The 1St Dynamic Digital Radiography Seminar

The 1st Dynamic Digital Radiography Date and time： 14:00 to 17:30, Seminar Saturday, October 13, 2018 Venue： JP Tower 14F Konica Minolta Co., Ltd. bizhub SQUARE

CONTENTS

Part1 Keynote Speech Part3 Clinical Research Report Dynamic Digital Radiography that changes common Progress of Dynamic Digital Radiography sense in respiratory imaging in our hospital ………………………………………………… 08 -A static image that captures the form and a dynamic image that reﬂ ects physiology Department of Respiratory Medicine, Tokai University ………………………………………………… 02 Fumio Sakamaki, MD Hachioji Hospital / Respiratory Division, Department of Internal Medicine, Tokai University School of Medicine Chairman, Board of Directors, Japan Anti-Tuberculosis Shoji Kudoh, MD, PhD Association / Professor Emeritus, Nippon Medical School Foundation Examination of evaluation method of respiratory function by Dynamic Digital Radiography ………………………… 10 Part2 RSNA 2016 Award Lecture Department of Respiratory Medicine, Kanazawa University Certificate of Merit Noriyuki Ohkura, MD Hospital Dynamic Chest Radiography Using Flat Panel Detector System: Technique …………………………………………… 04 Practical use of Dynamic Digital Radiography in lung College of Medical, Pharmaceutical, & Health Sciences, resection ………………………………………………………… 12 Rie Tanaka, PhD Kanazawa University

Department of Thoracic, Cardiovascular and General Surgery, Magna Cum Laude Masaya Tamura, MD Kanazawa University Dynamic Chest Radiography Using Flat Panel Detector System: Clinical Usefulness ……………………………… 06 Evaluation of surgical indication by Dynamic Digital Department of Diagnostic Radiology, Radiography …………………………………………………… 14 Yoshitake Yamada, MD, PhD Keio University School of Medicine

Division of General Thoracic Surgery, Department of Jun Hanaoka, MD, PhD Surgery, Shiga University of Medical Science

Part4 Discussion Clinical value and potential of Dynamic Digital Radiography -From each specialized area …………………………………… 16 Chairpersons Department of Diagnostic Radiology, Fukujuji Hospital, Japan Anti- Atsuko Kurosaki, MD, PhD Tuberculosis Association Terumitsu Hasebe, MD, PhD Department of Radiology, Tokai University School of Medicine

Commentators Yoko Shibata, MD, PhD Department of Pulmonary Medicine, Fukushima Medical University Department of Respiratory Care and Rehabilitation, Fukujuji Hospital, Mitsuru Tabusadani, PhD Japan Anti-Tuberculosis Association Hiromi Oda, MD, PhD Director of Saitama Medical University Hospital The 1st Dynamic Digital Radiography Seminar Part 1 Keynote Speech Dynamic Digital Radiography image that changes common sense in respiratory imaging - A static image that captures the form and a dynamic image that reflects physiology

Chairman, Board of Directors, Japan Anti-Tuberculosis Association / Shoji Kudoh, MD, PhD Professor Emeritus, Nippon Medical School Foundation

In this lecture, based on the Chest image diagnosis has evolved exams, and this is explained using history of respiratory imaging, from simple chest radiographs to a model of hydrostatic pressure in we will discuss the possibilities chest CTs and high resolution CTs, a textbook written by J.B. West in and expectations of Dynamic in response to the desire to see the 1962 1) (Fig. 2). Digital Radiography (DDR) morphology in more detail. High- In static images, for example, when image that change the resolution CT has made it possible to congestive heart failure occurs, the conventional wisdom. analyze the structure of the second- ascending blood vessel becomes ary lobule of the lung, and the reso- visible, and it is understood that History of respiratory lution has been further improved. information refl ecting physiological diagnostics It is the basic procedure of the information is also included. The pioneers of respiratory diagnos- history of respiratory imaging that tics sought a way to know the inter- has developed into high-resolution Impression of DDR image nal condition of the lung without images that “refl ect form.” When I fi rst got the introduction of dissection, which led to the develop- dynamic chest X-ray image from ment of a percussion method in 1761 Effects of gravity on the Konica Minolta, it was of course and the invention of a stethoscope pulmonary circulation naturally moving due to breath- in 1816 (Fig. 1). Although the chest and static images ing, and I felt that I could catch image diagnosis starts with the On the other hand, the chest X-ray the heartbeat and the movement of discovery of the X-ray in 1895, it can also has an element that “reflects the diaphragm well (Fig. 3). And be seen that it was widely spread in physiology”. The lungs affected by since it is a standing X-ray exams, the 1920s, and the chest plain X-ray gravity are less likely to be visible the physiological information influ- has played an important role in in blood vessels above the hilum of enced by gravity is refl ected, and an respiratory diagnosis. healthy subjects in standing X-ray image in which the density changes

Desire to know the inside status of the lungs The pioneers of respiratory diagnostics Pulmonary circulation is West, J. B. aﬀected by gravity Discovery of percussion method 1761 Auenbrugger, L.（1722-1809）

Invention of the stethoscope 1816 Laennec, R.T.H（1781-1826） X-ray discovery 1895 Roentgen, W.K.（1845-1922）

Beginning of chest imaging diagnosis Healthy person Congestive heart failure Fig. 1 History of respiratory diagnostics

What I thought by looking at dynamic images

◆ Working with ventilation (especially the diaphragm) ◆ Standing and physiological (gravity) ◆ Density changes with inspiration and expiration ◆ Maybe able to separate ventilation and blood flow. Desire to know the inside status of the lungs The pioneers of respiratory diagnostics Pulmonary circulation is West, J. B. affected by gravity Discovery of percussion method 1761 Desire to know the inside status of the lungs Auenbrugger, L.（1722-1809） The pioneers of respiratory diagnostics Pulmonary circulation is West, J. B. affected by gravity Invention of the stethoscope 1816 Discovery of percussion method 1761 Laennec, R.T.H（1781-1826） Auenbrugger, L.（1722-1809） X-ray discovery 1895 Invention of the stethoscope 1816 Roentgen, W.K.（1845-1922） Laennec, R.T.H（1781-1826） X-ray discovery 1895 Roentgen, W.K.（1845-1922）

Beginning of chest imaging diagnosis Healthy person Congestive heart failure

Beginning of chest imaging diagnosis Healthy person Congestive heart failure Fig. 2 Effect of gravity on the pulmonary circulation

What I thought by looking at dynamic images What I thought by looking at dynamic ◆ Working with ventilation images (especially the diaphragm)

◆ Working with ventilation ◆ Standing and physiological (especially the diaphragm) (gravity) ◆ Standing and physiological ◆ Density changes with (gravity) inspiration and expiration ◆ Density changes with ◆ Maybe able to separate inspiration and expiration ventilation and blood ﬂow. Fig. 3 Impression of DDR image ◆ Maybe able to separate ventilation and blood ﬂow.

between inspiratory and expiratory DDR image is useful for measur- ●References 1）West, J.B. : Regional differences in can be obtained. Based on these ing effects of respiratory rehabili- gas exchange in the lung of erect man. characteristics, we thought that it tation and for diagnosing phrenic J. Appl. Physiol., 6 : 893-898. 1962. might be possible to separate intake nerve palsy and chronic obstructive 2）Yamada, Y., Ueyama, M., Abe, T., et al. : Time-Resolved Quantitative Analy- and blood fl ow. pulmonary disease (COPD) 2), 3). sis of the Diaphragms During Tidal The particular important thing in Besides, by observing blood flow Breathing in a Standing Position Using exhaled breath physiology is the distribution and ventilation distribu- Dynamic Chest Radiography with a Flat Panel Detector System（“Dynamic physiology of gas exchange. The tion in a standing position, diagnosis X-Ray Phrenicography”）; Initial mapping of the “Ventilation Blood of thrombotic pulmonary disease, Experience in 172 Volunteers. Acad. Flow Ratio measured by standing local distribution abnormality of Radiol., 24（4） : 393-400, 2017. ・・ 3）Hida, T., Yamada, Y., Ueyama, M., et position (VA / QC )” published in J.B. COPD, congestive heart failure, etc. al.: Decreased and slower diaphrag- 4) West’s textbooks has been used for will be possible . The DDR image matic motion during forced breath- respiratory physiology over the past is a technology originating in Japan, ing in severe COPD patients; Time- resolved quantitative analysis using 55 years. It remains as a central and I think that it is an area that dynamic chest radiography with a fl at dogma, but until now no one could Japan should lead at once in antici- panel detector system. Eur. J. Radiol., verify it. However, it is considered pation of the world now, as papers 112 : 28-36, 2019. 4）Yamada, Y., Ueyama, M., Abe, T., et that there is a possibility that this are starting to appear in Japan. al. : Difference in the craniocaudal verifi cation can be performed by the gradient of the maximum pixel value X-ray dynamic image. change rate between chronic obstructive pulmonary disease patients and normal subjects using sub-mGy Expectation to DDR image dynamic chest radiography with a fl at The visualization of the movement panel detector system. Eur. J. Radiol., 92 : 37-44, 2017. of the diaphragm and thorax with

3 The 1st Dynamic Digital Radiography Seminar Part 2 RSNA 2016 Award Lecture Certificate of Merit Dynamic Chest Radiography Using Flat Panel Detector System: Technique

Rie Tanaka, PhD College of Medical, Pharmaceutical, & Health Sciences, Kanazawa University

In this lecture, we will report images enables evaluation of the kushima (Beautiful Fukushima) on the technical features of range of movement, timing of move- Next-Generation Medical Indus- Dynamic Digital Radiography ment, and left-right synchrony. Also, try Agglomeration Project (2014- (DDR) and results of our by measuring the distance from the 2016), and conducted experiments experiments on animal. apex of the lungs to the diaphragm using pigs with the cooperation for each frame, and graphing the of Shiga Medical University and Technical features of DDR movement amount and range of Fukushima Medical University. In DDR is a new diagnostic method for movement, movement timing, and this experiment, we examined two lung function by using low-dose 1) . synchrony etc., the detailed quanti- themes of ① drawing the increase Shoot for 10 seconds at 15 fps and tative evaluation becomes possible. and decrease of inspiratory volume acquire 150 frames of X-ray images. Furthermore, it should be noted that, by pixel value and expressing the The difference from chest plain in chest radiography, the changes in amount of change by color intensity, radiography is breathing. In addi- pixel values in the lung fi eld caused ② artificially creating an atelecta- tion, the exposure dose of DDR can by differences in X-ray transparency sis and delineating it as a defect in be kept lower than the total dose of can be in black and white shades. color. 1.9 mGy of two-directional plain There are two patterns followed By this experiment, with regard to chest radiography recommended by changes in pixel value. One is ① , the pixel value is also increased by the International Atomic Energy density change of pulmonary blood according to the increase of inspira- Agency (IAEA). This is because vessels and bronchial volume per tory volume, and it can be expressed technological advances in FPD have unit volume; and the lung field by color intensity, and high correla- made it possible to perform imaging becomes white in exhalation and tion between the inspiratory volume at lower doses than in the prior tech- dark in inhalation. The other pattern and change amount of pixel value nology. Konica Minolta’s FPD has is that the lung fi eld is white during was confi rmed (Fig. 1). Also, when high linearity between incident dose systole and dark during diastole due comparing the tidal volume between and output pixel value. By combin- to changes in circulatory dynamics the normal model and the right ing it with an X-ray generator emit- associated with heart beat. However, lung atelectasis model, there is no ting X-ray pulses of 3 to 15 fps, the because it is difficult to evaluate signifi cant difference between right DDR in a general imaging room these with the naked eye, the digital and left lungs in the normal model, becomes possible. image processing is performed to but in case of right lung atelectasis In DDR, the movement of the create a color image that emphasizes model, the pixel value of the right diaphragm, chest, ribs, heart wall, on ventilation and blood fl ow. lung is significantly decreased and and changes in density in the lung the pixel values of normal left lung field due to respiration and heart Evaluation of DDR by is increased. This is considered to beat can be observed by moving animal experiments be because the tidal volume of the images. The observation of the We received financial support for normal left lung has been increased diaphragm movement by moving medical expenses from the Utsu- to maintain function.

4 Airway obstruction at the beginning of the inspiratory phase

Catheter tip

100 ml 200 ml 300 ml 400 ml 500 ml

10 10 10 10 10

8 8 8 8 8

6 6 6 6 6

4 4 4 4 4 Airway obstruction 2 2 2 2 2 ⊿ Pixel value % ⊿ 0 0 0 0 0 0 5 10 15 20 0 5 10 15 20 0 5 10 15 20 0 5 10 1520 0 5 10 15 20 Time（sec）

Fig. 1 Alveolar hypoventilation syndrome caused by right diaphragmatic nerve palsy

Airway obstruction at the beginning of the inspiratory phase

Catheter tip

and it has been shown that a mini- 100 ml 200 ml 300 ml 400 ml 500 ml mally invasive lung function diag- 10 10 10 10 10 nosis can be realized in a general 8 8 8 8 8

6 6 6 6 6 X-ray room without using a contrast

4 4 4 4 4 Airway medium. Besides, we also exam- obstruction 2 2 2 2 2 ined the possibility of pulmonary ⊿ Pixel value % ⊿ 0 0 0 0 0 0 5 10 15 20 0 5 10 15 20 0 5 10 15 20 0 5 10 1520 0 5 10 15 20 blood ﬂ ow analysis and changed the Time（sec） pixel value according to the blood Fig. 2 Quantitative comparison of diaphragm movement ﬂ ow, and were able to perform color mapping.

Future outlook With regard to ②, we checked the also confirmed that the pixel value It is important to keep in mind that pixel values in the early expira- increased with each exhalation. It DDR does not depict lung ventilatory phase of normal left lung and seems that this is capturing hyperin- tion at the alveolar level, but rather right lung which was intentionally fl ation in the lung fi eld, and we got depicts relative lung functions such airway-obstructed using a catheter. a result that DDR can also visualize as changes in lung blood vessel and It has been confi rmed that the pixel air trapping. We also examined each bronchial density. However, the value of the normal left lung was lung lobe with atelectasis model, we DDR can be said to be a new lung increased and the pixel value of the were able to visualize the decrease function diagnostic technology that obstructed right lung was decreased and loss of color intensity at the atel- has the possibility of dramatically and became flat (Fig. 2). In addi- ectasis part. increasing the diagnostic infor- tion, when airway obstruction was These examinations revealed that mation obtained in general X-ray performed in the initial exhalation DDR can be used to make a relative rooms, “from static to dynamic, phase immediately after inspiration, assessment of the inspiratory volume from form to function”. the pixel values of obstructed right and detect lung ventilatory impair- lung became fl at while maintaining ment on a per lobe basis. In addition, ●References 1）Tanaka, R. : Dynamic chest radiog- high values, and it was considered it is thought that differential diag- raphy; fl at-panel detector (FPD) based that air trapping occurred. Further- nosis of air trapping and air flow functional X-ray imaging. Radiol., Phys. more, in the atelectasis model, it is restriction can also be performed, Technol ., 9（2） : 139-153, 2016.

