Three-dimensional Surface Imaging for Clinical Decision Making in Pectus Excavatum

      To evaluate pectus excavatum, 3-dimensional surface imaging is a promising radiation-free alternative to computed tomography and plain radiographs. Given that 3-dimensional images concern the external surface, the conventional Haller index, and correction index are not applicable as these are based on internal diameters. Therefore, external equivalents have been introduced for 3-dimensional images. However, cut-off values to help determine surgical candidacy using external indices are lacking. A prospective cohort study was conducted. Consecutive patients referred for suspected pectus excavatum received a computed tomography (≥18 years) or plain radiographs (<18 years). The external Haller index and external correction index were calculated from additionally acquired 3-dimensional images. Cut-off values for the 3-dimensional image derived indices were obtained by receiver-operating characteristic curve analyses, using a conventional Haller index ≥3.25, and computed tomography derived correction index ≥28.0% as indicative for surgery. Sixty-one and 63 patients were included in the computed tomography and radiograph group, respectively. To determine potential surgical candidacy, receiver-operating characteristic analyses found an optimum cut-off of ≥1.83 for the external Haller index in both the computed tomography and radiograph group with a positive predictive value between 0.90 and 0.97 and a negative predictive value between 0.72 and 0.81. The optimal cut-off for the external correction index was ≥15.2% with a positive predictive value of 0.86 and negative predictive value of 0.93. The 3-dimensional image derived external Haller index and external correction index are accurate radiation-free alternatives to facilitate surgical decision-making among patients suspected of pectus excavatum with values of ≥1.83 and ≥15.2% indicative for surgery.

      Graphical Abstract



      3D (Three-dimensional), AUROC (Area under the receiver-operating characteristic curve), BMI (Body mass index), CT (Computed tomography), IQR (Interquartile range), MRI (Magnetic resonance imaging), NPV (Negative predictive value), PPV (Positive predictive value), ROC (Receiver-operating characteristic), SD (Standard deviation), STARD (Standards for reporting of diagnostic accuracy studies)
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      Linked Article

      • Commentary: In With The New: Three-Dimensional Surface Imaging For Pectus Excavatum
        Seminars in Thoracic and Cardiovascular SurgeryVol. 34Issue 4
        • Preview
          Patients with pectus excavatum have historically been evaluated with computed tomography (CT) scans, from which a Haller index may be calculated.1 It is traditionally thought that a Haller index of >3.25 constitutes a significant pectus excavatum deformity, although one limitation of using this parameter is that it can overestimate or underestimate the distortion of the chest wall in individuals because of the overall shape of the thoracic cavity. The correction index, which takes into account whether or not patients are built “thin” or “deep” in an anteroposterior dimension, can be utilized to correct for body habitus.
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      • Commentary: Lighting the Way Forward for Clinical Decision Making in Pectus Excavatum
        Seminars in Thoracic and Cardiovascular SurgeryVol. 34Issue 4
        • Preview
          Patient selection for corrective surgery for pectus excavatum varies nationally and regionally. However, the most widely agreed upon standards have typically included a radiographic measurement to quantify the degree of defect. Since first being described in 1987, the Haller Index (HI) ≥3.25 has largely remained the requisite measurement standard for surgical correction.1 More recently, this has been occasionally supplemented by the Pectus Corrective Index (PCI).2 Both indices rely on radiographic measurements derived from either plain radiography or computed chest tomography which may unnecessarily expose children to ionizing radiation.
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