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Ann Thorac Surg 1996;62:811-817
© 1996 The Society of Thoracic Surgeons

Original Articles: General Thoracic

Spiral CT With Multiplanar and Three-Dimensional Reconstructions Accurately Predicts Tracheobronchial Pathology

Joseph LoCicero, III, MD, Phillip Costello, MD, Christian T. Campos, MD, Nicola Francalancia, MD, Kevin M. Dushay, MD, Ronald C. Silvestri, MD, Joseph D. Zibrak, MD

Division of Thoracic Diseases and Department of Radiology, New England Deaconess Hospital, Harvard Medical School, Boston, Massachusetts


   Abstract
Top
 Footnotes
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background. This study was designed to evaluate the clinical accuracy of multiplanar reconstructions and three-dimensional shaded surface displays compared with conventional transaxial computed tomography, bronchoscopy, and surgical pathologic findings.

Methods. Transaxial computed tomographic images, two-dimensional nonstandard multiplanar reconstruction images, and three-dimensional images obtained from patients with tracheobronchial disease were prospectively evaluated for the relationship to adjacent structures, lesion characterization, and surgical anatomic correlation before invasive procedures.

Results. Compared with conventional transaxial computed tomographic images, multiplanar reconstructions and three-dimensional shaded surface displays provided a correlative map of bronchoscopic and surgical anatomy in patients with benign and malignant tracheobronchial pathology. The longitudinal extent of abnormalities are better demonstrated on the multiplanar reconstruction and three-dimensional images, whereas the transverse extent of disease and relationships to adjacent structures were better shown on axial computed tomographic sections.

Conclusions. Three-dimensional and multiplanar two-dimensional images are additive to transaxial computed tomography for evaluation of diseases involving the central airways. They are beneficial for planning invasive procedures. More importantly, they provide consistent, highly accurate measurements for routine follow-up and for future clinical trials.


   Introduction
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 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
See also page 817.

In 1992, Weber and Grillo [1] recommended a wide variety of radiologic testing for determining airway pathology. These tests ranged from the standard chest roentgenography and tomography to angiography [1]. Around the same time, computed tomography (CT) and magnetic resonance imaging (MRI) were being evaluated for the same purpose. Shepherd and McLoud [2] noted that the multiplanar techniques of MRI showed significant progress in evaluating the airways because of the ability of MRI to change the traditional orientation of the scan and show pathology along the length of the trachea. At that time, CT had no such capability. However, within the past few years, improvements in technology now allow CT scanning to provide similar images for airway visualization without the need for intravenous contrast [3, 4]. Two recent reports demonstrated the usefulness of multiplanar techniques for the evaluation of tracheobronchial stenosis [5, 6]. This report demonstrates the applicability of multiplanar techniques and three-dimensional (3-D) reconstructions for accurate anatomic depiction of other airway pathology in addition to tracheobronchial stenosis.


   Material and Methods
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
From July 1992 to December 1995, all patients with known or suspected tracheobronchial pathology underwent spiral CT scanning before invasive procedures. All scans were performed on Siemens Somatom Plus and Siemens Somatom Plus 4 together with standard reconstruction software. First, a standard thoracic survey CT scan was performed. The scan parameters were 137 kVp at 180 mAs. Eight-millimeter slices were obtained using a spiral technique with a table speed of 8 mm/second for a total exposure of 32 seconds. The superior extent of the scan was the superior margin of the clavicles above the lung apices, and the inferior extent was the posterior costophrenic sulcus. Postacquisition reconstructions were 8 mm supplemented by 4 mm for questionable findings. Two reconstructions were performed. A high-resolution reconstruction was performed for lung detail. A second reconstruction was used for mediastinal or hilar anatomy and pathology. The orientation for both reconstructions was transaxial. Intravenous contrast, when used, was either high osmolar contrast medium (282 mg iodine per mL [60% solution] or low osmolar contrast medium [320 mg iodine per mL]). The rate of infusion was 2 mL/second, and the initial scan delay was 20 seconds. A total of between 80 and 100 mL of contrast was given.

