Revisiting the prognostic value of preoperative (18)F-fluoro-2-deoxyglucose ( (18)F-FDG) positron emission tomography (PET) in early-stage (I & II) non-small cell lung cancers (NSCLC).

PURPOSE: The aims were to determine if the maximum standardized uptake value (SUV(max)) of the primary tumor as determined by preoperative (18)F-fluoro-2-deoxyglucose ((18)F-FDG) positron emission tomography (PET) is an independent predictor of overall survival and to assess its prognostic value after stratification according to pathological staging. METHODS: A retrospective clinicopathologic review of 363 patients who had a preoperative (18)F-FDG PET done before undergoing attempted curative resection for early-stage (I & II) non-small cell lung cancer (NSCLC) was performed. Patients who had received any adjuvant or neoadjuvant chemotherapy or radiation therapy were excluded. The primary outcome measure was duration of overall survival. Receiver-operating characteristic (ROC) curves were plotted to find out the optimal cutoff values of SUV(max) yielding the maximal sensitivity plus specificity for predicting the overall survival. Survival curves stratified by median SUV(max) and optimal cutoff SUV(max) were estimated by the Kaplan-Meier method and statistical differences were assessed using the log-rank test. Multivariate proportional hazards (Cox) regression analyses were applied to test the SUV(max)'s independency of other prognostic factors for the prediction of overall survival. RESULTS: The median duration of follow-up was 981 days (2.7 years). The median SUV(max) was 5.9 for all subjects, 4.5 for stage IA, 8.4 for stage IB, and 10.9 for stage IIB. The optimal cutoff SUV(max) was 8.2 for all subjects. No optimal cutoff could be established for specific stages. In univariate analyses, each doubling of SUV(max) [i.e., each log (base 2) unit increase in SUV(max)] was associated with a 1.28-fold [95% confidence interval (CI): 1.03-1.59, p = 0.029] increase in hazard of death. Univariate analyses did not show any significant difference in survival by SUV(max) when data were stratified according to pathological stage (p = 0.119, p = 0.818, and p = 0.882 for stages IA, IB, and IIB, respectively). Multivariate analyses demonstrated that SUV(max) was not an independent predictor of overall survival (p > 0.05). CONCLUSION: Each doubling of SUV(max) as determined by preoperative PET is associated with a 1.28-fold increase in hazard of death in early-stage (I & II) NSCLC. Preoperative SUV(max) is not an independent predictor of overall survival.

Outcomes of patients considered for, but not admitted to, the intensive care unit.

OBJECTIVE: The purpose of this study is to evaluate factors associated with decisions to reject patients from medical intensive care unit (MICU) admission and assess the outcome of these patients. DESIGN: Prospective, observational cohort study. SETTING: Large tertiary referral, teaching hospital. PATIENTS: Consecutive patients evaluated for MICU admission but not admitted. MEASUREMENTS: Patient characteristics and demographics, location of evaluation, clinical and laboratory data, major organ system dysfunction, 48-hr patient status, and 6-month mortality. MAIN RESULTS: A total of 1,302 patients were admitted to the MICU, 353 patients were evaluated for the MICU but were not admitted, and 324 patients were used in analysis. Mean age was 68.6 +/- 17.1 yrs, and 57.7% were women. Hospice care was instituted during or immediately after evaluation in 8.3% (n = 27) of cases. MICU care was declined by the patient in 5.2% (n = 17) of evaluations. The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 17.4 +/- 6.0. Factors associated with death at 6 months included age, APACHE II score, entering hospice, and patient choice to decline care. Of the patients considered too well to benefit, 9% were admitted to the MICU within 48 hrs and 35.5% died within 6 months; however, no deaths occurred within 48 hrs. CONCLUSIONS: Patients who are considered for critical care are at very high risk of mortality within 6 months. Given that no deaths occurred within 48 hrs and that only 9% needed intensive care unit admission within 48 hrs, the house staff's decision process is safe at this one institution.

Endobronchial mass caused by tuberculosis.

We report a case that illustrates an unusual manifestation of tuberculosis with massive atelectasis secondary to an endobronchial polypoid lesion. The rarity of this manifestation, coupled with the nonspecific findings on biopsy, delays recognition and therapy. Tuberculosis should be considered in the differential diagnosis of endobronchial mass lesions in the right clinical setting.

Routine chest radiographs in exacerbations of chronic obstructive pulmonary disease. Diagnostic value.