5 The 1st Dynamic Digital Radiography Seminar Part 2 RSNA 2016 Award Lecture Magna Cum Laude Dynamic Chest Radiography Using Flat Panel Detector System: Clinical Usefulness

Yoshitake Yamada, MD, PhD Department of Diagnostic Radiology, Keio University School of Medicine

This lecture reports on evaluation diaphragm moved signifi cantly more decline in gas exchange function in of diaphragm movement, than the right diaphragm. In multi- COPD patients ventilation weighted image variate analysis, the higher value We also evaluated the diaphrag- and blood flow enhanced of both BMI and tidal volume, the matic movements of healthy and image by using Dynamic greater movement of the diaphragm. COPD patients under forced breath- Digital Radiography (DDR). Furthermore, in comparison of ing. When dividing into mild (grade diaphragm movements between 1/2) and severe (grade 3/4) accord- Evaluation of diaphragm 47 normal subjects and 39 chronic ing to GOLD classifi cation, patients movement obstructive pulmonary disease with grade 3/4 have significantly Since the DDR is continuous image (COPD) patients, COPD patients smaller diaphragmatic movements data, in addition to the distance of moved signifi cantly more under rest under forced respiration than normal the movement of the diaphragm, breathing. In previous studies under subjects and grade 1/2 patients. the speed of movement of the forced breathing, COPD patients diaphragm can be evaluated by had smaller movements, but the Ventilation emphasis performing differentiation (Fig. 1). result was opposite. In addition, the image In this study of healthy volunteers, multivariate analysis also revealed Lung pixel values change with respi- the diaphragm movement under to be higher BMI in COPD patients, ration and cardiac output. By using a resting breathing in 172volunteers greater movement of the diaphragm low-pass fi lter and a high-pass fi lter (Japanese) averaged 11 mm in the under resting breathing 1). This in DDR, it is possible to visualize right diaphragm and 15 mm in seems to be moving the diaphragm the change of X-ray permeability the left diaphragm, and the left significantly to compensate for the by ventilation with pixel values and create a ventilation emphasis image. The ventilation emphasis image is

displayed in greenDynamic where radiographs the pixel Contrast-enhanced CT a b value decreases with inhalation and in orange where the pixel value increases during exhalation. When comparing the ventilation emphasis images of normal and COPD patients, the green and orange colors

change uniformlyVentilation-weighted in normal subjects, image Perfusion-weighted image ・Using a Prewitt Filter. c ・The average excursions of the diaphragms during tidal breathing : and the green and orange colors d 11.0 mm（right）and 14.9 mm（left）in 172 Volunteers. ・Diaphragmatic motion of the left is larger and faster than that of the right. change in COPD patients unevenly. ・Higher BMI and tidal volume are associated with increased excursions of the bilateral diaphragm. In the cases of following right lung cancer resection and radiotherapy Fig. 1 Evaluation of diaphragmatic movement by DDR image in Fig. 2, the ventilation emphasis

down up 6 （white） X-ray density （black）

a b c Ventilation-weighted images derived from Ventilation scintigraphy Ventilation scintigraphy dynamic chest radiography anterior image posterior image Dynamic radiographs Contrast-enhanced CT a b

Ventilation-weighted image Perfusion-weighted image ・Using a Prewitt Filter. c ・The average excursions of the diaphragms during tidal breathing : d 11.0 mm（right）and 14.9 mm（left）in 172 Volunteers. ・Diaphragmatic motion of the left is larger and faster than that of the right. ・Higher BMI and tidal volume are associated with increased excursions of the bilateral diaphragm.

down up （white） X-ray density （black）

a b c image (Fig. 3d), the left lung showed Ventilation-weighted images derived from Ventilation scintigraphy Ventilation scintigraphy a change consistent with heart-beat, anterior image posterior image dynamic chest radiography but was not observed in the right lung. In the DDR image (Fig. 3a), only the left lung changed pixel values in accordance with the heartbeat, and no change was observed in the right lung. From this, it can be said that changes in pixel values are accurately extracted to some extent Fig. 2 Right lung cancer after resection and radiotherapy (68 years old, male) in both the ventilation emphasis a: Ventilation weighted image b, c: Lung ventilation scintigraphic image image and the blood fl ow emphasis image. Dynamic radiographs Contrast-enhanced CT a b Summary DDR has the advantage that ventilation and heart beat can be evaluated in the standing or sitting position. In our study, the left diaphragm moved more than the right diaphragm under Ventilation-weighted image Perfusion-weighted image ・Using a Prewitt Filter. c ・The average excursions of the diaphragms during tidal breathing : d resting and forced breathings, and 11.0 mm（right）and 14.9 mm（left）in 172 Volunteers. higher than BMI, and larger than the ・Diaphragmatic motion of the left is larger and faster than that of the right. ・Higher BMI and tidal volume are associated with increased movement of the diaphragm under excursions of the bilateral diaphragm. resting breathing. Furthermore, in comparison with normal subjects and COPD patients, the move- down up ment of the diaphragm was greater （white） X-ray density （black） in normal subjects under forced Fig. 3 Right pulmonary artery thromboembolism respiration and in COPD patients (75 years old, female) a: Dynamic X-ray analysis image under rest breathing. In addition, in b: Contrast-enhanced CT image ventilation emphasis images, differ- c: Ventilation emphasis image d: Blood fl ow emphasis image ences were seen in changes in pixel a b c Ventilation-weighted images values due to ventilation in healthy derived from Ventilation scintigraphy Ventilation scintigraphy dynamic chest radiography anterior image posterior image subjects and COPD patients. On the other hand, the blood fl ow emphasis image (Fig. 2a) has the bulla portion possible to extract changes in pixel image is expected to allow assess- of the right lung moving in reverse values of the lung due to heart beats, ment of coarse pulmonary artery to the normal portion. Also in lung and to create a blood flow empha- thromboembolism without the use ventilation scintigraphy (Fig. 2b, c), sis image. Fig. 3 is a case of right of contrast agents. the uptake of nuclide was observed pulmonary artery thromboembo- only in the normal part of the right lism, and in the ventilation emphasis ● References lung, which was consistent with the image (Fig. 3c), the green shading 1）Yamada, Y., Ueyama, M., Abe, T., et al. : Diff erence in diaphragmatic motion ventilation emphasis image. indicates inspiration and orange during tidal breathing in a standing shading indicates expiration, and position between COPD patients and Blood fl ow emphasis both are uniformly distributed. Both normal subjects ; Timeresolved quantitative evaluation using dynamic chest image lungs are believed to uniformly radiography with flat panel detector Furthermore, by using the low-pass distribute air inspired. On the other system（"dynamic X-ray phrenicogra- filter and the high-pass filter, it is hand, in the blood flow emphasis phy"）. Eur. J. Radiol., 87 : 76-82, 2017.

7 The 1st Dynamic Digital Radiography Seminar Part 3 Clinical Research Report Progress of Dynamic Digital Radiography in our hospital

Department of Respiratory Medicine, Tokai University Hachioji Hospital / Fumio Sakamaki, MD Respiratory Division, Department of Internal Medicine, Tokai University School of Medicine

In our hospital, we have the prognosis differs greatly even defi nition CT) and so on. been conducting clinical in similar cases of COPD and idio- research on medical treatment pathic pulmonary fi brosis (IPF). 1. Process fl ow for system of respiratory diseases by For example, in COPD, in the new confi guration and tests in Dynamic Digital Radiography GOLD classifi cation revised in 2011, our hospital (DDR) using Konica Minolta’ s it is classifi ed into four of A to D in In our hospital, we use the FPD system from 2018. In this consideration of mMRC, CAT score, Konica Minolta DDR system lecture, we outline the clinical exacerbation risk, etc. in the conven- to shoot for approximately research performed at our tional staging (stage 1-4). In such 10 seconds in the shooting room, hospital while presenting cases, it is recommended to change and save the static image in PACS, actual cases. the treatment approach. The exacer- and transfer the movie to a dedi- bation of COPD is likely to occur in cated movie analysis workstation Means and problems of specific patients 1) , but the issue is to perform motion analysis. The respiratory disease medi- how to extract it. usefulness of this system is that the cal treatment exposure dose is as small as several In the severe cases of chronic Clinical research practice plain radiographs and that imaging progressive lung disease [such as in our hospital is easy. Findings similar to CT can chronic obstructive pulmonary Thus, we think that we may be able be obtained with simpler and lower disease (COPD) and interstitial to extract cases with high sever- dose than CT. pneumonia] among respiratory ity and risk of exacerbation by diseases, in recent years, shortness performing analysis by taking chest 2. Outline of previous cases of breath evaluation by a medical X-ray dynamic images at the first The breakdown of cases in which interview [corrected MRC (mMRC), examination at our hospital, and chest dynamic analysis was COPD assessment Test (CAT) score] we initiated clinical research from performed until September 2018 and the number of acute exacerba- January 2018. The subjects are is as follows: COPD (the largest tions (exacerbation risk) are very normal control approximately 10-20 group): 19 cases, interstitial pneu- important. In addition, the imaging cases, COPD approximately 20-30 monia: 8 cases, pulmonary throm- diagnostics such as plain radiogra- cases, pulmonary emphysema and boembolism: 9 cases, lung cancer: phy, CT, pathological examination, pulmonary fi brosis (CPFE) approxi- 1 case, other conditions: 5 cases. and the functional examination such mately 5-10 cases, and other diseases Among these cases, COPD was as ventilation function assessment, approximately 20 cases. Clinical data most frequently stage 2 and least lung volume fractionation (residual include symptom records (mMRC, frequently stage 3 as a result of eval- mass), diffusion ability (DLco), and CAT score, number of exacerbations/ uating severity using the conven-

biochemical examination indica- year), oxygen saturation (SpO2), lung tional GOLD classification from tive of pathology are assessed using function (as far as possible to DLco), 1-second dose vs. predicted value index values, and it can be seen that plain radiograph, CT (with high (% FEV1) of spirometry. On the

8 ・ 41-year-old woman ・ Patient experienced shortness of breath and edema

at work, SpO2 = 92%. Patient was diagnosed at another hospital with idiopathic pulmonary arterial hypertension. ・ MPA = 37 mmHg, PVR = 541 dyne/sec/cm－5 ・ 41-year-old woman ・ ABG: pH 7.34, PaO2 56, PaCO2 73 ・・ Patient VC = 1.54 experienced L (58%), shortnessFRC = 2.03 of Lbreath (107%), and RV/TLC edema = at49%, work, TLC SpO =2 3.0= 92%. L (77%), Patient DLco was = diagnosed118% at ・ anotherPulmonary hospital hypertension with idiopathic with type pulmonary II respiratory arterial hypertension.failure (introduction to NIPPV) ・・ The MPA cause = 37 of mmHg, type II PVRrespiratory = 541 failuredyne/sec/cm was －5 ・ ABG:unknown: pH 7.34, The PaOpresence2 56, ofPaCO neuromuscular2 73 disease ・ VCwas = also1.54 negative.L (58%), FRC = 2.03 L (107%), RV/TLC = 49%, TLC = 3.0 L (77%), DLco = 118% ・ Pulmonary hypertension with type II respiratory failure (introduction to NIPPV) ・ The cause of type II respiratory failure was unknown: The presence of neuromuscular disease Fig. 1 Alveolar hypoventilation was also negative. syndrome due to right diaphragmatic nerve palsy

a：COPD Diaphragm did not move smoothly during second The patient was a 73-year-old male inspiration. Patient was unable to exhale. ，男性

a：COPD Diaphragm did not move smoothly during second b：NormalThe patient was a 73-year-old male inspiration. Patient was unable to exhale. The，男性 patient was a 38-year-old female

b：Normal The patient was a 38-year-old female In the normal case, no obstruction to the COPD Normal movement of the diaphragm is visible even at the second inspiration. Fig. 2. Quantitative comparison of diaphragm movement

In the normal case, no obstruction to the Expectations for chest other hand, whenCOPD the same case wasNormal 118%,movement and of thethe diaphragm lung parenchymais visible even was evaluated by the new GOLD clas- consideredat the second inspiration.not to be impaired. Chest dynamic imaging sification (A to D) in consideration dynamic imaging revealed respirato- Chest dynamic imaging is expected of the exacerbation risk, B was the ry failure due to right diaphragmatic to make it possible to observe chest largest even in the same four stages, nerve palsy that was not known movement, collapse of the central and A, C, and D were almost the in the static image, and was diag- airway, imbalance of ventilation, and same. In other words, it was found nosed with alveolar hypoventilation assessment of severity and exacerba- that, among the same %FEV1 cases, syndrome. tion risk in COPD and ventilatory those with a high risk of exacerba- In addition, in severe COPD cases, the failure. This is believed to be useful tion were included. regions with less change during exha- in the assessment of the severity lation and inhalation are observed in and exacerbation risk of interstitial 3. Case presentation chest dynamic imaging compared to lung disease, and early diagnosis Fig. 1 : The patient was a 41-year- normal lungs, and its quantiﬁ cation is of pulmonary circulatory disorders old female. The patient was diag- required in the future. in emergency outpatients. In addi- nosed with idiopathic pulmonary In addition, our hospital is also tion, since this method can also be arterial hypertension (PAH) at conducting research to compare the expected to be able to remove the another hospital because of short- movement of the diaphragm of cases overlap between tumor and bone, ness of breath, edema, and hypox- with different respiratory func- which is a weakness of ordinary emia, and visited our hospital. In tions quantitatively. When COPD chest radiographs, it is expected lung function test, the lung capac- and normal cases are compared, no to be effective as a screening for ity decreases with 58%, and the disorder is found in the movement of neoplastic lesions in the future. functional residual capacity (FRC) the diaphragm in healthy cases (Fig. increases with 107%, but the total 2b), but in COPD, the movement ●References lung capacity (TLC) is small with of the diaphragm is irregular at the 1）Hurst, J.R., et al., N. Engl. J. Med ., 77%, while DLco is normal with second inhalation (Fig. 2a). 363（12）: 1128-1138, 2010.

