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ERS monograph
Imaging
Imaging is key to the screening and diagnosis of many
respiratory conditions. It is also an area of significant debate,
particularly with regard to questions surrounding safety and Edited by
overuse. This Monograph will be of interest to pulmonologists
R. Graham Barr, David G. Parr and
in all areas of respiratory medicine. The book covers two main
areas: imaging methodology and safety; and imaging use
Jens Vogel-Claussen
in specific respiratory conditions. Chapters include: safety
issues in CT and MRI, MRI methods, radionuclide imaging,
chest radiography, COPD, cystic fibrosis, asthma, lung cancer,
pulmonary hypertension, and much more.
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Print ISSN: 2312-508X ISBN 978-1-84984-063-7 0
Online ISSN: 2312-5098
Print ISBN: 978-1-84984-065-1
Online ISBN: 978-1-84984-066-8
December 2015
9 781849 840637
€55.00
Imaging
Edited by
R. Graham Barr, David G. Parr
and Jens Vogel-Claussen
Editor in Chief
Robert Bals
Th is book is one in a series of ERS Monographs. Each individual issue
provides a comprehensive overview of one specifi c clinical area of
respiratory health, communicating information about the most advanced
techniques and systems required for its investigation. It provides factual and
useful scientifi c detail, drawing on specifi c case studies and looking into
the diagnosis and management of individual patients. Previously published
titles in this series are listed at the back of this Monograph.
ERS Monographs are available online at www.erspublications.com and print
copies are available from www.ersbookshop.com
Continuing medical education (CME) credits are available through many issues of the ERS
Monograph. Following evaluation, successful Monographs are accredited by the European
Board for Accreditation in Pneumology (EBAP) for 5 CME credits. To earn CME credits, read
the book of your choice (it is clearly indicated on the online table of contents whether CME
credits are available) then complete the CME question form that is available at www.ers-
education.org/e-learning/cme-tests.aspx
Editorial Board: Antonio Anzueto (San Antonio, TX, USA), Leif Bjermer (Lund, Sweden), John R. Hurst (London,
UK) and Carlos Robalo Cordeiro (Coimbra, Portugal).
Managing Editor: Rachel White
European Respiratory Society, 442 Glossop Road, Sheffield, S10 2PX, UK
Tel: 44 114 2672860 | E-mail: [email protected]
Published by European Respiratory Society ©2015
December 2015
Print ISBN: 978-1-84984-065-1
Online ISBN: 978-1-84984-066-8
Print ISSN: 2312-508X
Online ISSN: 2312-5098
Printed by Latimer Trend and Company Ltd, Plymouth, UK
All material is copyright to European Respiratory Society. It may not be reproduced in any way including
electronic means without the express permission of the company.
Statements in the volume reflect the views of the authors, and not necessarily those of the European Respiratory
Society, editors or publishers.
C O P E COMMITTEE ON PUBLICATION ETHICS
This journal is a member of and subscribes to
the principles of the Committee on Publication
Ethics.
ERS monograph
Contents
Imaging Number 70
December 2015
Preface v
Guest Editors vi
List of abbreviations viii
1. MRI methods for structural and functional assessment of the lungs: 1
proton and multinuclear
Neil J. Stewart and Jim M. Wild
2. Radionuclide imaging 20
Frank M. Bengel
3. Chest radiography: performance, indications and interpretation 34
Dag Wormanns
4. Lung cancer: screening and staging 47
Theresa C. McLoud and Adam Bernheim
5. Pulmonary embolism 60
Sumit Karia and Nicholas Screaton
6. Chronic obstructive pulmonary disease 80
Robert A. Stockley and David G. Parr
7. Interstitial lung diseases 99
Cornelia Schaefer-Prokop and Helmut Prosch
8. The pleura 116
Cheng Xie and Fergus Gleeson
9. Pneumonia and acute respiratory distress syndrome 141
Caron S. Parsons and Emma J. Helm
10. Pulmonary hypertension 158
Cathelijne E.E. van der Bruggen, Onno A. Spruijt, Lilian J. Meijboom
and Anton Vonk Noordegraaf
11. Asthma 171
Simonetta Baldi, Ruth Hartley, Chris Brightling and Sumit Gupta
12. Imaging cystic fibrosis lung disease with MRI 188
Mark O. Wielpütz and Hans-Ulrich Kauczor
13. The cardiopulmonary unit 207
Andrew J. Swift
14. Measurement of pulmonary structure and function 216
Miranda Kirby, Pierre Lane and Harvey O. Coxson
15. Regulatory perspective on the use of lung imaging in drug development 233
Laura Fregonese
16. Risks of thoracic CT 253
Jonathan G. Goldin and Katrina Beckett
17. Safety issues in MRI 263
Alex Frydrychowicz and Oliver Wieben
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ERS monograph
Preface
Robert Bals
“A picture is worth athousand words”
Imaging of the lungs is a central step in the diagnosis of lung
disease. While the classical chest image has its role in daily
practice, in recent years multiple new techniques have been
developed that often involve the use of computerised complex
data analysis. Most respiratory physicians and othercaregivers in
respiratory medicine look at images of the lung on a daily basis.