A second data set was collected for multiplanar reconstructions and 3-D imaging. The scan parameters were 137 kVp at 180 mAs. Three-millimeter slices were obtained at a table speed of 5 mm/second for a total exposure of 32 seconds (two overlapping spirals for full thoracic coverage). The superior extent of the scan was the lung apices (except for cervical tracheal pathology, in which case the superior extent was the larynx), and the inferior extent was the posterior costophrenic sulcus. Reconstructions were performed only in the high-resolution mode with 3-mm increments over normal areas of the chest and 1-mm to 2-mm increments over the area of pathology. These images were presented either as sagittal or coronal reconstructions. In addition, 3-D and minimum intensity projection images of the airways were generated specifically for definition of the type of airway pathology present.

All scans were reviewed prospectively before invasive procedures. Invasive procedures were planned to document the pathology as completely as possible. All endoluminal pathology had photographic documentation during endoscopy. Other pathology, where possible, was documented by intraoperative photography. Detailed operative notes along with photographic documentation were used to compare with the CT findings.


   Results
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 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
Eleven patients with tracheobronchial pathology (Table 1Go) were evaluated using spiral (helical) CT with multiplanar reformations and 3-D shaded imaging. The pathologic findings in these patients included 4 primary carcinomas, 2 fistulas, 1 metastatic cancer, 1 benign tumor of the trachea, and 3 obstructions including 1 stenosis, 1 aspirated denture, and 1 stent. In all but 1 case, the multiplanar reconstructions accurately defined the endobronchial anatomy. The inaccuracy occurred in 1 patient with primary cancer of the trachea in whom mucous above the lesion obscured proper definition. However, standard transaxial CT defined the extent of disease well in that patient. In 3 patients, surgical plans were changed based on the information provided by the scan. In 2 patients, additional information was provided: preoperative diagnosis of a tracheal hamartoma and discovery of a contained bronchomediastinal fistula. In the patient with tracheal stenosis, the anatomy of the tracheal wall at the site of stenosis was carefully defined by the CT scanning. However, the dynamic component of obstruction was better defined by bronchoscopy. A brief summary of 4 patients is provided to better illustrate the usefulness of the scans.


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  		Table 1. . Tomographic and Operative Findings
 
Patient 2, an 85-year-old woman, had acute dyspnea and new onset of atrial fibrillation. An echocardiogram demonstrated left ventricular hypertrophy, aortic stenosis and regurgitation, and an enlarged left atrium. When the patient was given warfarin for her atrial fibrillation, hemoptysis developed. Review of a chest roentgenogram demonstrated a space-occupying lesion in the upper trachea. The multiplanar CT scan and 3-D reconstruction (Fig 1Go A-C) demonstrated a 2-cm obstructing tracheal lesion beginning 3 cm below the vocal cords. Anesthesia was planned accordingly and the patient was successfully intubated with a 6-mm endotracheal tube. Tumor excision could then be performed through the rigid bronchoscope (Fig 1DGo).






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  		Fig 1. . (A) Transaxial CT demonstrating lesion with extension to peritracheal soft tissue and possible invasion of vascular structures. (B) Coronal CT showing lesion with intraluminal component and partial obstruction of the trachea. (C) Three-dimensional CT using a surface rendering (thresholding) technique graphically demonstrating the entire tumor with extensive airway compromise. (D) Endobronchial view of tumor at the time of bronchoscopic resection. This does not show the extent of wall involvement as well as helical CT.

 
In patient 3, a 65-year-old man, massive hemoptysis developed secondary to postoperative radiation after a right upper lobectomy for stage II carcinoma of the lung. A completion pneumonectomy was required to salvage the patient. He had an early bronchial stump leak requiring re-resection and intercostal muscle flap reinforcement of the bronchial closure. A postpneumonectomy empyema developed, which was treated with open drainage. When the patient was being prepared for muscle interposition, a CT scan with 3-D reconstruction (Fig 2Go) demonstrated a persistent bronchopleural fistula in the right main bronchus. This necessitated a change in operative strategy. A transsternal stapling of the right main bronchus was carried out before muscle interposition.