Routine admission chest radiographs were abnormal in 35 (14%) of 242 patients hospitalized with an exacerbation of chronic obstructive pulmonary disease and resulted in management changes that were appropriate and clinically significant in only 11 cases (4.5%). Based on our analysis of clinical variables predictive of significant radiographic abnormalities and our assessment of clinically important findings, we propose the following indications for admission chest radiographs in patients with an acute exacerbation of chronic obstructive pulmonary disease: white blood cell count above 15 x 10(9)/L and polymorphonuclear leukocyte count above 8 x 10(9)/L, history of congestive heart failure, history of coronary artery disease, chest pain, or edema. In view of the low yield of clinically significant abnormalities, we believe that routine chest radiographs need not be performed in this patient population. The use of selective criteria could eliminate unnecessary studies while assuring recognition of important new radiographic abnormalities.

Tuberculous enteritis and peritonitis. Report of 36 general hospital cases.

We studied 36 patients with gastrointestinal tuberculosis: 21 had peritonitis, 11 had enteritis, and four had both. Diagnostic criteria were (1) caseating granulomas or positive smear or culture from an abdominal specimen; (2) culture-proved pulmonary tuberculosis plus ascitic fluid containing protein, greater than 3.0 g/dL, and more than 50% lymphocytes, or granulomatous enterlitis on x-ray studies that resolved with antituberculous therapy. In only four of 15 patients with enteritis was the disease confined to the ileocecal region. Fourteen patients (40%) had complications: bowel obstruction in ten, perforation in six, and fistula in five. Five of these died. Two perforations and one death followed paracentesis and needle biopsy. Tuberculous peritonitis can be diagnosed without biopsy when lymphocytic exudative ascites responds to antituberculous chemotherapy given for concurrent culture-proved pulmonary tuberculosis. Patients with pulmonary tuberculosis and persistent abdominal complaints who have granulomatous enteritis should be considered to have tuberculous enteritis. Surgery is reserved for bowel obstruction, perforation, fistula, or a mass that does not resolve with drug therapy.

Gallium-67 citrate scanning--a new adjunct in the detection and follow-up of extrapulmonary tuberculosis: concise communication.

Gallium-67 citrate scans were obtained in 11 patients considered at risk for extrapulmonary tuberculosis. Radiographic and bacteriologic studies were performed routinely and tissue biopsy selectively. Of five patients with proven extrapulmonary tuberculosis, there were three with renal tuberculosis, one with Pott's disease, and one with peritoneal tuberculosis. The Ga-67 scan correctly predicted presence or absence of active extrapulmonary foci in all 11 patients. Follow-up scans correlated well with clinical response to therapy. The diagnosis of extrapulmonary tuberculosis is often overlooked because of nonspecific symptoms and frequent lack of concurrent lung involvement. Scanning with Ga-67 citrate offers a reliable and simple means of screening patients at risk and of monitoring response to treatment.

Optimum anesthesia with intrapleural lidocaine during chemical pleurodesis with tetracycline.

Chemical pleurodesis with tetracycline is frequently complicated by pleuritic chest pain. The most promising approach to control pain is to optimize the use of intrapleural lidocaine. While administering amounts of intrapleural lidocaine larger than commonly reported, we attempted to determine a safe and more effective dose, by using a subjective and objective assessment of pain, by measuring serum concentrations of lidocaine, and by observing patients for possible toxic effects of lidocaine. Chemical pleurodesis with tetracycline was performed on ten patients receiving an intrapleural dose of 200 mg of lidocaine (group 1) and on ten patients receiving a 250-mg dose (group 2). A significantly greater number of patients in group 2 were free of pain following pleurodesis (7/10 vs 1/10; p = 0.006). Of the 80 serum lidocaine levels obtained, only one value (6.1 micrograms/ml), in an asymptomatic patient in group 1, exceeded the therapeutic range (1.5 micrograms/ml to 5.5 micrograms/ml). One patient in group 2 experienced transient numbness of the right hand, a possible side effect of lidocaine. We conclude that to achieve optimum anesthesia during chemical pleurodesis with tetracycline, it is necessary to use doses of intrapleural lidocaine large than previously reported. Until the feasibility of a further escalation is demonstrated, 250 mg should be considered the standard dose.

Xerotomography of peripheral lung lesions.

Xerotomography was compared to conventional tomography in 72 patients with peripheral lung lesions. The xerotomogram was superior to the conventional tomogram in 41 patients, and yielded no additional information in 31. Details of lesions were better displayed, especially the margins: cavitations, air bronchogram and bronchiectasis, and calcification. Differentiation between benign, inflammatory and malignant lesions was facilitated. The xerotomographic process improved the image detail of lesions due to the edge enhancement property and the greater recording latitude of contrast of the xeroradiographs. Xerotomography is recommended only in selected patients for a few tomographic cuts because of the high radiation dosage.

Tuberculosis. How can we halt its resurgence?