9 The 1st Dynamic Digital Radiography Seminar Part 3 Clinical Research Report Examination of evaluation method of respiratory function by Dynamic Digital Radiography image

Noriyuki Ohkura, MD Department of Respiratory Medicine, Kanazawa University Hospital

At our hospital, we used a by comparison with lung volume years), and the rate of change in Konica Minolta Dynamic fractionation, maximal effort call- pulmonary area (% Change) due to Digital Radiography (DDR) ing curve, and COPD assessment respiratory change is (maximum system to examine respiratory test (CAT) score. In this way, we inspiratory lung area-maximum function. In this lecture, aim at establishment of respiratory exhaled lung area) / maximum inspi- we will discuss actual function test with little burden on ratory lung area. The breakdown of examination method and its patients, construction of alternative cases was as follows: lung cancer results. method of precision lung function in the normal spirometric range: test, evaluation of physical activity. 36 cases, COPD: 46 suspected cases Purpose and methods The method is the examination of and 7 confirmed cases, intersti- The purpose of this study was to chest X-ray movie and respiratory tial pneumonia: 24 cases, asthma: verify the relationship between lung function in 121 subjects (80 males, 3 cases, other conditions: 5 cases. area change and respiratory function 41 females, age range: 68.5 ± 9.3 The imaging system is almost the same as the conventional static Correlation between lung area Correlation between rate of changeimage in pulmonary shooting area except for pulse (maximum inspiratory position) and respiratory function and respiratory function

Lung area （n = 121） %Changeirradiation,（n and = 121） performs shooting r p rfor 15 pframes over a period of 10-20 VC 0.72 < 0.05 VC 0.21 <0.05

FEV1 0.53 < 0.05 FEV1 0.31seconds <0.05 from deep exhalation to FEV1/FVC －0.33 < 0.05 FEV1/FVC 0.05 0.61 MMF 0.004 0.96 MMF 0.15deep 0.11inspiration. The exposure dose FRC 0.86 < 0.05 FRC －0.10is equivalent 0.28 (0.23mSv) to the front + RV 0.69 < 0.05 RV －0.18 <0.05 RV/TLC 0.001 0.99 RV/TLC －0.40side <0.05view of a still image even with Fig. 1 Correlation between TLC 0.82 < 0.05 TLC 0.07 0.46 lung area and res- a 20-second exposure. Lung area (maximum inspiratory position) was piratoryThe rate of functionchange in lungat area is positively correlated with vital capacity, functional ・vital capacity, 1 second volume and a weak positive residual capacity, and total lung capacity. maximum correlation inspiratorywere observed. Evaluation and Discus- position・A negative correlation was found between and residual rate. sion

Correlation between lung area Correlation between rate of change in pulmonary area The subject was relatively elderly (maximum inspiratory position) and respiratory function and respiratory function

Lung area （n = 121） %Change （n = 121） and approximately a half of them r p r p had some form of air flow restric- VC 0.72 < 0.05 VC 0.21 <0.05 Correlation between rate of change in pulmonary area and CAT score FEV1 0.53 < 0.05 FEV1 0.31 <0.05 tion, and as such the 1-second rate （n = 14） FEV1/FVC －0.33 < 0.05 Normal respiratory function (SAS) FEV1/FVCSevere 0.05 COPD 0.61 1 MMF 0.004 0.96 MMF 0.15 0.11 (FEV / FVC%) tended to be low 25 FRC 0.86 < 0.05 FRC －0.10 0.28 at 70%. Looking at the correlation RV 0.69 < 0.05 RV －0.18 <0.05 between lung area and respiratory20 RV/TLC 0.001 0.99 RV/TLC －0.40 <0.05 Fig. 2 Correlation between 15 TLC 0.82 < 0.05 TLC 0.07 0.46 rate of change in function at the maximum inspiratory Lung area (maximum inspiratory position) was The rate of change in lung area is pulmonary area and position (Fig. 1), vital capacity (VC),10 positively correlated with vital capacity, functional ・vital capacity, 1 second volume and a weak positive respiratory function residual capacity, and total lung capacity. correlation were observed. CAT score 5 ・A negative correlation was found between and residual rate. due to respiratory functional residual capacity (FRC), 0 fluctuation total lung－0.5 capacity －0.4 －0.3(TLC), －0.2 etc. －0.1 A 0 % changeof area 10 r=0.605，p=0.02

Correlation between rate of change in pulmonary area and CAT score The rate of change in lung area was correlated with CAT score in COPD patients. Normal respiratory function (SAS) Severe COPD （n = 14）

CAT score 5

0 －0.5 －0.4 －0.3 －0.2 －0.1 0 % changeof area

r=0.605，p=0.02

The rate of change in lung area was correlated with CAT score in COPD patients. Correlation between lung area Correlation between rate of change in pulmonary area (maximum inspiratory position) and respiratory function and respiratory function

Lung area （n = 121） %Change （n = 121） r p r p VC 0.72 < 0.05 VC 0.21 <0.05

FEV1 0.53 < 0.05 FEV1 0.31 <0.05

FEV1/FVC －0.33 < 0.05 FEV1/FVC 0.05 0.61 MMF 0.004 0.96 MMF 0.15 0.11 FRC 0.86 < 0.05 FRC －0.10 0.28 RV 0.69 < 0.05 RV －0.18 <0.05 RV/TLC 0.001 0.99 RV/TLC －0.40 <0.05 TLC 0.82 < 0.05 TLC 0.07 0.46

Lung area (maximum inspiratory position) was The rate of change in lung area is positively correlated with vital capacity, functional ・vital capacity, 1 second volume and a weak positive residual capacity, and total lung capacity. correlation were observed. ・A negative correlation was found between and residual rate.

Correlation between lung area Correlation between rate of change in pulmonary area Correlation between rate of change in pulmonary area and CAT score (maximum inspiratory position) and respiratory function and respiratory function （n = 14） Lung area （n = 121） Normal respiratory%Change function (SAS) （n = 121） Severe COPD progressed, and the movement of the r p r p 25 VC 0.72 < 0.05 VC 0.21 <0.05 lungs was worse as the lungs shrank. FEV1 0.53 < 0.05 FEV1 0.31 <0.05 These findings suggest that quanti- 20 FEV1/FVC －0.33 < 0.05 FEV1/FVC 0.05 0.61 MMF 0.004 0.96 MMF 0.15 0.11 ﬁ cation of lung area change may be 15 FRC 0.86 < 0.05 FRC －0.10 0.28 useful for evaluating the progression 10 RV 0.69 < 0.05 RV －0.18 <0.05

RV/TLC 0.001 0.99 RV/TLC －0.40 <0.05 of COPD and interstitial pneumonia.CAT score 5 TLC 0.82 < 0.05 TLC 0.07 0.46 In fact, when DDR were used to 0 Lung area (maximum inspiratory position) was The rate of change in lung area is －0.5 －0.4 －0.3 －0.2 －0.1 0 ・vital capacity, 1 second volume and a weak positive compare normal respiratory func- positively correlated with vital capacity, functional % changeof area residual capacity, and total lung capacity. correlation were observed. ・A negative correlation was found between and residual rate. tion (sleep apnea syndrome : SAS) r=0.605，p=0.02 with severe COPD, it was conﬁ rmed

Fig. 3 Image comparison of normal respiratory function (sleep that theThe lungs rate of werechange hyperinflatedin lung area was correlated with CAT score apnea syndrome) and severe COPD and movementin COPD patients. was poor in severe COPD cases (Fig. 3). Correlation between rate of change in pulmonary area and CAT score Thus, QOL was also evaluated in the （n = 14） Normal respiratory function (SAS) Severe COPD COPD cases. The CAT score, which 25 is widely used in clinical practice, 20 is an evaluation method that scores 15 eight questions related to QOL, such 10 as cough, sputum, dyspnea, activity, CAT score 5 and depression tendency. The higher 0 －0.5 －0.4 －0.3 －0.2 －0.1 0 the score, the stronger the symp- % changeof area toms. On the other hand, the rate of

r=0.605，p=0.02 change in pulmonary area decreased as the symptoms became stronger, The rate of change in lung area was correlated with CAT score and showed a correlation with the in COPD patients. CAT score (Fig. 4). In other words, Fig. 4 Correlation between rate of change in pulmonary area and it is shown that lung motion was CAT score in COPD not only correlated with respiratory function but also with QOL evalua- positive correlation was found, but ventilatory impairment were mixed tion. no correlation was found between the in this subject, the analysis was

1-second volume (FEV1 ) obtained first limited to cases with airflow Result from the forced expiratory curve, restriction (obstructive ventilatory The lung area was strongly corre- the 1-second rate, and the maximum impairment). When the stratifi cation lated with the lung volume fraction. expiratory flow rate (MMF). Next, and rate of change in pulmonary The rate of change in pulmonary looking at the correlation between area were divided according to the area associated with respiratory lung area change rate and respira- predicted value within one second, fluctuation was correlated with the tory function with respiratory fluc- the rate of change in pulmonary residual air rate and decreased with tuation (Fig. 2), vital capacity and area decreased with the prog- the progress of airflow restriction 1 second dose were weakly positive- ress of airflow limitation, and the and decreased vital capacity, and in ly correlated, and residual rate (RV/ lung movement was worse as the COPD patients, the correlation with TLC) was negatively correlated. In obstructive ventilatory impairment CAT score was also observed. From particular, the correlation with the progressed. Next, when restric- the above, DDR image is expected residual rate suggests that the lung tive ventilation disorder (interstitial to be used as substitutes for respira- movement may deteriorate as hyper- pneumonia) cases were stratifi ed for tory function test with low patient infl ation progresses. each vital capacity and examined, burden and physical activity evalua- Furthermore, since obstructive venti- the rate of change in pulmonary area tion. latory impairment and restrictive decreased as vital capacity decline

11 The 1st Dynamic Digital Radiography Seminar Part 3 Clinical Research Report Practical use of Dynamic Digital Radiography (DDR) in lung resection

Masaya Tamura, MD Department of Thoracic, Cardiovascular and General Surgery, Kanazawa University

At our hospital, we perform verification method compares the rate of change in lung area tended to pulmonary resection for lung lung area change rate of the affected be lower in these patients (p = 0.07). cancer. We considered that side lung for each group for the Comparing X-ray dynamic images Dynamic Digital Radiography presence or absence of preoperative of upper lobectomy case and lower (DDR) would be useful in background lung, resected leaves, lobectomy case, it can be seen that, the perioperative period, and postoperative complications. in the lower lobectomy case, the and ①examined non-invasive The rate of change in pulmonary movement of the blood vessel shad- respiratory function evaluation area is calculated by the formula ow and diaphragm is large overall method for pulmonary [(maximum inspiratory lung area− and the rate of change in pulmonary resection case, and ②examined maximum expiratory lung area)/ area is high, but in the upper lobec- the application of DDR in maximum expiratory lung area]. tomy case, there was a tendency for pulmonary resections. the movement of the affected side 1. Comparison of preopera- to be small. After one month, there Examination of respirato- tive background lung was almost no difference in rate of ry function evaluation for Comparison of rate of change in change in pulmonary areas in both pulmonary resection case pulmonary area of lung in the groups. In 58 patients who underwent lobec- preoperative background with tomy for lung cancer between Febru- normal lung, emphysema complicat- 3. Comparison of postop- ary 2016 and December 2017, rate ed fibrosis, pulmonary fibrosis and erative complications of change in pulmonary area was pulmonary emphysema. Although Comparison of rate of change in examined using DDR. Background: there is no significant difference, pulmonary area before surgery for Case breakdown: normal lungs: 21 patients with pulmonary fibrosis the group [complication (+)] and cases, emphysema complicated by were preoperatively compared with the group [complication (-)] not fibrosis: 10 cases, pulmonary fibro- normal lungs, and the rate of change showing postoperative complica- sis: 7 cases, pulmonary emphysema: in lung area tended to be lower in tions, complications (+) tended to 20 cases. The resected lobes were these patients (p = 0.07). be slightly lower than complications located in the upper lobe in 33 cases (-) (p = 0.09). In addition, complica- and in the lower lobe in 25 cases. 2. Comparison of resected tions (+) were signiﬁ cantly lower at Postoperative complications were pulmonary lobes one week after surgery (p = 0.04). seen in 11 cases: 5 cases of pneu- Comparison of rate of change in The possibility that the inﬂ uence of monia, 1 case of acute exacerbation pulmonary areas between upper and the insertion of a drain may have an of interstitial pneumonia, and in 5 lower lobectomy groups showed no effect on patients with air leakage cases of air leakage. particular tendency before surgery, cannot be ruled out, but in compari- The radiographs were taken before but when the upper lobectomy group son with the presence or absence of surgery, one week after surgery, was compared to the lower lobec- postoperative complications, there is and one month after surgery. The tomy group 1 week after surgery, the a tendency for the rate of lung area

12 observed from the blood vessel shadow, and it is thought that it can be used for follow-up observation after surgery. Fig. 1 is a (dynamic) image of the patient who underwent resection of the right lung 50before 40 Left lung surgery, one week after surgery,30 and 20 one month after surgery. One week Right lung Improvement of 10

lung movement distance [mm] after surgery, the lungs were0 still Apical-diaphragm 0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 Before surgery One week after surgery One month after surgery affected by withdrawal and respira- Time [sec] The movement of the lung is approved from the blood vessel shadow Independent evaluation of left and tory motion was poor, but after one right diaphragm movement month, we found that this motion Fig. 1 Follow-up observation after pulmonary resection had improved. DDR can be used for quantitative analysis. By measuring the distance between the lung apex and the diaphragm, the movement of the left and right lungs and diaphragm can be evaluated 50 40 separately. In the case of diaphrag- Left lung 30 20 matic nerve palsy, quantitative Right lung Improvement of 10 evaluation clearly shows that the

lung movement distance [mm] 0 Apical-diaphragm 0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 movement of the right diaphragm Before surgery One week after surgery One month after surgery Time [sec] Fig. 2 Confirmation of is less than that of the left, and The movement of the lung is approved from the blood vessel shadow Independent evaluation of left and right diaphragm movement diaphragmatic that the left-right synchrony is lost nerve palsy (Fig. 2). Such a left-right difference is information that is difficult to grasp in a still image, and is an area where DDR image can be used. In addition, DDR can be used to change to decrease with complica- the operation was signiﬁ cantly lower confirm adhesions and infiltration. tions (+). It can be said that. than those with no postoperative Dynamic images that allow visual complications. observation of blood vessel shadows 4. Summary These findings suggest that DDR and chest wall motions can easily Background: In the comparison may be able to evaluate lung func- estimate adhesion sites where move- of lung, patients with pulmonary tion before and after pulmonary ment is restricted and infiltration fibrosis tended to have a lower resection and may contribute to sites, and are useful for preopera- rate of change in lung area before postoperative complication predictive and postoperative evaluation of surgery. In addition, in compari- tion. pulmonary resection. son of resected leaves, patients who received upper lobe resection Examination of utilization Summary usually tended to have a decrease in method of DDR in pulmo- DDR is very useful in postoperative rate of change in pulmonary area for nary resection case follow-up, detection of diaphrag- one week after surgery. There was The possibility of using DDR in matic nerve palsy, detection of adhe- also tendency for the rate of change pulmonary resection is explained sions, detection of chest wall inva- in pulmonary area before operation based on actual case images. sion and aortic invasion, etc., and to decrease and the rate of change in In the dynamic image, the move- may be used in the perioperative pulmonary area for one week after ment of the lung can be visually period of pulmonary resection.

