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Prediction of Postoperative Lung Function in Patients with Lung Cancer

Comparison of Quantitative CT with Perfusion Scintigraphy

Ming-Ting Wu1,2, Huay-Ben Pan1,2, Ambrose A. Chiang3,4,5, Hon-Ki Hsu2,6, Huang-Chou Chang2,6, Nan-Jing Peng2,7, Ping-Hong Lai1,2, Huei-Lung Liang1,2 and Chien-Fang Yang1,2

1 Department of Radiology, Kaohsiung Veterans General Hospital, 386 Ta-chung 1st Rd., Kaohsiung, 813, Taiwan.
2 School of Medicine, National Yang-Ming University, 155, Li-Nong St., Sec. 2, Peitou, Taipei, Taiwan, R.O.C.
3 Division of Respiratory Care, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, 813, Taiwan, R.O.C.
4 Present address: Division of Respiratory and Critical Care Medicine, Duke University Medical Center, Erwin Rd., Durham, NC 27710.
5 Present address: Department of Medicine, Maria Parham Hospital, 566 Ruin Creek Rd., P. O. Drawer 59, Henderson, NC 27536.
6 Department of Surgery, Division of Thoracic Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, 813, Taiwan R.O.C.
7 Division of Nuclear Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, 813, Taiwan, R.O.C.



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  		Fig. 1A. —Assessment of fractional lung function by quantitative CT versus perfusion scintigraphy. Preoperative forced expiratory volume in 1 sec (FEV1) in 73-year-old man with chronic dyspnea with recent hemoptysis for 2 months was 1.21 L. FEV1 after left-sided pneumonectomy was 0.81 L. Loss of FEV1 was 33%, close to prediction by quantitative CT. Quantitative CT map shows "functional lung volume" of representative slice. Lung parenchyma was first outlined from mediastinum and chest wall by default range of -200 and -1,024 H (white-line contours). Tumor (Tu) was also excluded. After applying dual threshold, three segments in lung parenchyma were generated. White area below -910 H denoted emphysema (E), black area above -500 H denoted infiltration and atelectasis (I), and gray area between -500 and -910 H denoted functional lung volume (FLV). HT = heart.

 


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  		Fig. 1B. —Assessment of fractional lung function by quantitative CT versus perfusion scintigraphy. Preoperative forced expiratory volume in 1 sec (FEV1) in 73-year-old man with chronic dyspnea with recent hemoptysis for 2 months was 1.21 L. FEV1 after left-sided pneumonectomy was 0.81 L. Loss of FEV1 was 33%, close to prediction by quantitative CT. Attenuation histogram of quantitative CT integrated from multiple slices encompassing both lungs entirely. Entire lung volume was calculated from area under curve measuring from -1,024 to -200 H. Functional lung volume was fractional volume between -500 and -910 H (two vertical lines). Functional lung volume of left lung was 1,363 mL; functional lung volume of right lung was 2,292 mL. Left/right ratio of functional lung volume was 35% versus 65%. Quantitative CT—predicted forced expiratory volume in 1 sec (FEV1) loss was 35%. R = right lung, L = left lung, R + L = combination.

 


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  		Fig. 1C. —Assessment of fractional lung function by quantitative CT versus perfusion scintigraphy. Preoperative forced expiratory volume in 1 sec (FEV1) in 73-year-old man with chronic dyspnea with recent hemoptysis for 2 months was 1.21 L. FEV1 after left-sided pneumonectomy was 0.81 L. Loss of FEV1 was 33%, close to prediction by quantitative CT. Perfusion scintigram (posterior image) of left/right lung shows functional distribution was 48% versus 52%. Predicted FEV1 loss was 48%.

 


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  		Fig. 2A. —Agreement between predictions of quantitative CT and perfusion scintigraphy by Bland-Altman method [20]. Graphs show pneumonectomy group (A) and lobectomy group (B). Limit of agreement, mean ± 2 SD. FEV1 = forced expiratory volume in 1 sec, top horizontal line = + 2 SD, middle horizontal line = mean, bottom horizontal line = -2 SD. QCT—Predict = quantitative CT—predicted, PS—Predict = perfusion scintigraphy—predicted. L = liter.

 


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  		Fig. 2B. —Agreement between predictions of quantitative CT and perfusion scintigraphy by Bland-Altman method [20]. Graphs show pneumonectomy group (A) and lobectomy group (B). Limit of agreement, mean ± 2 SD. FEV1 = forced expiratory volume in 1 sec, top horizontal line = + 2 SD, middle horizontal line = mean, bottom horizontal line = -2 SD. QCT—Predict = quantitative CT—predicted, PS—Predict = perfusion scintigraphy—predicted. L = liter.

 


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  		Fig. 3. —CT scan of tumor involvement of vasculature greater than bronchi in hilum in 74-year-old man with lung cancer blocking right main pulmonary artery (arrow) without endobronchial invasion. This caused profound disproportional perfusion defect in right lung on scintigraphy (only 16% of total radioactivity, not shown) and, therefore, underestimation of lung functional loss by perfusion scintigraphy.

 


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  		Fig. 4. —CT scan of tumor involvement of severe endobronchial stenosis without atelectasis in 64-year-old woman with tumor blocking left main pulmonary artery and upper lobe bronchus completely. Lower lobe bronchus had severe stenosis (arrow), but lower lung was not atelectatic. Lower lobe was calculated by quantitative CT histogram as 26% of functional lung (not shown) but had only 8% of total radioactivity on scintigraphy (not shown). Exact lung function loss was 10% after pneumonectomy.

 

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