Bul score
1 0 0 0 0 0 0 0 0 0
2 35 35 28 8 3 6 8 3 0
3 23 14 25 8 5 0 10 2 0
4 58 61 30 9 2 5 9 5 0
5 0 0 14 6 0 0 8 0 0
6 0 0 3 0 0 0 3 0 0
7 0 0 4 0 0 0 4 0 0
8 10 10 11 5 2 0 4 0 0
9 7 7 11 3 0 1 7 0 0
10 3 0 2 0 0 0 2 0 0
11 6 0 11 0 0 0 10 1 0
12 72 72 51 17 8 12 13 1 0
13 2 3 13 2 0 0 9 2 0
14 2 2 22 6 2 0 13 1 0
15 0 0 7 0 0 0 7 0 0
16 0 0 2 0 0 0 0 2 0
17 33 38 - - - - - - -
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FINDINGS“PLETISMOGRAPHY –
RESPIRATORY FUNCTION TESTS”
– positive relation btw FEV1 and TLC, %FEF25-75, VC (Spearman correlation coefficient; 0.604, 0.587 ve 0.833)
– negative relation between FEV1 and Raw, RV/TLC (Spearman correlation coefficient; -0.720 ve -0.436)
Patient No
FEV1
%N
TLC%N
%FEF25-75
%N
VC%N
Raw%N
RV/TLC%
1 100 108 119 109 108 22
2 106 131 84 124 181 27
3 116 110 112 118 100 17
4 65 112 31 93 244 36
5 78 102 53 99 204 24
6 93 90 120 99 182 14
7 107 131 75 127 123 25
8 109 119 124 119 121 23
9 98 105 94 106 140 22
10 95 119 67 127 164 18
11 77 93 63 87 189 27
12 47 100 54 50 206 61
13 90 101 96 104 126 21
14 109 127 78 125 160 25
15 96 87 108 100 199 11
16 82 - 65 - - -
17 72 89 104 67 159 42
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FINDINGS ”pRFT and Imaging”
Vent S score
Perf S score
Torakal HRCT Score
Total B.ect P.Bron thick
Muc Plug
Air trap Atelekt/ consolid.
RV/TLC 0.603* 0.562* 0.598*
0.542*
0.455 0.607*
0.498 0.464
• Among RFT parameters only RV/TLC showed significant relationship with VPS and tHRCT scores.
** correlation significant at 0.01 value (2-tailed)* correlation significant at 0.05 value (2-tailed)
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FINDINGS ”pRFT and Imaging”Patient
NoRV/TLC
%VS
scorePS
scoreTotal tHRCT score
B.ect. score
PbrThi score
MuCPl score
Atl/con score
1 22 0 0 0 0 0 0 0
2 27 35 35 28 8 3 6 3
3 17 23 14 25 8 5 0 2
4 36 58 61 30 9 2 5 5
5 24 0 0 14 6 0 0 0
6 14 0 0 3 0 0 0 0
7 25 0 0 4 0 0 0 0
8 23 10 10 11 5 2 0 0
9 22 7 7 11 3 0 1 0
10 18 3 0 2 0 0 0 0
11 27 6 0 11 0 0 0 1
12 61 72 72 51 17 8 12 1
13 21 2 3 13 2 0 0 2
14 25 2 2 22 6 2 0 1
15 11 0 0 7 0 0 0 0
16 - 0 0 2 0 0 0 2
17 42 33 38 - - - - -
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FINDINGS• FEV1, Raw and %FEF25-75
showed no significant relarionship with imaging scores (VPS ve HRCT)
PatientNo
VS score
PS score
Tot tHRCT score
FEV1%N
%FEF 25-75%N
Raw%N
1 0 0 0 100 119 108
2 35 35 28 106 84 181
3 23 14 25 116 112 100
4 58 61 30 65 31 244
5 0 0 14 78 53 204
6 0 0 3 93 120 182
7 0 0 4 107 75 123
8 10 10 11 109 124 121
9 7 7 11 98 94 140
10 3 0 2 95 67 164
11 6 0 11 77 63 189
12 72 72 51 47 54 206
13 2 3 13 90 96 126
14 2 2 22 109 78 160
15 0 0 7 96 108 199
16 0 0 2 82 65 -
17 33 38 - 72 104 159
Correlative findings
RFT significantly
more abnormal
Imaging significantly
more abnormal
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Patient No 6
14y, M
Perf Scint Score : 0Vent Scint Score : 0
Tor HRCT Score : 3
Plet-RFTFEV1 (%N) : 93%FEF25-75 (%N) : 120VC (%N) : 99TLC (%N) : 90RV/TLC (%) : 14Raw (%N) : 182
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Patient No 12
11y, M
Perf Scint Score : 72Vent Scint Score : 72
Tor HRCT Score : 51
Plet-RFTFEV1 (%N) : 47%FEF25-75 (%N) : 54VC (%N) : 50TLC (%N) : 100RV/TLC (%) : 61Raw (%N) : 206
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Patient No 2
16y, F
Perf Scint Score : 35Vent Scint Score : 35
Tor HRCT Score : 28
Plet-RFTFEV1 (%N) : 106%FEF25-75 (%N) : 84VC (%N) : 124TLC (%N) : 131RV/TLC (%) : 27Raw (%N) : 181
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Patient No 5
14y, M
Perf Scint Score : 0Vent Scint Score : 0(defect score:0 but heterogenous aerosol deposition was reported)
Tor HRCT score : 14
Plet-RFTFEV1 (%N) : 78%FEF25-75 (%N) : 53VC (%N) : 99TLC (%N) : 102RV/TLC (%) : 24Raw (%N) : 204
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DISCUSSION• Findings of VS, PS and HRCT are found correlative
between both three modalities.
The high correlation shows that each of three modalities can be used alternatively for similar purposes. This is also can be said for choosing between scintigraphy and HRCT.
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DISCUSSION
• Imaging scores showed correlation with RFT parameters but only RV/TLC showed statistically significance.
– Normal imaging Clinically and RFT abnormal patients !
– Significant pathological imaging findings Close to normal RFT’s and clinically silent patients !
These findings are pointing that using only physical examination and RFT’s for assessing severity of the lung involvement (to modulate treatment and follow up) in the management of patients with CF can not be enough.
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CONCLUSION
• Findings that suggest adding one of the three imaging modalities (which has high correlation in scores with each other) to routine can positively support follow-up of patients with CF.
• It is hoped to reach to more accurate and true knowledge with increase in the number of patients for this study.
***