13 The 1st Dynamic Digital Radiography Seminar Part 3 Clinical Research Report Evaluation of surgical indication by Dynamic Digital Radiography

Jun Hanaoka, MD, PhD Division of General Thoracic Surgery, Department of Surgery, Shiga University of Medical Science

We perform approximately function in pulmonary % FEV1.0 after surgery is less than 230 operations a year in our resection 40%, there is a very high risk, so hospital, of which around DDR can visualize and quantify reduction surgery is considered. 120 are pulmonary resection ventilation and blood fl ow informa- Postoperative respiratory func- for primary lung cancer. tion, but in our hospital, we focused tion prediction is to calculate the During the perioperative on blood fl ow and decided to study postoperative respiratory function period of pulmonary its application in respiratory surgery. using a formula based on the size of resection, respiratory With regard to the validity of the remaining lung after resection function evaluation has been dynamic X-ray analysis, it is and the respiratory function before performed by spirometry, reported that the correlation signal operation. The lungs are divided but early examination after value and blood flow scintigraphy into the upper lung, the middle lobe, the operation may not have (99m Tc), which represent blood flow and the lower lobe, and the left lung, been able to be measured and ventilation, were observed from the upper lobe and the lower lobe. suffi ciently due to wound pain. Fukujuuji Hospital (R = 0.72) 1), and The blood flow and the airway are In addition, at our hospital, it has been shown that kinetic blood divided into 19 anatomical areas. evaluation was performed by flow evaluation can substitute lung For example, if there is a tumor in CT volumemetry before, but it blood fl ow scintigraphy. the right upper lobe and resection was not possible to evaluate Preoperative risk assessment is of the right upper lobe (3 areas) is it dynamically because it was important for highly invasive performed, the lung volume after taken under maximum breath pulmonary resection. In particular, resection is reduced by 16%, so lung respiratory arrest. cardiopulmonary function is empha- function (%FEV1.0) is 100% to 84% Dynamic Digital Radiography sized, and the “lung cancer medical before surgery I think it will decline. (DDR) that enables dynamic care guideline” recommends that By multiplying this with the result evaluation is considered to spirometry-based respiratory func- of the respiratory function before be able to evaluate how the tion evaluation be performed in the operation, the postoperative predic- lungs are changing during determination of surgical indication. tion value is calculated. forced breathing and at rest In respiratory function evaluation, Although this method is very breathing, and after approval measurement of vital capacity (VC) simple, if you have chronic obstruc- by our ethics committee, and 1 second rate (%FEV1.0) by tive pulmonary disease (COPD) clinical imaging started in spirometry, measurement of lung or interstitial pneumonia, the lung

June 2018. In this lecture, we diffusion ability (DL CO) in preci- function has already decreased, introduce DDR research in our sion lung function test, calculation so the present method of simply hospital. risk assessment is performed, such calculating based on the number of as postoperative respiratory function areas has low predictive accuracy. prediction. In postoperative respi- Thus, we perform lung blood flow Evaluation of respiratory ratory function prediction, if the scintigraphy in order to evaluate in

14 Dynamic analysis

post-operative FEV1 = number of resected area pre-operative FEV1 × 1－contribution rate on the diseased side× （ number of aﬀected area ）

【merit】 Dynamic imaging with high predictive accuracy requires less eﬀort and cost, and can be examined quickly to consider the state of blood ﬂow and ventilation for each lung

Fig. 1 Postoperative respiratory function prediction by dynamic analysis

more detail at our hospital, calculate We are planning to carry out two said to recover to the predicted the postoperative respiratory func- confirmatory studies in the future. value in 3 to 6 months after surgery, tion prediction value by considering The first will be a comparison of and we will consider including the the contribution rate on the affected postoperative respiratory function course of the recovery. side, and decide the appropriate predictions with actual measure- treatment approach. However, lung ments. We will verify which method Future outlook blood ﬂ ow scintigraphy test is time- is appropriate by comparing the As a future perspective of DDR, it consuming and costly, and the predicted values of postoperative is thought ﬁ rst that local abnormal- examination date is limited at our respiratory function calculated ity evaluation of lung function could hospital, and the lack of urgency is from the calculation methods of the be performed. Since it is said that an issue. conventional method and kinetic the respiratory function is reduced analysis with the measured values and cause complications if there Postoperative respiratory of respiratory function measured is pulmonary emphysema or simi- function prediction by after the operation. The second lar conditions in remaining lung DDR will be a comparison based on the tissue during pulmonary resection, Therefore, we focused on postop- presence of complications. We will we expect that our findings will be erative respiratory function predic- compare the groups where post- useful in connection with dynamic tion and decided to examine the operative complications occurred analysis to accurately estimate surgi- possibility of using DDR (Fig. 1). and the group where no complica- cal risk. Dynamic analysis does not allow tions occurred, and verify whether The other is an evaluation of detailed evaluation of lung lobes and there is a significant difference in oxygenated blood flow ratio (V/Q) areas, but it is considered possible postoperative respiratory function mismatch, and it is expected that to evaluate left and right lungs sepa- prediction value. At the same time, evaluation will be possible by DDR rately. Dynamic analysis is expected we plan to examine factors related with less labor, cost, and exposure, to have high predictive accuracy to complications from the animation so we will examin the method. because it accounts for the state of and analysis results. blood flow and ventilation for each In addition, the imaging time is ●References of the left and right lungs. In addi- implemented at the timing of one 1）Aoki, M., et al：Dynamic Chest X-Ray tion, Dynamic radiography requires month, three months, six months, Examination For Pulmonary Blood Flow Function: In Comparison With less effort and cost, and enables and twelve months before surgery, Tc-99m MAA Scintigraphy. American quick examination. postoperatively. Lung function is Thoracic Society 2012.

15 The 1st Dynamic Digital Radiography Seminar Part 4 Discussion Clinical value and potential of Dynamic Digital Radiography - From each specialized area

Chairpersons Atsuko Kurosaki, MD, PhD Department of Diagnostic Radiology, Fukujuji Hospital, Japan Anti-Tuberculosis Association Terumitsu Hasebe, MD, PhD Tokai University School of Medicine Commentators Yoko Shibata, MD, PhD Department of Pulmonary Medicine, Fukushima Medical University Mitsuru Tabusadani, PhD Department of Respiratory Care and Rehabilitation, Fukujuji Hospital, Japan Anti-Tuberculosis Association Hiromi Oda, MD, PhD Director of Saitama Medical University Hospital

In the 4th part of the discussion, many respiratory physicians have standing position. It is considered we had active discussion longed for, and we have great hope that DDR images can be used in after 4 commentators for future indications. such cases to verify the patient’s commented the clinical values For example, chronic respiratory respiratory status and effective and potential regarding diseases may be exacerbated by teaching methods. the clinical application of respiratory tract infections etc., In addition, DDR images may be Dynamic Digital Radiography but the difference between stable useful for verifying the effective- (DDR) images in each respiration and dyspnea has not ness of mouth-to-mouth breath- specialization area under yet been clarified. It is thought ing for the prevention of airway the title “Clinical value and that it is possible to evaluate what obstruction at the time of expira- potential of Dynamic Digital infl uence V/Q mismatch has on the tion conducted by patients with Radiography-From each pathological condition of chronic asthma or COPD. It is expected specialized area”. respiratory diseases by using DDR that it will become possible to images. For this purpose, it is observe in a moving image that Respiratory medicine important in the future to consider “air-wrapping” is eliminated by Possibility of replacing a highly quantitative evaluation whistling breathing. In addition, lung ventilation scintigra- method. although instruction is given on phy inhalation for inhaled drugs such Mr. Shibata: In the field of Rehabilitation, emergen- as bronchodilators, there are a respiratory medicine, it is impor- cy and disaster medicine large number of patients who tant to evaluate the imbalance of Expectation for use in cannot perform inhalation correct- ventilation/blood flow ratio (V/Q respiratory rehabilitative ly, so if the dilation of the trachea mismatch) that causes hypoxemia. guidance and air fl ow by inhaling broncho- Conventionally, lung ventilation Mr. Tabusadani: In our hospital, dilators can be confi rmed visually scintigraphy has been used as an we have been teaching abdominal by DDR images, I thought it would evaluation method, but its spread breathing, which is an efficient be useful for confi rming the effec- has not progressed because of breathing method in the rehabili- tiveness of inhalation instruction. complicated inspection proce- tation of patients with respiratory Apart from respiratory organs, the dures, exposure, and high cost. disease. There is a patient who can indications for rehabilitation of However, the appearance of DDR start to sit and stand from a supine swallowing are expected. Although images may facilitate the evalua- position, but cannot perform swallowing imaging (VF) is useful tion of V/Q mismatch. This is what abdominal breathing while in a for assessment of dysphagia, DDR

16 may be useful as an alternative more easily by using DDR, and the ing angle and can maintain its examination in facilities that are improvement of treatment accu- inherent deep area perception, not well equipped and cannot be racy can also be expected in the it needs to peel off the attached implemented in this technique. In future. part, thus making the procedure addition, in rehabilitation in the difficult. It is possible to increase field of orthopedic surgery, the Orthopedics the indication of CR type surgery adaptation to evaluation of joint Possibility to preoperative and improve the accuracy of the movement can be considered. evaluation of total knee procedure by evaluating the length On the other hand, the usefulness arthroplasty of this affixation section exfolia- of DDR images is also expected Mr. Oda: The indications for tion by using DDR image before in emergency care and super acute DDR images in the ﬁ eld of ortho- surgery. care environments such as the pedics include the preoperative In addition, indications for ICU. We are performing postural evaluation of total knee arthro- lumbar spinal stenosis can also be drainage in patients with lower plasty. Types include cruciate expected. At present, myelogra- lung injury, but it is important to retention-type (CR-type) which phy is performed in patients who accumulate information such as preserves the posterior cruciate have surgery indication, but it is the location of atelectasis in the ligament and posterior stabilizer- possible to evaluate the indication lung which is responsible for blood type (PS-type) which involves of surgery etc., by observing the ﬂ ow decline or respiratory failure. placement of knee prosthesis. movement with DDR image. At present, CT is performed, but Although the CR type has no it is becoming possible to assess limitation on the maximum bend-

The 1st Dynamic Digital Radiography Seminar

Published March 21, 2019 Issue: KONICAMINOLTA, INC 1 Sakura-machi, Hino-shi, Tokyo 191-8511, Japan Tel: +81 42-589-8145 Fax: +81 42-589-1716

Volume 35 Issue 3(Serial Vol. 408) The 2nd March 2020 Issue Dynamic Digital Radiography Seminar Date and time： 14:00 to 17:30, Saturday, November 2, 2019 Venue：Fukuracia Yaesu Conference Room A

CONTENTS

Part2 Clinical Research Report Part3 Report on usefulness in clinical practice: Discussion Evaluation of pulmonary circulation by Dynamic Digital Radiography : Dynamic Digital Radiography: Comparison with Method on chest application ……………………………… 12 pulmonary perfusion scintigraphy ……………………… 02 Radiological Technology Department, Clinical Technology Division, Munehisa Takata, MD Department of Thoracic Surgery, Kanazawa University Ryotaro Yuji Tokai University Hachioji Hospital

Prediction of postoperative pulmonary function Focusing on patients with COPD, using Dynamic Digital Radiography …………………… 04 and Ventilation defect ……………………………………… 14

Department of Respiratory Medicine, Tokai University Division of General Thoracic Surgery, Department of Jun Hanaoka, MD, PhD Fumio Sakamaki, MD Hachioji Hospital/Respiratory Division, Department of Surgery, Shiga University of Medical Science Internal Medicine, Tokai University School of Medicine

Evaluation of pulmonary function by Dynamic Digital Study on application to chronic respiratory disease Radiography: basic study in cynomolgus monkeys …… 06 ……………………………………………………………………… 16

Department of Critical and Intensive Care Medicine, Hidemitsu Miyatake, MD Department of Pulmonary Medicine, Fukushima Shiga University of Medical Science Takefumi Nikaido, MD, PhD Medical University

Study on new pulmonary function evaluation method Interstitial disease movement …………………………… 18 using Dynamic Digital Radiography …………………… 08

Noriyuki Ohkura, MD Department of Respiratory Medicine, Kanazawa University Masakuni Ueyama, MD Department of Respiratory Medicine, Tenri Hospital

Study on clinical usefulness of tracheal diameter Evaluation of pulmonary circulation evaluation using Dynamic Digital Radiography …… 10 by Dynamic Digital Radiography ………………………… 20

Department of Radiology, Shiga University of Medical Department of Clinical Radiology, Graduate School of Akinaga Sonoda, MD, PhD Science Yuzo Yamasaki, MD, PhD Medical Sciences, Kyushu University

Executive Remark …………………………………………… 22

Chairman, Board of Directors, Japan Anti-Tuberculosis Shoji Kudoh, MD, PhD Association / Professor Emeritus, Nippon Medical School Foundation The 2nd Dynamic Digital Radiography Seminar Part 2 Clinical Research Report Evaluation of pulmonary circulation by Dynamic Digital Radiography: Comparison with pulmonary perfusion scintigraphy

Munehisa Takata, MD Department of Thoracic Surgery, Kanazawa University

We have been examining the period, and 23 patients of them tion between the relative perfusion evaluation of pulmonary had lung cancer. The lung fi eld was contribution by DDR and that of circulation using a Dynamic divided into six zones, and the rela- pulmonary scintigraphy in the right Digital Radiography (DDR). tive perfusion contribution of each upper lung field, right middle lung In this presentation, I will zone was measured by the improved fi eld, and right lower lung fi eld. On mainly report the comparison PH-MODE (Cross-correlation calcu- the other hand, as for the left lung, with pulmonary perfusion lation) of the DDR and pulmonary the left upper lung field and left scintigraphy. perfusion scintigraphy. Then, the middle lung field showed correla- relative perfusion contribution of tion, but the left lower lung fi eld did Evaluation of pulmonary each zone by pulmonary perfusion not show significant correlation. circulation : Comparison scintigraphy was plotted on the This seems to be due to the cardiac with pulmonary perfusion X-axis, and that of DDR was plotted shadows. From these results, it can scintigraphy on the Y-axis, and the correlation be said that the DDR would be an We compared the relative perfusion between those was analyzed. If the alternative examination for lung contribution by DDR and that by the correlation coefficient was <0.2, it perfusion evaluation. pulmonary perfusion scintigraphy. is regarded as no correlation, if that Based on this, we will present a The subjects were 26 patients (7 was 0.2-0.4, regarded as weak corre- case. This patient was 78-year-old before surgery and 19 after surgery) lation, if that was >0.4, regarded as man who underwent resection of who underwent Dynamic Digital correlation, and P value <0.05 was the right upper lobe lung cancer. Radiography and pulmonary perfu- regarded as signifi cant difference. Three months after the operation, sion scintigraphy during the same There was a significant correla- his dyspnea worsened, and he was