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  		Fig 2. . (A) Coronal CT demonstrating two large bronchopleural fistulas. (B) Three-dimensional CT confirming two fistulas directly into empyema cavity and long right main bronchial stump.

 
Patient 8, a 59-year-old man, presented with acute cholecystitis. A preoperative chest roentgenogram demonstrated a density in the upper chest that was overlying the tracheal air column. A CT scan with 3-D reconstruction (Fig 3AGo-C) demonstrated a mass with a sessile base in the midtrachea obstructing 40% of the lumen. Computed tomographic numbers of the mass demonstrated a predominant fat content consistent with a hamartoma. Bronchoscopy (Fig 3DGo) confirmed the position and the degree of obstruction. Histopathologic evaluation of the resected specimen demonstrated a tracheal hamartoma.







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  		Fig 3. . (A) Transaxial CT demonstrating lesion in trachea. (B) Coronal CT demonstrating location and sessile attachment of the tumor to the tracheal wall; CT numbers of lesions suggested the diagnosis of hamartoma. A second area in the left main bronchus was a collection of mucus. (C) Three-dimensional CT demonstrating exact location, attachment, and extent of tumor. (D) Endobronchial view of the same lesion with a sessile base. (Reprinted with permission from Semin Ultrasound, CT, MRI 1994;15: 90–106.)

 
Patient 9, a 22-year-old woman with chondromalacia, had severe stridor requiring stenting of the entire tracheobronchial tree. Postoperatively, she would periodically present with obstructions due to granulation tissue formation at the ends of the silicone stents. There was a considerable degree of granulation tissue on the right side and less on the left. However, the stent seemed to be partially obstructing the left main bronchus (Fig 4AGo). Three-dimensional reconstruction demonstrated angulation of the Y stent due to a combination of gradual enlargement of the aorta and continued volume loss in the right lung (Fig 4BGo).




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  		Fig 4. . (A) Three-dimensional CT of stent clearly demonstrating angulation of Y into airway. (B) Endoscopic view demonstrating T-Y connection and both ends of the Y stent before laser application. Left-sided obstruction is due to obstruction by stent.

 

   Comment
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
In the early 1980s, the value of CT and MRI scanning for characterization of tumors of the lung and evaluation of lymph nodes was well defined. Reports published in the last few years also show the significant advantages of these specialized scans for the detection of airway pathology. Honjou and associates [7] have used MRI to examine the layers of the tracheal wall and are able to distinguish between the submucosa, the edge of the bronchial wall, and the peribronchial and peritracheal fat.

Computed tomographic scanning also demonstrated some distinct advantages. Carr and associates [8] examined 17 patients with cystic fibrosis. They found that CT images more clearly detected bronchiectasis, bronchial thickening, and mucous plugging. Several reports have shown the usefulness of MRI for detecting the high fat content in aspirated peanuts [9, 10] and in carcinoid tumors [11]. However, as 1 of the patients in this series demonstrates, increased fat content also is detectable by CT scanning.

Other techniques for airway evaluation are sometimes useful, including xenon-133 nuclear scans for detection of bronchopleural fistulas [12], examination of tracheal wall morphology by high-end (20 and 30 MHz) ultrasound [13], and Doppler detection of pulmonary sequestration in an atelectatic lung [14]. However, these techniques have very limited applicability and would not be useful as general tools to evaluate the wide variety of airway pathology.

With improvement in CT design and postacquisition software, multiplanar techniques previously limited to MRI can now be matched by CT scanning. Newmark, Costello, Kinsella, Quint, and Whyte and their associates have demonstrated how these techniques using a helical or spiral CT scanner may be applied [3–6,15]. Although transaxial planar reconstruction is the usual method of presentation of patient information, these data can be displayed at any angle and degree of rotation so that all segments of the airway column in the trachea and bronchi can be visualized. This degree of flexibility not only makes detection and characterization of a stenosis easy but also, as we have demonstrated, defines all forms of airway pathology equally well including extrinsic compression, intraluminal lesions, and fistulas.