In comparison with other areas of medicine, imaging techniques
are a major part of the diagnostic workup of patients with lung
disease. For example, imaging techniques are critical for the
diagnosis of pneumonia, essential for staging lung cancer and
vital to the classification of interstitial lung disease. The use of
imaging techniques in respiratory medicine also involves the
close interaction of several disciplines, resulting in the
constructive exchange of knowledge from different areas.
This ERS Monograph comprises chapters on specific techniques,
such as MRI methods, chest radiography, and radionucleotide
imaging, as well as individual disease areas. Additional sections
focus on the use of imaging techniques in drug development
and address safety and risk management when using imaging
techniques.
The book also considers the speed at which developments have
been made in medical technology. The application of
computerised and highly specialised technologies implies the
need for close communication between respiratory and imaging
physicians. This multidisciplinary approach is reflected in the
range of authors selected to write in this Monograph, providing
readers with different views on the patient. The Guest Editors,
R. Graham Barr, David G. Parr and Jens Vogel-Claussen,
worked hard and verysuccessfully in selecting the topics covered
and integrating the different aspects of imaging into a
comprehensive bookon the current knowledge in the field.
I would like to thank the Guest Editors and all authors for their
work on this excellent book. I hope readers find this book useful
in their daily clinical practice.
Copyright©ERS2015.PrintISBN:978-1-84984-065-1.OnlineISBN:978-1-84984-066-8.PrintISSN:2312-508X.OnlineISSN:2312-5098.
ERSMonogr2015;70:v.DOI:10.1183/2312508X.10002916 v
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ERS monograph
Guest Editors
R. Graham Barr
R. Graham Barr is Associate Professor of Medicine, Associate
Professor of Epidemiology, and Chief of the Division of General
Medicine at Columbia University Medical Center (New York,
NY, USA). He is a general internist and respiratory
epidemiologist. He received his medical degree from McGill
University (Montreal, QC, Canada), before undertaking
residency training at Columbia Presbyterian Medical Center
(New York, NY, USA). He went on to undertake a fellowship at
Massachusetts General Hospital (Boston, MA, USA), a
respiratory epidemiology fellowship at the Channing Laboratory
(Brigham and Women’s Hospital, Boston, MA, USA), and a
doctorate in epidemiology from Harvard School of Public
Health (Boston, MA, USA).
Graham Barr’s research interests lie in emphysema and COPD,
withaparticularfocusonpulmonaryvasculardamageanditsrole
in cardiopulmonary function. He uses novel imaging approaches
(CT and MRI) applied to population-based samples and is
principal investigator of the Multi-Ethnic Study of Atherosclerosis
(MESA) Lung Study, the MESA COPD Study, and the Columbia
Clinical Center of SPIROMICS (Subpopulations and Intermediary
Outcome Measures in COPD Study), in addition to running the
spirometry reading centre for the Hispanic Community Health
StudyandtheLongLifeFamilyStudy.
David G. Parr
David G. Parr is Clinical Director for the Cardio-Respiratory
Division and Consultant Respiratory Physician at University
Hospital Coventry (Coventry, UK). He trained at the Universityof
Cambridge (Cambridge, UK), the London Hospital Medical
College at the University of London (London, UK) and the
University of Birmingham (Birmingham, UK). His clinical
interests include COPD and α -antitrypsin deficiency, pulmonary
1
vascular disease and interstitial lung disease, and his research
interestisinquantitativeimagingofchroniclungdiseases.
Copyright©ERS2015.PrintISBN:978-1-84984-065-1.OnlineISBN:978-1-84984-066-8.PrintISSN:2312-508X.OnlineISSN:2312-5098.