Pre- and Postoperative DCR (Cross-correlation calculation processing)

a: Preoperative b: Postoperative

Fig. 1 Improved PH-MODE for resection of right upper lobe lung cancer

2 Pre- and Postoperative DCR (Reference frame ratio processing)

a: Preoperative b: Postoperative

Fig. 2 PL-MODE of the same patient as Fig. 1 re-examined. Lung ventilation and ence or absence of adhesion and its hardly observed in the low-risk perfusion scintigraphy showed that degree were also evaluated based groups with PAPS of 0 or 1, and both ventilation and perfusion of on the video captured during the pleural adhesion was more observed the right lung were significantly surgery as the reference, in order in the high-risk groups with PAPS lower than those of left lung. DDR to check if pleural adhesion could of 2 or 3 with a sensitivity of 95% was also captured for this patient be detect by DDR image before and a specifi city of 96%. From this, and analysis was performed. In surgery. The abnormal factors, it can be said that the use of PAPS comparing the preoperative and which is DDR image feature of pleu- obtained by the DDR would be able postoperative images of the DDR, ral adhesion based on our expertise, to predict moderate or more pleural postoperatively the movement of included the following three signs adhesions. the vascular shadow in the right such as “Gradation sign (G-sign)” lung field reduced(PH-MODE) with abnormal pulmonary vascular/ Conclusion and the movement of the diaphragm bronchial movement, “Fixed sign The DDR is inexpensive, easy to was abnormal. Abnormalities in the (F-sign)” with fixed pulmonary operate, has high versatility, and mediastinum movement were also vascular/bronchi with no movement, lower dose compared to pulmonary observed by PL-MODE (Reference and “Tension sign (T-sign)”, which blood flow scintigraphy, and useful frame ratio processing) (Figs. 1 and moves as if the funicular shadow for predicting postoperative pulmo- 2). As described above, the DDR can were pulled. nary function and for searching the capture dynamic function informa- The sum of those three findings cause of pulmonary function decline tion that cannot be obtained by other (0/1/2/3) was used as the pleural after lung resection. Furthermore, modalities. adhesion prediction score (PAPS), it is possible to detect dynamic and the grade of the adhesion was abnormal findings during thorax Detection of pleural adhe- classified into following 5 catego- movement with the DDR, which sion ries; Grade 0: no adhesion, Grade 1: was diffi cult to evaluate in the past. We have been studying the applica- localized adhesion, Grade 2: adhe- Based on these findings, DDR may tion of the DDR to thoracic surgery. sion in thorax 1/3 or less, Grade 3: be a potential alternative to pulmo- In order to examine the indications adhesion in thorax 1/3 to 2/3, and nary perfusion scintigraphy, and it for preoperative pleural adhesion Grade 4: total adhesion. In addition, can predict moderate or more pleu- diagnosis, preoperative DDR of 151 we examined whether adhesion of ral adhesions, and can also be used patients who underwent thoracic moderate (Grade 2) or higher could to evaluate adjacent organ invasion surgery were captured. Abnormal be detected using PAPS of 2 or more in some cases. factors suggesting adhesion were as a cutoff line. extracted from DDR , and the pres- As a result, pleural adhesion was

3 The 2nd Dynamic Digital Radiography Seminar Part 2 Clinical Research Report Prediction of postoperative pulmonary function using Dynamic Digital Radiography

Jun Hanaoka, MD, PhD Division of General Thoracic Surgery, Department of Surgery, Shiga University of Medical Science

The number of lung cancer scintigraphy into consideration, but cycle. Spirometry was measured patients with poor pulmonary there are problems such as labor, before surgery and at 1, 3, and function has been increasing, cost, exposure, and lack of urgency. 6 months after surgery to evaluate and it is important to Therefore, we conducted the study the FEV1. The correlation between evaluate strictly indications on the patients who underwent radi- FEV1 measured value and the and risk factors for radical cal surgery for primary lung cancer predict postoperative FEV1 three surgery for lung cancer. In to validate a prediction method of different methods; 1)the conven- this presentation, we report postoperative pulmonary function tional method based on the number the validation of prediction which is taking the perfusion infor- of segments to be resected, 2)the of postoperative pulmonary mation by DDR account. method taking perfusion contribu- function using the relative tion ratio calculated from perfu- perfusion contribution by 1.(Preoperative) Subjects and Postoperative methods 1 month Postoperativesion 6 scintigraphy months Postoperative and 123)the months method Dynamic Digital Radiography The 34 patients who underwent radi- taking perfusion contribution ratio (DDR). cal surgery for primary lung cancer calculated from DDR were evalu- in our department were included. ated with the Pearson's correlation Validation of prediction of Preoperative DDR was captured for coeffi cient (R). postoperative pulmonary all patients and, the left and right function using DDR perfusion contribution ratios were 2. Result (Fig. 1) Perioperative risks of lung resection calculated from pixel values change There was a strong correlation are related to predicted postopera- corresponding to the pulsation of between the perfusion contribution tive pulmonary function such as pulmonary artery during the cardiac ratio of perfusion scintigraph and FEV1 and FEV1 expressed as % predicted. Postopera- tive pulmonary function has Predicted value (area) Predicted value (dynamic) Predicted value (scintillation) been evaluated based on 4000 3500 3500 preoperative spirometry 3500 3000 3000 3000 2500 2500 and the number of segments 2500 2000 2000 2000 to be resected. However, 1500 1500 1500 it is necessary to improve 1000 1000 1000 500 500 500 its accuracy in cases near 0 0 0 0 1000 2000 3000 4000 0 1000 2000 3000 4000 0 1000 2000 3000 4000 FEV1 predicted value [L] FEV1 predicted value [L] FEV1 predicted value [L] the threshold value. There FEV1 FEV1 FEV1 are several published paper actual measurement value [L] actual measurement value [L] actual measurement value [L] demonstrated that the accu- R=0.91 R=0.92 R=0.88 （P<0.01）（P<0.01）（P<0.01） racy can be improved by N=34 N=34 N=22 taking the relative perfusion contribution by perfusion Fig. 1 Measured and predicted FEV (one month after surgery).

4 that of DDR (R=0.90, p<0.01, n=22). The correlation between the FEV1 measured value one month after surgery and predicted postoperative FEV1 by three different method were strong as 1) R=0.91, 2) R=0.92 and 3) (Preoperative) Postoperative 1 month Postoperative 6 months Postoperative 12 months R=0.88 (all p<0.01). Similar tendency was observed at three months after surgery; 1) R=0.94, 2) R=0.94 and 3) R=0.94 (all p<0.01), and at six months after surgery; 1) R=0.94, 2) R=0.94 and 3) R=0.91 (all p<0.01) Fig. 2 Evaluation of postoperative pneumonia

3. Discussion The postoperative prediction FEV1 pulmonary disease (COPD), and continued to significantly reduce. using the perfusion contribution underwent resection for left upper When the volume of each of whole ratio obtained from DDR showed a lobe lung cancer. Preoperative CT lung lobe was measured from the high correlation with the measured showedPredicted ground-glass value (area) opacities Predicted in value (dynamic)CT data at Predictedthe workstation, value (scintillation) preop-

FEV1 values. However, there was no the4000 right lung. One month 3500after the eratively the3500 remaining lower lobe signifi cant difference in the predic- operation,3500 the patient complained3000 on the operation3000 side was 896 mL 3000 2500 2500 2500 tion accuracy between the three of malaise and breathlessness.2000 A whereas at 6 2000months postoperatively 2000 1500 1500 methods, which was presumed to be static1500 chest radiography was taken, it was 1,255 mL, which is hyper- 1000 1000 1000 due to the small variation in perfu- but500 no fi ndings were found.500 CT scan inflation of about500 1.5 times. It was 0 0 0 sion contribution among the patients. revealed0 1000 a 2000magnifi 3000 4000ed glassy shadow,0 1000 2000 considered 3000 4000 that0 the 1000 blood 2000 3000 volume 4000 FEV1 predicted value [L] FEV1 predicted value [L] FEV1 predicted value [L] FEV1 FEV1 FEV1 Compared to scintigraphy, DDR actualsuggesting measurement exacerbation value [L] actualof pneu- measurementrelatively value [L] decreasedactual measurement due to hyperin- value [L] have the advantage of being able to monia. InR=0.91 DDR taken at the sameR=0.92 fl a t i o .n R=0.88 obtain functional information at the time, a （P<0.01）decrease in blood flow was（P<0.01）（P<0.01） same time as static chest radiogra- suggestedN=34 in accordance with the N=34Conclusion N=22 phy, and have the advantage of being shadow area of the CT. Improvement According to this study, the perfu- a simple, short-time and lower radia- was seen at six months after the sion contribution ratio calculated by tion dose exam. As future tasks, it operation, and almost one year later DDR was similar to that of perfu- is considered necessary to increase the patient recovered. Postoperative sion scintigraphy. In addition, it was the number of cases, examine the pneumonia that were not apparent suggested that more accurate predic- prediction accuracy of the surgical on static chest radiography could be tions could be made by adding the side and by the resected lung, evalu- evaluated by DDR. perfusion contribution ratio of DDR ate cases with uneven perfusion to the conventional postoperative contribution, and evaluate with other 2. Confi rmation of the pulmonary function prediction pulmonary function indices. effect of hyperinfl ation of method. DDR can be more easily the remaining lung on the taken to evaluate blood fl ow, and are Cases for which blood fl ow operation side considered to be useful methods that evaluation is expected to The patient had COPD and under- can be expected in the future. be useful went resection of the left upper lobe lung cancer. Preoperatively, the 1. Evaluation of postopera- blood flow on the left side slightly tive pneumonia (Fig. 2) reduced, and postoperatively, the The patient had chronic obstructive blood flow in the lower left lobe

5 The 2nd Dynamic Digital Radiography Seminar Part 2 Clinical Research Report Evaluation of pulmonary function by Dynamic Digital Radiography: basic study in cynomolgus monkeys

Hidemitsu Miyatake, MD Department of Critical and Intensive Care Medicine, Shiga University of Medical Science

We report the evaluation on a table, and a pulmonary blood lung fi eld in supine position. On the of pulmonary blood flow fl ow obstruction model was created other hand, in the standing posi- and detection of pulmonary by inserting a Swan-Ganz cath- tion, there was a significant differ- embolism using cynomolgus eter. Then, the pixel values of DDR ence in the range of the pixel value monkeys by Dynamic Digital images in both lung field of the change in the upper lung field and Radiography (DDR). normal model and the PE model that in the width of change in the were compared. lower lung field. Statistical analysis Purpose of this study In this study, we developed a bed revealed that in the normal model, In recent years, pulmonary embo- that could be rotated 90° vertically the pixel value change rate was lism following a large-scale natu- and captured DDR image in supine lower in the standing position than ral disaster has become a topic and standing positions. DDR image in the supine position, and in both in cardiovascular care. Contrast- for eight seconds was taken under the left and right upper lung fields, enhanced CT is the gold standard stop breathing. As an analysis meth- the pixel value in standing positions for diagnosing pulmonary embo- od, Region of Interest (ROI) were was significantly lower. This result lism, but there are risks such as set at the top, bottom, left, and right suggested that in the standing posi- radiation, allergy, and renal dysfunc- of the lung fi eld of the taken images, tion, blood fl ow amount in the lower tion, and it can be performed only and the average and maximum lung fi eld would be less than that in in facilities equipped with CT and change of the pixel values in each the upper lung (Fig. 1). other equipment. On the other hand, ROI during one cardiac cycle was On the other hand, in PE model, DDR can evaluate the motion of the measured. In addition, the difference the range of the pixel value change lungs, blood fl ow, and the motion of in pixel values between the left and in left lung, where the pulmonary the heart with a minimally invasive right lungs of the normal model and artery was occluded, decreased, and motion image. Therefore, we exam- those of the PE model was analyzed that in right lung where occlusion ined whether it is possible to evalu- using SPSS, and a color-coded wasn’t there, increased signifi cantly. ate pulmonary blood flow in the image of the pixel value change of In addition, on the color-coded supine and standing positions and DDR was also created. image, the lower left lung fi eld was detect pulmonary embolism(PE) A periodicity was observed in the less red-colored and much black- using the cynomolgus monkey by waveform of the pixel values change colored than the lower right lung DDR. in the normal model. The wave- fi eld. Statistical analysis showed that form that change in similar cycle as there was no difference between the Methods&Results ECG was extracted with removing range of pixel value change in left low frequency component, which is and that in right in normal cases, but 1. Experiments with cyno- corresponding to respiratory cycle. in PE model, the range of the pixel molgus monkeys There was no signifi cant difference value change on the occluded side In this study, five cynomolgus between the pixel value change at was significantly less than that on monkeys were intubated and fixed upper lung field and that at lower the un-occluded side (Fig. 2).