Three-dimensional reconstruction adds the final piece to the puzzle. This technique, described in the last 2 years by Costello [4], Lacrosse and associates [16], and Manson and colleagues [17], provides the spatial relationships that are necessary to plan surgical procedures. In the case of the patient with a tracheal hamartoma, the sessile nature of the lesion's base led to a decision to perform a segmental resection of the trachea. Preoperative determination that the lesion was most likely a hamartoma allowed planning for a shorter tracheal resection. In the patient with the postpneumonectomy empyema, discovery of a persistent bronchopleural fistula led to postponement of the muscle flap interposition until definitive transsternal bronchial closure could be accomplished.

As suggested by Pujol and associates [18], 3-D reconstruction CT scanning will allow definitive follow-up and evaluation of the efficacy of therapies without the need for even simple invasive procedures such as bronchoscopy. This was illustrated in the patient with recurrent carcinoma causing extrinsic compression of the airway. Bronchoscopy was performed only for brachytherapy and was not required for the diagnosis of extrinsic compression.

Some problems remain with these new scanning techniques. Secretions retained within the airway may obscure the mass or enhance a mass present within the lumen. They may also cause false images suggestive of a mass, as in the case of our second example. All detailed scanning for such reconstructions requires acquisition of data over 30 seconds; thus, it requires a cooperative, quiet, breath-holding patient. Certain individuals with significant dyspnea may not be able to cooperate fully to obtain proper images. This problem can be addressed in part by using variable-mode spiral (helical) acquisition. Three separate continuous scans, each acquired over 10 seconds, can be used. Because each breath may be different, meshing the images may be difficult. Another potential solution is to increase the pitch of the spiral from 3 mm to 8 mm. Much fewer data are acquired and thus there is lower resolution to the images. Finally, some dynamic components of obstruction may be missed during breath holding. Thus, patients with symptoms of significant obstruction, not confirmed by CT scan, may require aerodynamic testing, bronchoscopy, or other imaging modalities for clarification.

Time and cost are always an important consideration today. Because the patient has a complete routine CT scan before the specially detailed spiral (helical) scan, the patient time is doubled. The time for special reconstructions is only 5 minutes per view. Additional charges vary from hospital to hospital, but the Deaconess Hospital adds no additional charges for the technical component or the professional component.

As earlier generation scanners are upgraded, CT will become the primary radiologic test for airway pathology, supplanting all other testing. After a standard chest roentgenogram, a combination of the standard transaxial image obtained on a machine capable of spiral or helical CT and sagittal imaging with multiplanar and optional 3-D reformations should be obtained. Because additional intensive scanning with the spiral (helical) CT must be performed to produce these images, the radiologist should be alerted to any patient with suspected airway pathology at the time of the survey CT scan. This will allow the patient to have the appropriate additional scanning performed at the same time. Intravenous contrast is not required for these specialized scans but may be beneficial in certain situations to better define adjacent vascular structures [19].

Standard tomograms or laminograms and bronchography are superfluous and increasingly unavailable in the modern radiology suite. Magnetic resonance imaging is rarely needed. In the case of dynamic obstruction, pulmonary function testing with flow-volume loops, video bronchoscopy, and cine CT or MRI may be necessary to elucidate the exact nature of the problem.


   Footnotes
Top
 Footnotes
Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 
Presented at the Poster Session of the Thirty-second Annual Meeting of The Society of Thoracic Surgeons, Orlando, FL, Jan 29-31, 1996.

Address reprint requests to Dr LoCicero, General Thoracic Surgery, New England Deaconess Hospital, 110 Francis St, Suite 2C, Boston, MA 02215 (E-mail: locicero{at}harvarda.harvard.edu).


