Mehmet Aslan 1 , Murat Tuncel 1 , Ebru Yalçın 2 , Berna Oğuz 3 , Mehmet Köse 2 ,

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

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.

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

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.

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.

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

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

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)

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

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.

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 -

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*

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 - - - - - - -

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

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)

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 - - - - -

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

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

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

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

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

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.

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.

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.

***