6 From those results, it can 2.5 Results be said that (1) the pixel Results Supine position Supine position Standing position Standing position 3 3 value change in lung field 2 P=0.483 P=0.001 P=0.015 P=0.701 P=0.001 P=0.002 has similar cycle as ECG, p<0.05 p<0.05 p<0.05 2.5 2.5 ⊿Pixel value% ⊿Pixel value% Pixel value change 2 2 which is Pulsation, after 1.5 1.5 1.5 removing low frequency 1 1 1 component. (2) the amount 0.5 0.5 of the pixel value change in 0 0 0.5 RLRLRL RLRLR L the upper lung field is less Normal Right PE Left PE Normal Right PE Left PE model model model model model model than that in the lower lung N=5 N=3 N=5 N=4 N=3 N=4 0 field at the standing posi- Right upper Right lower Left upper Left lower Upper/Lower ratio Compared with the normal model, in the pulmonary embolism model, the pixel value tion when compared with In the upper lung field, the pixel values on both the left and right sides decreased significantly change decreased on the embolism side and increased on the non-embolism side. in the supine position, and in the standing position. (3) the amount of the pixel Fig. 1 Pixel value change difference between supine and standing positions value change at occlusion site is less than that in the 2.5 Results Results non-occlusionSupine position site. Supine position Standing position Standing position 3 3 2 The amount of pixel value P=0.483 P=0.001 P=0.015 P=0.701 P=0.001 P=0.002 p<0.05 p<0.05 change wouldp<0.05 be corre- 2.5 2.5 ⊿Pixel value% ⊿Pixel value% Pixel value change 2 2 1.5 sponding to the blood 1.5 1.5 flow amount, and it would 1 1 1 be thought that either 0.5 0.5 the change in pulmonary 0 0 0.5 RLRLRL RLRLR L artery pressure or diameter Normal Right PE Left PE Normal Right PE Left PE model model model model model model is cause of the pixel value N=5 N=3 N=5 N=4 N=3 N=4 0 Right upper Right lower Left upper Leftchange lower Upper/Lowerin this case. ratio Compared with the normal model, in the pulmonary embolism model, the pixel value In the upper lung field, the pixel values on both the left and right sides decreased significantly change decreased on the embolism side and increased on the non-embolism side. in the standing position. 2. Experiment with vessel phantom Fig. 2 Comparison of the pixel value change rate between normal model and PE model As an additional experiment, DDR image of two types of vessel phantom was Conclusion hand, human do have that and also captured. A pressure sensor was From this study, it was suggested there would be a variety of factors connected to an artificial blood that the amount of change in the affecting the pixel value change, so vessel and a pressure-resistant tube pixel value of the lung is correlated future investigation is required. (both were filled with physiological with the pulmonary artery blood DDR is a simpler and less invasive saline) and pressure was manually flow. Compared with conventional method for evaluating pulmonary applied to both. The pixel change contrast-enhanced CT and pulmo- blood flow compared to existing of DDR image was observed. As a nary perfusion scintigraphy, DDR imaging modality, and is useful result, in the artificial blood vessel, may be able to diagnose PE earlier, for detecting diseases that cause the correlation between the pixel less invasively, at lower cost, and at decreased blood supply such as PE. value and the pressure was observed, various places outside the hospital. Based on this study, we are currently but not for the pressure-resistant It is thought to be useful diagnostic making an application to the Minis- tube. This suggests that the pixel tool for disaster medical care. try of Health, Labour and Welfare values change of DDR image would There were several limitations in for a prospective study DDR for reflects dilation of artery rather than this study. The cynomolgus monkeys heart failure and PE in humans. pressure. used in this experiment generally do have arteriosclerosis. On the other

7 The 2nd Dynamic Digital Radiography Seminar Part 2 Clinical Research Report Study on new pulmonary function evaluation method using Dynamic Digital Radiography

Noriyuki Ohkura, MD Department of Respiratory Medicine, Kanazawa University

We have been studying the average, Residual Capacity (RV) area decreased as the disease clinical application of Dynamic was elevated and Lung Diffusion progressed from moderate to severe, Digital Radiography (DDR). Capacity (DLCO) was decreased. indicating that the change rate of In this presentation, we report As for the relationship between lung area decreased as the airflow the study results on the change the change rate of lung area and restriction progressed. rate of lung area due to Body plethysmography results(lung In addition, in comparison of each respiratory variability. volumes) and Spirometry results, the parameter with that of the Most- results showed that the lung volumes Graph, which can visualize pulmo- Introduction such as RV had a higher correla- nary function under ventilation at Chest DDR can evaluate the pulmo- tion value than Spirometry results rest, the values of airway resistance nary function in a minimally inva- such as FEV1 (Table 1). The high- and respiratory reactance were all sive and simple manner, and visu- est is RV, which is considered as significantly correlated, and it was alize and observe the pulmonary hyperinflation. Furthermore, when considered to be related to airflow function. We examined the change the patients were stratified based restriction and imbalanced ventila- rate of lung area due to respira- on FEV1 ( FEV1 ≧ 80%: mild case, tion. tory variability using chest DDR in 80%> FEV1≧ 50% : moderate case, The patient was 53-year-old man, patients with obstructive ventilatory FEV1< 50%: severe case), mild cases who had obstructive ventila- defect and interstitial lung disease. are not much different from normal tory defect during preoperative cases, but the change rate of lung pulmonary function test (Fig. 1). Study in obstructive ventilatory defect In this study, of the 233 patients who Table 1 Relationship between the change rate of lung are and lung volumes in obstructive ventilatory defect . underwent chest DDR, 118 patients with preoperative lung cancer with Relationship of lung area change rate (Rs) with lung volume fraction X-ray dynamic analysis before and after LAMA/LABA treatment FEV1% < 70%, chronic obstructive and forced exhalation curve in patients with obstructive ventilatory defect (n=118) Before treatment After treatment (3 months) pulmonary disease (COPD), bron- Rs r p chial asthma, and asthma and COPD VC（% pred.） -0.29 <0.01 overlapping syndrome (ACO) were FVC（% pred.） -0.28 <0.01

included. Of these, 87 were males, FEV1（% pred.） -0.33 <0.01 the average age was 71.4 years, and FEV1 /FVC -0.19 0.04 MMF（% pred.） -0.26 <0.01 they were a mild COPD population. FRC（% pred.） -0.14 0.12 [Lung area over time] FEV1% = 59% on average, % FEV1 300 RV（% pred.） 0.31 <0.01 Before treatment 250 = 95.9% on average, which was TLC（% pred.） -0.01 0.93 Changes in 200 lung area increased. considered as mild airflow limita- RV/TLC ratio 0.48 <0.01 After treatment (3 months) Lung area [cm2] 150 DLCO （% pred.） -0.12 0.18 0.0 5.0 10.0 15.0 tion, and % maximum expiratory Elapsed time [sec] medium flow (% MMF) = 28% on

Relationship of lung area change rate (Rs) with lung volume fraction, and forced exhalation curve in patients with interstitial lung disease (n = 40) Rs r p VC（% pred.） -0.43 <0.01 FVC（% pred.） -0.43 <0.01

FEV 1（% pred.） -0.32 0.04

FEV 1 /FVC 0.09 0.56 MMF（% pred.） -0.06 0.70 FRC（% pred.） -0.16 0.32 RV（% pred.） 0.01 0.94 TLC（% pred.） -0.19 0.23 RV/TLC ratio -0.39 0.01

DL CO（% pred.） -0.27 0.11 between the change rate of the lung Relationship of lung area change rate (Rs) with lung volume fraction X-ray dynamic analysis before and after LAMA/LABA treatment and forced exhalation curve in patients with obstructive ventilatory area, lung volumes, and Spirometry, defect (n=118) Before treatment After treatment (3 months) Rs Relationship of lung area change rate (Rs) with lung volume fraction in X-raythe dynamiccase of analysis obstructive before and ventila- after LAMA/LABA treatment and forced exhalation curve in patients with obstructive ventilatory r p defect (n=118) tory defect,Before they treatment were significantlyAfter treatment (3 months) Rs VC（% pred.） -0.29 <0.01 r p correlated, and correlation with FVC（% pred.） -0.28 <0.01 VC（% pred.） -0.29 <0.01 the residual volume rate (RV/TLC) FEV1（% pred.） -0.33 <0.01 FVC（% pred.） -0.28 <0.01 FEV1 /FVC -0.19 0.04 was also found (Table 2). When FEV1（% pred.） -0.33 <0.01 MMF（% pred.） -0.26 <0.01 the patients were stratifi ed based on FEV1 /FVC -0.19 0.04 FRC（% pred.） -0.14 0.12 [Lung area over time] ≧ MMF300 （% pred.） -0.26 <0.01 %VC ( mild : 80% %VC, moder- RV（% pred.） 0.31 <0.01 Before treatment ≧ FRC250（% pred.） -0.14 0.12 ate: 80%> %VC[Lung area 65%,over time] severe : TLC（% pred.） -0.01 0.93 Changes in 300≦ RV200（% pred.） 0.31 lung<0.01 area increased. %VC 65%), theBefore change treatment rate of RV/TLC ratio 0.48 <0.01 After treatment (3 months) 250 TLCLung area [cm2] 150（% pred.） -0.01 0.93 Changes in DLCO （% pred.） -0.12 0.18 lung area becomes lower in moder- 0.0 5.0 10.0 15.0 200 lung area increased. RV/TLC ratio Elapsed time0.48 [sec] <0.01 After treatment (3 months) ate andLung area [cm2] 150 severe cases as in the case DLCO （% pred.） -0.12 0.18 0.0 5.0 10.0 15.0 Fig. 1 Case: 53-year-old male patient with COPD of obstructive ventilatoryElapsed time [sec] defect, and the change rate of lung area also decreased with a decrease in %VC. Table 2 Relationship between the change rate of lung are and lung volumes in interstitial lung disease The relationship between the change Relationship of lung area change rate (Rs) with lung volume fraction, and forced exhalation curve in patients with interstitial lung disease rate of lung area and the 6-minute (n = 40) Rs Relationship of lung area change rate (Rs) with lung volume fraction, walking distance was examined r p and forced exhalation curve in patients with interstitial lung disease (n = 40) Rs in 20 patients with interstitial lung VC（% pred.） -0.43 <0.01 r p FVC（% pred.） -0.43 <0.01 disease. The results showed that the VC（% pred.） -0.43 <0.01 FEV 1（% pred.） -0.32 0.04 lower the change rate, the shorter the FVC（% pred.） -0.43 <0.01 FEV 1 /FVC 0.09 0.56 walking distance, which indicated FEV 1（% pred.） -0.32 0.04 MMF（% pred.） -0.06 0.70 FEV 1 /FVC 0.09 0.56 a correlation with physical activ- FRC（% pred.） -0.16 0.32 MMF（% pred.） -0.06 0.70 ity. This indicated that it would be RV（% pred.） 0.01 0.94 FRC（% pred.） -0.16 0.32 possible to evaluate exercise toler- TLC（% pred.） -0.19 0.23 RV（% pred.） 0.01 0.94 RV/TLC ratio -0.39 0.01 ability by DDR. TLC（% pred.） -0.19 0.23 DL CO（% pred.） -0.27 0.11 RV/TLC ratio -0.39 0.01 Conclusion DL CO（% pred.） -0.27 0.11 The change rate of lung area in obstructive ventilatory defect refl ects airflow restriction and a hyperinflation. The lower change rate of lung area in interstitial lung disease refl ects lower %VC and less exercise The patient had no complications Study in interstitial lung tolerance. Based on those results, it or a history of bronchial asthma disease was confirmed that DDR would be or rhinitis, but was the current In this study, of 40 patients with an imaging modality that was clini- smoker with a CAT score of 15. interstitial lung disease were studied cally useful as a new method for %FEV1 was 49.7%, RV increased, among 233 patients who underwent evaluating pulmonary function. In DLCO decreased, and COPD was DDR. The patients were composed the future, it is necessary to study suspected from symptoms and func- of mainly idiopathic pulmo- more detailed analysis such as the tion. When anticholinergic inhalant nary fibrosis (IPF), scleroderma, type and stage classifi cation on vari- (LAMA) and β2-agonists (LABA) and interstitial lung disease with ous disease, and the application of were administered, the change rate progressive fibrosis with decreased artificial intelligence (AI) for that of lung area increased after certain vital capacity (VC), restricted purpose would be expected. period. dysfunction, DLCO as low as 38.3% on average. As for the relationship

9 The 2nd Dynamic Digital Radiography Seminar Part 2 Clinical Research Report Study on clinical usefulness of tracheal diameter evaluation using Dynamic Digital Radiography

Akinaga Sonoda, MD, PhD Department of Radiology, Shiga University of Medical Science

Since Dynamic Digital ing to the voice guidance, and DDR the trachea at the end of expiration Radiography(DDR) enables imaging was taken for 15 seconds (the narrowest) were measured. The direct observation of tracheal from maximum inspiration to expi- measurement location was between movement, it may be a convenient ration and inspiration at frame of 15 the caudal side of the sternoclavicu- tool for screening patients with fps. lar joint and one vertebral head side ventilatory disorders such as of the tracheal bifurcation. tracheomalacia and Excessive Results As a result, the tracheal diameter Dynamic Airway Collapse Result 1: Difference in the was significantly narrowed in the where the trachea moves during degree of tracheal narrowing obstructive ventilatory disorder inspiration and expiration. depending on the type of group compared to the normal group In this presentation, we will ventilation disorder and the restrictive ventilation disor- introduce a study on tracheal Of 52 patients, 7 patients who der group (Fig. 1). In the obstruc- diameter evaluation using DDR. underwent Spirometry at another tive ventilatory disorder group, the hospital and 1 patient with mixed trachea was considered likely to be Method ventilation disorder were excluded, narrowed during expiration. Of the patients scheduled to undergo and 28 normal subjects, 12 patients thoracic surgery at our hospital, 52 with obstructive ventilatory defect Result 2: Inter-observer patients with written consent partici- and 4 patients with restricted venti- differences pated in the study. DDR image was lation disorder were included. The Three observers, who did not know captured in the supine position. The diameter of the trachea at the start the results of Spirometry, measured patient was forced to breathe accord- of expiration (the most dilated) and manually the diameter of the trachea at the start of expiration (most [Result 4] [Result 1: In obstructive ventilatory defect, tracheal diameter reduced dilated) and the trachea at the end compared to normal case or restrictive disorder] of expiration (mostNarrowing narrowed) group in 28 vs No narrowing group R2nd <70.7% R2nd ≧70.7% Tracheal narrowing average (mm) normal subjects and 12 patients with 8 obstructiveFEV1%-G（%） ventilatoryFEV1（L） disorder. V75（L/sec） V50（L/sec） V25（L/sec） 7 p<0.01 p<0.05 p=0.12 p<0.01 p<0.01 P<0.05 P<0.05 As a result, there was no large No narrowing No narrowing No narrowing 6 6.52 No narrowing 5 difference in the results between the No narrowing 4 measurers, and the trachea tended 3 3.13 to be narrowed in the obstruc- Narrowing 2 Narrowing 1 1.73 tive ventilatory disorder group atNarrowing Narrowing Narrowing 0 the time of expiration as in result Normal case Obstructive Restrictive • Narrowing group’s FEV1%, FEV1, V50 & V25 N=28 disorder disorder 1. Therefore,were tend to itbe issmaller considered than No narrowing that group. N=12 N=4 obstructive ventilatory defect may Fig. 1 Result 1: Degree of tracheal narrowing by type of be detectable by DDR. ventilation disorder

10 [Result 4] [Result 1: In obstructive ventilatory defect, tracheal diameter reduced compared to normal case or restrictive disorder] Narrowing group vs No narrowing group R2nd <70.7% R2nd ≧70.7% Tracheal narrowing average (mm) 8 FEV1%-G（%） FEV1（L） V75（L/sec） V50（L/sec） V25（L/sec） p<0.01 p<0.05 p=0.12 p<0.01 p<0.01 7 P<0.05 P<0.05 No narrowing No narrowing No narrowing 6 6.52 No narrowing 5 No narrowing 4 3 3.13 Narrowing 2 Narrowing 1 1.73 Narrowing Narrowing Narrowing 0 Normal case Obstructive Restrictive • Narrowing group’s FEV1%, FEV1, V50 & V25 N=28 disorder disorder were tend to be smaller than No narrowing group. N=12 N=4

Fig. 2 Result 4: Relationship between tracheal narrowing and pulmonary function test