Tuberculosis is a well-known disease with classic clinical manifestations. However, a change in host defense mechanisms may cause atypical manifestations. A thorough understanding of presentations of the disease and of the principles of prevention and treatment is important in stopping the spread of tuberculosis.

Age, tumor size, type of surgery, and gender predict survival in early stage (stage I and II) non-small cell lung cancer after surgical resection.

BACKGROUND: Even after presumably curative resection the 5-year survival rates are only 60-80% in stage I and 40-50% in stage II NSCLC. Purpose of the present study was the identification of independent clinico-pathological predictors of their survival. METHODS: A retrospective review of 519 consecutive subjects who had undergone attempted curative resection for stage I or II NSCLC was performed. Patients who had received any adjuvant or neo-adjuvant chemo- or radiation therapy were excluded. Primary outcome measure was the duration of overall survival. RESULTS: Median survival was 7.25 years for stage IA, 5.71 years for stage IB and 3.85 years for stage IIB. In univariate analysis, six variables were significantly associated (p-value<0.05) with poorer survival: older age, larger size of the tumor, male gender, surgery other than lobectomy, squamous histology and later stages (stage IB and IIB). In multivariate analysis, age (Hazard ratio=1.06 per year increase in age; p<0.0001), larger tumor size (Hazard ratio=1.54 per doubling of tumor size; p<0.0001), type of surgery (Hazard ratio=1.50 for surgery other than lobectomy; p=0.036), and gender (Hazard ratio=1.45 for male gender; p=0.039) were the predictors of overall survival. CONCLUSIONS: In surgically treated early stage (I and II) NSCLC patients, age, tumor size, type of surgery, and gender are the important predictors of survival.

Endobronchial foreign body demonstrated by xerotomography.

A case of pneumonia secondary to aspirated foreign body is presented. Xerotomography was useful in detecting abnormalities of the tracheobronchial tree and in demonstrating endobronchial foreign bodies.

Lung carcinoma superimposed on pulmonary tuberculosis.

Review of patients with active pulmonary tuberculosis over a three-year period showed an increased incidence of bronchogenic carcinoma (5%). There had been considerable delay in establishing diagnosis of coexistent carcinoma which was attributed to finding of acid-fast bacilli and relative ease of ascribing all findings to that cause. Suspicious roentgen signs are reviewed and the importance of sputum cytology is also stressed.

Pulmonary and articular sporotrichosis.

A 46-year-old man presented with swelling and pain in the right knee and a history of nonproductive cough and weight loss. Sporotrichum schenkii was cultured from synovium, synovial fluid, sputum, and bronchial washings. No other pathogens were cultured. Neither skin lesions nor history of exposure to S. schenckii was present, but 7 years before this admission the patient had been treated for suspected pulmonary tuberculosis despite negative mycobacteriology. The case is believed to represent systemic spread from chronic pulmonary sporotrichosis and supports the hypothesis that the lung may serve as a portal of entry in noncutaneous systemic sporotrichosis.

Patterns of abnormal FDG uptake by various histological types of non-small cell lung cancer at initial staging by PET.

The aim of this study was to identify useful patterns of abnormal fluorine-18 fluorodeoxyglucose (FDG) uptake by different types of non-small cell (NSC) lung cancer and to assess their clinical implications. One hundred and three sequential patients with newly diagnosed, pathology-proven NSC lung cancer were included. FDG positron emission tomography (PET) images were acquired using a dedicated PET scanner. There were 35 squamous cell carcinomas (SQC), 17 large cell cancers (LGC), 38 adenocarcinomas (ADC), 1 bronchioloalveolar carcinoma (BAC) and 12 non-classified NSC cancers. PET images were categorized into detectable patterns of necrotic center in the primary tumor, satellite lesions (T4), hilar lymph nodes (N1), and N2, N3, and M1 lesions by visual interpretation of PET images for SQC, LGC, and ADC (n=90; BAC and non-classified NSC cancers were excluded). The PET lesions were correlated with surgical pathology and with CT findings in inoperable cases. Necrosis was more commonly present in the primary tumors of LGC (53%) and SQC (43%) than in those of ADC (26%) (P<0.0001 and <0.01, respectively). The frequencies of nodal uptake in ADC, SQC and LGC were similar (71%, 60%, and 59%, respectively). However, M1 lesions were present significantly more often in LGC (41%) and ADC (34%) than in SQC (3%) (both P<0.0001). Significantly more surgically inoperable cases were found by PET (T4, N3, M1) in ADC (50%) and LGC (41%) than in SQC (26%) (P<0.001 and <0.02, respectively). Our results suggest a wide variation of PET findings for different types of NSC lung cancer. Identification of these patterns is useful in clinical PET interpretation, in that knowledge of the most probable association between the PET patterns and the histological types will facilitate initial staging and planning of management.