ERSMonogr2015;70:vi–vii.DOI:10.1183/2312508X.10000916 vi
Jens Vogel-Claussen
Jens Vogel-Claussen is Professor of Radiology, Vice-Chair of the
Department of Diagnostic and Interventional Radiology and
Section Chief of Cardiothoracic Imaging at the Hannover
Medical School (Hanover, Germany). He undertook his doctoral
thesisatEberhard-Karls-Universität (Tübingen,Germany)before
moving onto an internship at Broomfield Hospital (Chelmsford,
UK)andaradiologicalresidencyatTheJohnHopkinsUniversity
Hospital (Baltimore, MD, USA). Alongside his current position,
he also holds a visiting faculty position at The Johns Hopkins
University Hospital and is Principal Investigator within the
GermanCenterforLungResearch(DZL).
Jens Vogel-Claussen’s research focuses on the translation of
novel functional cardiopulmonary MRI techniques into the
clinic for improved diagnosis and patient monitoring.
Jens Vogel-Claussen is a member of a number of committees.
He is part of the expert panel for the American College of
Radiology Appropriateness Criteria for Cardiac Imaging, and is
part of the Young Investigator Awards Committee for the
International Society for Magnetic Resonance in Medicine.
Jens Vogel-Claussen has had 71 peer-reviewed scientific articles
published and has acted as a consulting editor for Circulation:
Cardiovascular Imaging.
vii
List of abbreviations
ADC Apparent diffusion coefficient
COPD Chronic obstructive pulmonary disease
CT Computed tomography
CTEPH Chronic thromboembolic pulmonary hypertension
EBUS Endobronchial ultrasound
FDG 2-fluoro-2-deoxy-D-glucose
FDG-PET 2-fluoro-2-deoxy-D-glucose positron emission tomography
FEV1 Forced expiratory volume in 1 s
HRCT High-resolution computed tomography
MIP Maximum intensity projection
MRI Magnetic resonance imaging
OCT Optical coherence tomography
PET Positron emission tomography
SPECT Single photon emission computed tomography
UTE Ultra-short echo time
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Chapter 1
MRI methods for structural and
functional assessment of the lungs:
proton and multinuclear
Neil J. Stewart and Jim M. Wild
Despite the inherent challenges of MRI of the lungs, a number of quantitative techniques
with high functional sensitivity have been established for regional assessment of multiple
aspects of pulmonary structure and physiology. Conventional proton-based magnetic
resonance methods provide noninvasive anatomical imaging and diagnostic measures of
pulmonary perfusion, ventilation and gas-exchange functions. Multinuclear MRI of the lung,
including hyperpolarised noble gas MRI with 3He and 129Xe, has matured into a sensitive
functional tool for visualisation of pulmonary ventilation, quantification of gas diffusion and
evaluation of alveolar microstructure. These minimally invasive, safe and nonionising
radiation-based methods are well-suited to longitudinal assessment of disease progression
and treatment response, and recent technological and methodological advances are
facilitating the dissemination of previously unconventional techniques on a broader clinical
scale. In this article, we review the established and developing procedures for proton and
multinuclear MRI ofthepulmonarysystem, withapplicableclinical examples.
Conventional MRI involves nonionising radiofrequency radiation excitation and
detection of protons (hydrogen nuclei, 1H) within the lungs. Image contrast is
provided by fundamental differences in the properties of tissues of interest, including
proton density and magnetic resonance signal relaxation times. 1H MRI of the lungs is
inherently challenging due to the low proton density and complex magnetic environment
posed by the tissue and air interfaces. Nevertheless, a variety of methods (both 1H and
multinuclear, the latter employing inhaled gases as contrast agents) have been developed to
overcome these limitations and establish lung MRI as an important clinical tool for
assessment of both lung structure and several aspects of regional pulmonary function, with
high spatial and temporal resolutions.
In this chapter, an overview of 1H and multinuclear MRI methodologies for the human
lung is presented, from recognised clinical tools to recent technological advances. This
work aims to provide respiratory physiologists, imaging scientists and clinicians with an
introduction to the fundamental principles of magnetic resonance methods, and to
highlight relevant clinical developments.
AcademicUnitofRadiology,UniversityofSheffield,Sheffield,UK
Correspondence:JimM.Wild,AcademicUnitofRadiology,CFloor,RoyalHallamshireHospital,Sheffield,S102JF,UK.
E-mail:[email protected]
Copyright©ERS2015.PrintISBN:978-1-84984-065-1.OnlineISBN:978-1-84984-066-8.PrintISSN:2312-508X.OnlineISSN:2312-5098.
ERSMonogr2015;70:1–19.DOI:10.1183/2312508X.10002115 1