Result 3: Reduction of However, the movement of the change in tracheal diameter (Fig. 2). measurement errors diaphragm does not always match Those results suggested that patients In order to reduce the impact of the movement of the trachea, and with abnormal pulmonary function tiny fluctuation during breathing it has been reported that a hard could be detected by tracheal diam- on the measurement accuracy, the breathing leads to more severe eter narrowing evaluation. average value of trachea diameter tracheal narrowing. Therefore, it was during certain period was used for suggested that DDR would be better Conclusion the evaluation. The measurement tool for evaluating tracheal narrow- The number of patients in this study location was the midpoint between ing . was very small and there is also Th2 and the bronchial bifurca- several limitations such as measure- tion. Four patients with obstructive Result 4: Relationship ment accuracy and measurement ventilatory disorder and four normal between changes in trache- labor because the all measurement subjects were randomly selected, al diameter and pulmonary should be performed manually. The and the tracheal diameter was function test relationship between the degree of manually measured for 15 seconds We verified whether there was a tracheal diameter narrowing and the (225 frames per person). From the relationship between the change rate severity of obstructive ventilatory obtained data, the change rate of the of tracheal diameter and pulmonary defect will also need to be exam- tracheal diameter was calculated function in 28 normal subjects and ined. from the average diameter at the 12 patients with obstructive venti- DDR can dynamically observe the start of expiration and at the end of latory disorder. The change rate narrowing of the tracheal diameter expiration. The diameter for 1 sec, of tracheal diameter at the time that occurs during expiration, and which is a total 15 diameter values, of starting and ending of the was it would be possible to identify and were used for averaging. As a result, measured. In this study, subjects evaluate the severity of patients with it was confirmed that the change were divided into a group; tracheal obstructive ventilatory defect by rate in tracheal diameter tended to diameter narrowing (diameter observing and measuring tracheal be small due to obstructive ventila- change ≦ 70.7%) and a group with narrowing. The development of soft- tory disorder. non-narrowing. ware that can measure and evaluate The question like, the same result As a result, among the pulmonary the tracheal diameter more objec- can be obtained by static chest radi- function test results, the values of 1 tively and efficiently is our current ography at the maximum inspira- second rate (FEV1%), V50, and V25 task. tion and expiration, may be arisen. were significantly correlated to the

11 Report on usefulness in clinical practice: The 2nd Dynamic Digital Radiography Seminar Part 3 Discussion Dynamic Digital Radiography : Method on chest application

Ryotaro Yuji Radiological Technology Department, Clinical Technology Division, Tokai University Hachioji Hospital

In January 2018, our hospital “taking pictures” to “taking videos”. imaging device "RADspeedPro". introduced the first Dynamic Compared with conventional x-ray, As a supplementary function of a Digital Radiography(DDR) DDR requires more appropriate posi- conventional radiography system, a system in the world and tioning and understanding/cooperation dynamic x-ray image (a sequential started clinical research. In of patients for examination in order to radiography) can be captured with this presentation, we will capture the patient's disease condition. pulsed x-rays exposure at 15 frames report the outline of the system In addition, the examination may per second, and the obtained images and the actual ﬂ ow and points be performed a plurality of times are displayed as a movie. This movie of DDR for chest application. because it can be a functional has a spatial resolution of 400 μm inspection, and the reproducibility is and a gray scale image density reso- Evolution from static also important. lution is 16 bits. x-ray image to dynamic The normal procedure of conven- x-ray image Overview of DDR and tional radiography is to check In the DDR, it becomes possible to examination the patient condition and explain create an motion x-ray image having The DDR system is composed of how the exam is going to be, set a time resolution in addition to a Konica Minolta's x-ray dynamic the exposure conditions, conduct spatial resolution by adding a time image analysis workstation "KINO- positioning and exposure, check axis to a conventional x-ray. SIS", portable digital x-ray imag- whether the image has been properly The work of medical X-ray tech- ing device "AeroDRfine", and captured and processed, and deliver nicians is also changing from Shimadzu Corporation's general to physicians. In addition, DDR requires a more detailed explanation before the examination, attention to Misidentifation（patient, body Patient confirmation and explanation parts and etc.） patient positioning, and practice of + Explanation of dynamic imaging Explanation Prevention of false images and + Explanation of purpose of breathing to obtain maximum inspi- disturbing shadows examination ration and expiration (Fig. 1). Prior

Grid on/off explanation is particularly important Condition Imaging conditions SID, KV, mA, mAs for obtaining patient cooperation. In Whether AEC is used. our hospital, a leafl et for the exami- Positioning nation guide were prepared and the + Positioning that does not disturb Importance of image confirmation Positioning dynamics and reproducibility all patient is asked to read carefully + Exercise of movement before the examination.

Availability of imaging conditions In positioning, in order to reduce Appropriateness of image Image Appropriateness of taken image processing unnecessary tension of muscle used Determination of image size for breathing, the handle shall be grasped in a comfortable position, Fig. 1 Procedure Flow of DDR and the height of the forearm and

12 Hand position horizontal with Belt on the pelvis the elbow Fig. 2 Key Points of Positioning

Hand switch ON Hand switch OFF

Continue pressing the hand switch

Voice: Take a big breath voice Hold a Hold a The imaging is and inhale. Exhale slowly. Inhale slowly. guide breath. breath. over. Inhale, inhale, inhale. For 5 seconds For 2 For 2 (no exposure) seconds For 5 seconds seconds For 5 seconds

Diaphragm level pulsed x-ray

Breath holding Expiration phase Breath holding Inhalation phase

Maximum Maximum Maximum inhalation phase exhalation phase inhalation phase

Image acquision

Fig. 3 An example of breathing pattern (Deep breathing) with voice guide

wrist shall be horizontal so that dose) is calculated as 1 pulse dose × Conclusion the upper arm muscles won’t have 15 fps × imaging time (seconds). In With a leaflets for the patient and unnecessary tension. The pelvis our hospital, the average scan time procedure manuals for medical shall be fixed with a belt to prevent was 16.6 seconds, and the aver- X-ray technicians, high reproduc- body movement (Fig. 2). age exposure dose was 1.82 mGy, ible examinations are possible, and To improve the reproducibility of which is lower than the International our hospital has realized a system the examination, automated voice Atomic Energy Agency (IAEA) that can immediately respond to guide is used for breathing instruc- guidance level of 1.9 mGy for the exam order of DDR. In addition, it tions (Fig. 3). In addition, the voice front and side of the chest. In addi- is expected that the DDR would be guide can be operated for breathing tion, it is possible to perform exami- useful tool for the orthopedic appli- practice in the radiographing room, nations at a much lower exposure cation as well as the chest applica- so that the medical X-ray techni- dose than our low-dose lung CT tion in the future. cians can confirm how the voice screening. Medical X-ray technicians are also is heard and how the body of the Regarding the procedure of DDR, required to have a new role, includ- patient moves near the patient. By a manual was prepared by our hospital ing understanding of respiratory unifying the timing of the start of and Konica Minolta to ensure consis- physiology, and we believe that DDR radiography among the operator in tency of the examination. As a result, is one of the challenging modalities the radiology department, there is the average examination time from the for medical X-ray technicians. almost no difference among medical patient's calling to leaving the room X-ray technicians at present. at our hospital is 4.9 minutes. The exposure dose (entrance surface

13 Report on usefulness in clinical practice: The 2nd Dynamic Digital Radiography Seminar Part 3 Discussion Focusing on patients with COPD, and Ventilation defect

Department of Respiratory Medicine, Tokai University Hachioji Hospital/Respiratory Division, Department Fumio Sakamaki, MD of Internal Medicine, Tokai University School of Medicine

In our hospital, about 100 and deterioration of movement have upper-middle lung fi eld, the middle- cases of Dynamic Digital been reported. On the other hand, lower lung fi eld, and the upper-lower Radiography (DDR) have been in severe COPD, abnormal move- lung field was calculated, and the captured by October 2019 using ment of the ribs in the lower rib cage similarity of the movement between Konica Minolta's DDR system. (Hoover's sign) has been known for the ribs was compared. In this presentation, we report a long time, but there are few quan- the results of thoracic cage titative studies on this movement. 3. Results movement in patients with We analyzed the coordination of As for the similarity of the move- chronic obstructive pulmonary the posterior ribs and the movement ments of the posterior ribs in the disease (COPD), and report of the diaphragm from DDR in 31 mild group and the severe group, the the usefulness and potential patients with suspected COPD and lower rib moved in a different direc- of this system in COPD and compared mainly with the pulmo- tion from the upper and middle ribs alveolar hypoventilation nary function test 1). in the mild group, whereas it moved syndrome. in the same direction in the severe 2. Method group. On the other hand, there was Study on thoracic cage At the time of expiration and no difference in diaphragm move- movement in COPD inspiration, a fixed point was set ment due to airflow limitation. In patients immediately below the pleura of the addition, a correlation was found posterior rib, and the change in the between the airflow limitation (% 1. Background and purpose moving angle of the fi xed point was FEV1) and similarity. We conclude In COPD, it is known that the automatically tracked by special that there is a possibility that the diaphragm becomes flat due to software to calculate the direction of severity of COPD can be evaluated hyperinfl ation of the lungs, and para- movement. The angle of the move- visually and objectively using DDR. doxical movements of the diaphragm ment of the posterior rib between the

a: At the time of ﬁrst hospitalization b: 2nd hospitalization c: 3rd hospitalization 2018/3/1 2018/7/26 2018/10/22

Diaphragm displacement graph Diaphragm displacement graph Diaphragm displacement graph

Right Left Right Left Right Left Displacement [cm] Displacement [cm] Displacement [cm] Frame Frame Frame

Fig. 1 Case 1: Diaphragm Excursion

14 a: At the first imaging b: At the second imaging c: At the third imaging 2018/4/13 imaging 2018/11/15 imaging 2019/9/13 imaging (1st time) (2nd time) (3rd time)

Fig. 2 Case 3: PL-MODE on alveolar hypoventilation syndrome patient

Case presentation ate to severe COPD Furthermore, the improvement of This patient had %FEV1≃ 53%, which ventilation was confirmed in the Case 1: Severe case of means this patient was moderate PL-MODE (Reference frame ratio COPD (follow-up case) to severe COPD, and was hospital- calculation processing) image (Fig. This patient was hospitalized 3 times ized once due to exacerbation and 2), and the shortness of breath in 2018 due to worsening symptoms. had shortness of breath. FE-MODE index (mMRC) was also improved. Dyspnea and airfl ow limitation were (Frequency enhancement process- Pulmonary circulation improvement severe, and the severity classifica- ing) of DDR image can confirm was observed in PH-MODE (Cross- tion of COPD (ABCD classifica- trachea narrowing during expira- correlation calculation processing). tion) was as severe as D. Treatment tion, which is frequently observed in We believe that DDR could be an was conducted focusing on LABA/ severe cases. index of ventilation evaluation. LAMA combination drugs and inhaled steroids (ICS), and the stable Case 3: Alveolar hypoventi- Conclusion trend of patient condition began in lation syndrome (follow-up In COPD and alveolar hypoventila- 2019. case) tion syndrome, quantitative evalua- On DDR, the lung was slightly The patient was diagnosed with tion of posterior rib and diaphragm hyperinflated and the heart looked idiopathic pulmonary arterial hyper- movements on DDR images can be like “drop heart”, but FEV1 recov- tension at another hospital, but it an index for severity evaluation and ered slightly over time. There is no was considered to be type II respira- time-course observation. We also change over time in the movement of tory failure according to the results believe that it would be possible to the posterior ribs, but the displace- of pulmonary function test. The visually evaluate the rib cage movement graph of the diaphragm decreased mobility of the diaphragm ment, abnormality on the central (Fig. 1) shows a smooth up and detected on DDR images cannot be airway, ventilation imbalance and down movement without any imbal- ruled out as a cause of hypercapnia, pulmonary circulation defect. ance between the left and right and and noninvasive positive pressure COPD-specific shaking at the third ventilation (NPPV) was conducted ●References 1) Genki Takahashi et al., Annals of hospitalization. It is expected that during sleep, which improved the Japanese Respiratory Society, 8 the improving effect of pulmonary subjective symptoms. (Suppl.): 262, 2019. function could be confirmed from There was no change over time in the displacement of the diaphragm. forced vital capacity (FVC), but the maximum inspiratory volume (IC) Case 2: Patient with moder- increased from 0.99 L to 1.06 L.

15 Report on usefulness in clinical practice: The 2nd Dynamic Digital Radiography Seminar Part 3 Discussion Study on application to chronic respiratory disease

Takefumi Nikaido, MD, PhD Department of Pulmonary Medicine, Fukushima Medical University

We introduced Dynamic chronic respiratory diseases. Interstitial Pneumonia Digital Radiography (DDR) to In this presentation, we Case 1 was a 77-year-old male with evaluate pulmonary circulation present a case of interstitial idiopathic interstitial pneumonia for chronic pulmonary pneumonia and emphysema (IIP). Pulmonary function such thromboembolism. Furthermore, with giant bullae as an initial as vital capacity (VC) are within recently, we tried to apply DDR to study. normal ranges, and there is a slight decrease in lung diffusion capac-

ity (DL CO), but overall pulmonary function was considered as normal. Although there is no hypoxemia, serum markers for interstitial pneumonia are high.

Supine position Sitting position Standing position Static chest radiography showed diffuse reticular shadows, ground- glass opacity, and slight ventilation defect in the left lung. CT showed diffuse reticular shadows on the pleura side with emphysema and many ground-glass opacities. It was considered to be the case classified to Alternative Diagnosis (A shadow that could also be taken as

Fig. 1 Case 1: Interstitial Pneumonia. Ventilation evaluation image a predominant cyst/ground-glass shadow) of ATS/ERS/JRS/ALAT International Diagnosis Guideline 1) Supine position Sitting position Standing position Supine position Sitting position Standing position rather than IIP. Ventilation evaluation by DDR InhalationInhalation Inhalation Inhalation Inhalation Inhalation showed that the ventilation of the Supine position Sitting position Standing position Supine position Sitting position Standing position left lung reduced, but the lesion in the lower lobe was not so severe, Exhalation Exhalation Exhalation Exhalation Exhalation Exhalation Supine position Sitting position Standing position Supine position Sitting position Standing position and there was almost no differences between patient’s posture (Fig. 1).

Velocity ratio Velocity ratio Velocity ratio Velocity ratio Velocity ratio Velocity ratio Next, in the airfl ow velocity analy- (inhalation/exhalation) (inhalation/exhalation) (inhalation/exhalation) (inhalation/exhalation) (inhalation/exhalation) (inhalation/exhalation) sis image by DDR, the expiration Fig. 2 Case 1: Interstitial Pneumonia. Fig. 3 Case 1: Interstitial Pneumonia. Airflow velocity analysis Airflow velocity analysis image velocity, the inspiration velocity, image during tidal breathing during deep breathing and the velocity ratio (inhalation/

16 exhalation) were color-coded and Supine position Sitting position Standing position displayed superimposed on the image. Red (high velocity) to blue (low velocity) was set according to the velocity, and the velocity ratio was set to red/black (high velocity) to blue (low velocity). Data missing parts were blank. In this case, the velocity ratio during tidal breathing was higher in the supine position than in the standing position (Fig. 2), and even higher during deep Fig. 4 Case 2 : Emphysema. Ventilation evaluation image breathing (Fig. 3).