   References
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

  1. Weber AL, Grillo H. Tracheal lesions-assessment by conventional films, computed tomography and magnetic resonance imaging. Isr Med Sci 1992;28:233–40.
  2. Shepard JO, McLoud TC. Imaging the airways. Computed tomography and magnetic resonance imaging. Clin Chest Med 1991;12:151–68.[Medline]
  3. Newmark GM, Conces DJ, Kopecky KK. Spiral CT evaluation of the trachea and bronchi. J Comput Assist Tomogr 1994;18:522–4.
  4. Costello P. Thoracic helical CT. Radiographics 1994;14:913–8.[Abstract]
  5. Quint LE, Whyte RI, Kazerooni EA, et al. Stenosis of the central airways: evaluation by helical CT with multiplanar reconstructions. Radiology 1995;194:871–7.[Abstract/Free Full Text]
  6. Whyte RI, Quint LE, Kazerooni EA, Cascade PN, Iannettoni MD, Orringer MB. Helical computed tomography for the evaluation of tracheal stenosis. Ann Thorac Surg 1995;60:27–33.[Abstract/Free Full Text]
  7. Honjou K, Suda H, Soejima K, et al. Demonstration of the architecture of the tracheobronchial wall by MR imaging: an experimental study. Nippon Igaku Hoshasen Gakkai Zasshi 1991;51:1383–5.[Medline]
  8. Carr DH, Oades P, Trotman-Dickenson B, Mohiaddin R, Wells AU, Bush A. Magnetic resonance scanning in cystic fibrosis: comparison with computed tomography. Clin Radiol 1995;50:84–9.[Medline]
  9. Hisa Y, Tatemoto K, Dejima K, Nishiyama Y, Masuda Y, Ikuta H. Magnetic resonance imaging for aspirated peanut in the bronchus. J Laryngol Otol 1994;108:804–5.[Medline]
  10. Imaizumi H, Kaneko M, Nara S, Saito H, Asakura K, Akiba H. Definitive diagnosis and location of peanuts in the airways using magnetic resonance imaging techniques. Ann Emer Med 1994;23:1379–82.[Medline]
  11. Douek PC, Simoni L, Revel D, Cordier JF, Amiel M. Diagnosis of bronchial carcinoid tumor by ultrafast contrast-enhanced MR imaging. Am J Roentgenol 1994;163:563–4.[Free Full Text]
  12. Jacobson AF, Herzog SA. Open bronchial stump post-pneumonectomy: findings on xenon-133 ventilation imaging. J Nucl Med 1993;34:462–4.[Abstract/Free Full Text]
  13. Cavaye DM, Tabbara MR, Kopchok GE, Laas TE, Cormier F, White RA. A new technique for intraluminal hollow organ imaging: three-dimensional ultrasound. J Laparoendosc Surg 1991;1:259–68.[Medline]
  14. Smart LM, Hendry GM. Imaging of neonatal pulmonary sequestration including Doppler ultrasound. Br Radiol 1991;64:324–9.
  15. Kinsella D, Sissons G, Williams MP. The radiological imaging of bronchial atresia. Br J Radiol 1992;65:681–5.[Abstract/Free Full Text]
  16. Lacrosse M, Trigaux JP, Van Beers BE, Weynants P. 3D spiral CT of the tracheobronchial tree. J Comput Assist Tomogr 1995;19:341–7.[Medline]
  17. Manson D, Babyn P, Filler R, Holowka S. Three-dimensional imaging of the pediatric trachea in congenital tracheal stenosis. Pediatr Radiol 1994;24:175–9.[Medline]
  18. Pujol J-L, Parrat E, Lehmann M, et al. Lung cancer chemotherapy: response-survival relationship depends on the method of chest tumor response evaluation. Am J Respir Crit Care Med 1996;153:243–9.[Abstract]
  19. Touliopoulis P, Costello P. Helical (spiral) CT of the thorax. Radiol Clin North Am 1995;33:843–61.[Medline]

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