Supine position Sitting position Standing position Supine position Sitting position Standing position Emphysema Case 2 was a 64-year-old male with Inhalation Inhalation Inhalation InhalationInhalation Inhalation emphysema developing giant bullae. Supine position Sitting position Standing position Supine position Sitting position Standing position He had a history of repeated pneu- mothorax, and resection and sutur- Exhalation Exhalation Exhalation ExhalationExhalation Exhalation ing of bullae was performed on the Supine position Sitting position Standing position Supine position Sitting position Standing position left side in 2001 and on the right side in 2008. After that, he became Velocity ratio Velocity ratio Velocity ratio Velocity ratio Velocity ratio Velocity ratio (inhalation/exhalation) (inhalation/exhalation) (inhalation/exhalation) aware of the worsening of dyspnea (inhalation/exhalation) (inhalation/exhalation) (inhalation/exhalation) around 2017, and in 2019, his exac- Fig. 5 Case 2: Emphysema. Airflow Fig. 6 Case 2: Emphysema. Airflow velocity analysis image during velocity analysis image during erbation of dyspnea and emphyse- tidal breathing deep breathing matous change became prominent, and he was referred to our department. For evaluation, DDR was performed. Static chest radiography showed giant bullae and hyperpermeability, especially in the bilateral middle lung. The pulmonary function test showed obstructive ventilatory velocity ratio due to patient posture eters, that are useful for evaluat- defect, and the flow volume curve during tidal breathing (Fig. 5), ing disease states and progression, showed a typical obstructive disor- but showed a decrease in veloc- would be obtained, we have begun der pattern. CT showed marked ity during deep breathing (Fig. 6), accumulating various cases. In the emphysematous change in the upper which appeared to be different from future, we would like to evaluate lobe, giant bullae on both sides in interstitial pneumonia. the relationship of these data with the middle and lower lobes, and various information and test results emphysematous change in the lower Conclusion at the time of admission to hospital, lobe. At our institution, DDR has been or new biomarkers, as well as the Ventilation evaluation based on used to evaluate a regional ventila- relationship with disease progres- DDR showed that the ventilation/perfusion in chronic respiratory sion. tion volume decreased, especially diseases, especially chronic obstruc- according to the mid-lung bullae tive pulmonary disease (COPD) ● References 1) Raghu, G., et al., Am. J. Respir. Crit. (Fig. 4). Airflow velocity analysis and interstitial pneumonia. With Care Med., 198(5): e44-e68, 2018. images did not show an increase in the expectation that various param-

17 Report on usefulness in clinical practice: The 2nd Dynamic Digital Radiography Seminar Part 3 Discussion Interstitial disease movement

Masakuni Ueyama, MD Department of Respiratory Medicine, Tenri Hospital

In this presentation, we report and ground-glass shadows were collagen disease lung. The DDR the usefulness of Dynamic observed from around the bronchial image (Fig. 2) showed that the Digital Radiography (DDR) in vessels to the subpleura, though movement of the lower lung field interstitial pneumonia (IP) by there was not as much shadow as and the width of the rib cage was presenting cases. the upper lung field, suggesting a worse than in the normal case. In

Case 1: IP predominantly in the lower lung ﬁ eld Case 1 is a 68-year-old female with IP predominantly in the lower lung field. A cough developed in September 2018. An IP was pointed out by a another physician nearby on December, and she visited our department on January 2019. Currently, being followed-up with- Fig. 1 Case 1: CT image out any treatment. A former smoker (20 pieces/day × 30 years) with a history of renal disease, appendicitis, uterine adnexitis, and phleban- gioma. The results of the blood test were antinuclear antibody (ANA): 640-fold, anticentromere antibody: positive, KL-6: 1,082 U/mL, SP-D: Fig. 2 Case 1: DDR 362.1 ng/mL. According to the image (PA and Lateral) results of the pulmonary function test, the vital capacity (VC) was 2.19L(88.2% as percent predicted), and the lung diffusion capacity

(% DL CO) was 71.9% as percent predicted. Static chest radiography showed reticular shadows and ground-glass opacities predominantly in the lower lung fi eld. On CT image (Fig. Fig. 3 Case 1: Motion vector-map 1), in the lower lung fi eld, reticular

18 (Fig. 4) showed strong reticular shadows and consolidation in the upper lung fi eld. DDR image (Fig. 5) showed that the movement was generally poor and the movement of the diaphragm is abnormal, and lateral DDR image showed the impression that the lower lobe Fig. 4 Case 2: CT image of the lung mainly contributed to breathing. Even in the vector-map (Fig. 6), the movement of the entire lung fi eld seemed to be poor.

DDR for IP : Current status and future issues In our hospital, IP-focused DDR Fig. 5 Case 2: DDR has been performed, and data on 30 image (PA and Lateral) to 40 cases have been obtained so far. In all cases, PA and a Lateral DDR image were taken, and when the estimated lung volume obtained from those images was compared with the results of pulmonary function test, a good correlation was obtained. At present, there was only one stable case followed-up, and similar results were obtained in Fig. 6 Case 2: Motion vector-map comparison of the past and present image. The follow-up of deterio- rated cases, correlation with prog- addition, it seemed that the move- thus the patient visited the previ- nosis, and detection accuracy will ment of lower lung field is worse ous doctor. The DOE appeared be examined in the future. than normal control case based on a around July 2017, and she visited In addition, as a feature of move- motion vector-map (Fig. 3) created our department in February 2018 ment in IP, there is an impression from DDR image. and underwent cryobiopsy. She that lower lung fi eld movement and was a nonsmoker with a history of thorax cage movement are poor in Case 2: IP predominantly childhood asthma, appendicitis, and patients with IP predominantly in in the upper lung ﬁ eld fi broids. No serologically predomi- the lower lung fi eld, and that over- Case 2 was a 65-year-old female nant positive findings were found, all movement is poor in patients with IP predominantly in the upper with KL-6: 739 U/mL and SP-D: with IP predominantly in the upper lung fi eld. The main complaint was 829.5 ng/mL. The results of the lung fi eld. In all patients, the move- paroxysmal dyspnea on exercise pulmonary function test were VC ment of the thorax cage is better (DOE). An abnormal finding was (%VC): 1.91 L (74%) and %DLCO: in the upper part than in the lower pointed out on static chest radiog- 63.1%. part. Although we have not yet raphy in a annual health check-up Static chest radiography showed performed a quantitative analysis of for the first time in 2001, and an reticular shadows and infiltra- these, we would like to examine the abnormal condition was pointed out tion shadows predominantly differences in movement between again in a 2012 health check-up, in the upper lung field. CT image IP subtypes in the future.

19 Report on usefulness in clinical practice: The 2nd Dynamic Digital Radiography Seminar Part 3 Discussion Evaluation of pulmonary circulation by Dynamic Digital Radiography

Yuzo Yamasaki, MD, PhD Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University

In this presentation, I present but x-ray pulmonary circulation (5) PH due to unknown cause and/ pulmonary circulation image by DDR (Fig. 1b) revealed or complex factors, and these are imaging by Dynamic Digital multiple segmental defects in both differentiated in diagnosis. Radiography (DDR) on two lung fields. 99mTc-MAA pulmonary CTEPH is defined as the state patients. perfusion scintigraphy (Fig. 1c) having an organized thrombus in showed frequent segmental defects, the pulmonary artery that does not Case 1: Chronic thrombo- which is a characteristic of CTEPH, dissolve with anticoagulant therapy embolic pulmonary hyper- and this fi nding was consistent with for 6 months or more, and the mean tension (CTEPH) pulmonary circulation image by pulmonary artery pressure is ≥25 Case 1 was a 69-year-old female. DDR. Similar findings were found mmHg (normal value <20 mmHg). Around January 2019, she visited in iodine map of the contrast CT It has two aspects, PH and PE, and another hospital with a complaint of (Fig. 1d). As a result of right heart may be found triggered by PH with- shortness of breath during exercise, catheterization, the mean pulmo- out any apparent history of PE. and was diagnosed with pulmonary artery pressure was 43 mmHg, The recently proposed algorithm for nary embolism (PE). Anticoagulant and the patient was diagnosed with the diagnosis of PH1) emphasized therapy was performed, but the CTEPH. Pulmonary hypertension that early screening of CTEPH by symptoms remained and chronicity (PH) is classifi ed into fi ve types such pulmonary ventilation/perfusion was suspected. Therefore, DDR was as (1) Pulmonary arterial hyperten- scintigraphy was important. Howev- performed at our hospital. sion (PAH), (2) PH due to left heart er, we consider the possibility that Static chest radiography (Fig. 1a) disease, (3) PH due to lung disease pulmonary perfusion image by DDR showed no obvious abnormalities, and/or hypoxemia, (4) CTEPH, and can be used as the screening test

a: Static chest radiography b: X-ray pulmonary c: 99m Tc-MAA pulmonary d: Iodine map of circulation image perfusion scintigraphy the contrast CT

mPAP 43mmHg, PVR 6.9W.U., CI 3.3L/min, 6MWD 560m No thrombus in the main pulmonary artery

Fig. 1 Case 1: Chronic thromboembolic pulmonary hypertension (CTEPH)

20 a: Static chest radiography b: X-ray pulmonary circulation c: X-ray pulmonary ventilation image image

Fig. 2 Case 2: Giant cell arteritis, severe left pulmonary artery stenosis

a: Pulmonary ventilation/ perfusion scintigraphy (SPECT-CT fusion b: Iodine map of image) contrast-enhanced CT

Fig. 3 Ventilation/perfusion scintigraphy and Iodine map of contrast-enhanced CT in Case 2

before pulmonary ventilation/perfu- antibiotic treatment, so DDR was left pulmonary vessels was poor in sion scintigraph in the future. performed at our hospital. On static 3D pulmonary artery images. FDG- Comparison of pre- and postopera- chest radiography (Fig. 2a), the right PET/CT showed a high accumula- tive pulmonary artery angiography pulmonary vasculature was dilated tion of SUVmax = 7.6, which was with circulation image by DDR in while the left pulmonary vasculature consistent with the soft shadow of another patient with CTEPH also was less visible. The x-ray pulmo- contrast-enhanced CT. Based on showed that pulmonary circulation nary circulation image by DDR (Fig. these results, we diagnosed severe was restored after surgery. Thus, 2b) shows that the circulation in the left pulmonary artery stenosis due x-ray pulmonary circulation image left lung is extremely poor. On the to giant cell arteritis. by DDR was also expected to be other hand, x-ray pulmonary ventila- By performing DDR, pulmonary used for evaluation of pulmonary tion image by DDR (Fig. 2c) showed ventilation/perfusion information circulation before/after treatment. that both lungs were uniformly can be easily obtained, and it is ventilated. Similar findings were considered to be useful even in situ- Case 2: Giant cell arteri- obtained on pulmonary ventila- ations where contrast-enhanced CT tis, severe left pulmonary tion/perfusion scintigraphy and and scintigraphy cannot be used artery stenosis iodine map of contrast-enhanced easily. Case 2 was a 74-year-old male. CT (Fig. 3). Contrast-enhanced CT He visited a previous physician showed that the main trunk of the ● References 1) Frost, A., et al.: Diagnosis of pulmo- complaining of dyspnea and cough, left pulmonary artery was highly nary hypertension. Eur. Respir. J., 53 and diagnosed as having pneumonia. narrowed and soft shadows were (1): 1801904, 2019. The symptoms remained even after widespread around it. Depiction of

21 The 2nd Dynamic Digital Radiography Seminar Executive Remark

Chairman, Board of Directors, Japan Anti-Tuberculosis Association / Shoji Kudoh, MD, PhD Professor Emeritus, Nippon Medical School Foundation

I was amazed that there was a great research is expected. The fi rst edition was issued in 1965, progress in the research for just one Second, I felt the spread of applica- and 70 years have passed since the year since the first Dynamic Digi- tions. At the beginning of the devel- discovery of x-rays in 1895, and tal Radiography Seminar in 2018. opment of DDR, target diseases fi nally a "silhouette sign" was raised. I would like to express my sincere which came to mind, were a few With that in mind, I feel that having respect to the researchers who have such as chronic obstructive pulmo- many landmarks was like having a conducted research throughout nary disease (COPD) and interstitial treasure mountain in front of you, Japan. pneumonia. However, this time, and that there might be a possibility I would like to mention three things there were clinical case presen- of new discoveries over time. that were particularly impressive tations of application to various Currently, DDR has been intro- through today’s presentation and diseases such as alveolar hypoventi- duced to 17 facilities nationwide. discussion. First, I felt that the lation syndrome and chronic throm- We believe that a DDR, that has the possibility of realizing visualiza- boembolic pulmonary hypertension, advantage of being able to conduct tion of ventilation and perfusion by and studies on the relationship with examination in small and medium separating ventilation related signal diaphragm pacing were also report- hospitals, should ultimately aim for and perfusion related signal, which ed. I felt that the spread of applica- insurance coverage in Japan, but it was beginning of the development tions was very fresh and important. is also expected to be deployed in of Dynamic Digital Radiography Third, new points of interest have developing countries such as the (DDR), and detection of pulmonary been raised, such as the change rate Asian region. DDR could be used thromboembolism has increased. in lung area, tracheal diameter, and in developing countries where scin- Compared with ventilation and posterior ribs. In the "Atlas Concept tigraphy is not readily available. In perfusion scintigraphy, although of Movement" introduced in the terms of easy-to-perform, even in each modality has its own character- manufacturer's report, we received recent frequently occurring disas- istics, there may be a possibility that an important message that "dynamic ters such as earthquakes and fl oods, DDR image would be equivalent images have a large number of there is a possibility that economy- to those, or could be used instead. landmarks in the lung thorax". As class syndrome can be easily Above all, it could be widely used in for what we should pay attention screened in the evacuation centers, clinical practice because the exami- to, I think that the researchers who and its use is expected to expand nation cost is lower and it could are interested will work on each of in the future. I can't imagine what be performed in small - medium them, but it is important that there presentation will be coming in the hospitals. Although there are some are so many landmarks. I recall next seminar or later, but I'm really issues, there are some reports that the textbook "Felson's Principles of looking forward to them. they are on par with ventilation and Chest Roentgenology", by which I perfusion scintigraphy, and further fi rst studied static chest radiography.

22 The 2nd Dynamic Digital Radiography Seminar

Date: November 2, 2019 (Sat) Venue: Fukuracia Yaesu Conference Room A

Part 1 and 3 Chair: Atsuko Kurosaki, MD, PhD (Fukujuji Hospital, Japan Anti-Tuberculosis Association)

Part 2 Chair: Kazuo Kasahara, MD, PhD (Kanazawa University)

Part 3 Chair: Terumitsu Hasebe, MD, PhD (Tokai University)