Accuracy of F-18 fluorodeoxyglucose positron emission tomography for the evaluation of malignancy in patients presenting with new lung abnormalities: a retrospective review.

STUDY OBJECTIVE: To evaluate the accuracy of positron emission tomography (PET) in determining the presence of malignancy in patients presenting with new lung findings, either as an incidental finding or after treatment of a primary carcinoma. DESIGN: A retrospective review of the PET database of our hospital from April 29, 1997, to March 20, 1999, identified 196 patients referred for the evaluation of new lung findings, either as an incidental finding or following definitive treatment of a primary carcinoma. The diagnosis of either malignancy or a benign condition was established in 71 patients. This was determined by either histopathology from biopsy, or by subsequent imaging demonstrating disease progression, resolution, or stability of the initial lung findings. RESULTS: In patients presenting with new lung findings without a history of carcinoma (n = 37), the sensitivity and specificity of PET was 95% and 82%, respectively. In this population, the negative predictive value was 93% and the positive predictive value was 86%. PET was less sensitive and specific for evaluating metastatic or recurrent disease in patients previously treated for carcinoma. In patients presenting with a previously treated primary lung cancer (n = 13), the sensitivity of PET was 70%, with a specificity of 67%. The negative predictive value was only 40% and the positive predictive value was 88% in this subset of patients. In patients with an extrapulmonary primary carcinoma presenting with new lung nodules (n = 21), the sensitivity and specificity of PET was 92% and 63%, respectively. In this population, the negative predictive value was 83% while the positive predictive value was 80%. Of the 71 total cases for which follow-up data were available, there were 5 false-negative cases and 7 false-positive cases, for an overall sensitivity of 88%, specificity of 75%, negative predictive value of 81%, and positive predictive value of 84%. CONCLUSIONS: The sensitivity of PET is highest for the evaluation of new malignancy in patients without a known primary carcinoma. PET is less sensitive for evaluating metastatic or recurrent disease.

Utility of high resolution computed tomography in predicting bronchiolitis obliterans syndrome following lung transplantation: preliminary findings.

This study was undertaken to evaluate the efficacy of high resolution computed tomography (HRCT) in predicting the development of bronchiolitis obliterans syndrome (BOS) in lung transplant recipients. Fifty lung transplant patients who were clinically stable and without evidence of BOS were evaluated for the presence of four HRCT features reported to be associated with bronchiolitis obliterans: mosaic attenuation on inspiratory CT (mosaic perfusion), mosaic attenuation on expiratory CT (air trapping), bronchiectasis, and tree-in-bud opacities. CT exams were part of an annual surveillance process with the hope of predicting subsequent development of BOS. Diagnosis of BOS was made in 9 of 50 patients as indicated by a fall in FEV1 of greater than 20% of a stable baseline. None of the radiographic features associated with clinically established BOS were both sensitive and specific in the prediction of BOS. Air trapping demonstrated moderate sensitivity (56%, 5/9) and moderate specificity (76%, 35/46) for prediction of BOS in the year following the CT exam. Bronchiectasis, the most reliable indicator of the presence of BOS was a poor predictor of subsequent BOS with an 11% (1/9) sensitivity but had high specificity (96%, 44/46). No high resolution CT features accurately predicted the development of BOS.

Advanced emphysema: preoperative chest radiographic findings as predictors of outcome following lung volume reduction surgery.

PURPOSE: To determine whether preoperative chest radiographic findings alone can reliably predict which patients will achieve the best functional outcome of lung volume reduction surgery. MATERIALS AND METHODS: The preoperative chest radiographs obtained in 57 patients who had undergone lung volume reduction surgery were retrospectively scored by five blinded readers for severity and distribution of emphysema, evidence of lung compression, disease heterogeneity, and other features. Comparisons were made with the 3-6-month postoperative functional outcome for each patient. RESULTS: High disease heterogeneity (score > 2) and unequivocal lung compression (score 1) both were 100% predictive of a favorable outcome (FEV1 increase, > or = 30%). Low heterogeneity (score < 1) was 94% predictive of an unfavorable outcome (FEV1 increase < 30%), as was a lack of lung compression, which was 92% predictive of an unfavorable outcome. These two features also correlated with an improved 6-minute walk test result, although this correlation was weaker. CONCLUSION: Chest radiography alone may be sufficient for initial screening. High disease heterogeneity and lung compression on chest radiographs are highly predictive of a favorable functional outcome.

Bronchiectasis.

Bronchiectasis is characterized by irreversible dilatation of the airways. Associated with a variety of underlying disorders, the common pathway for the development of bronchiectasis is chronic or recurrent infection. Bronchiectasis can occur in the normal host after a bout of severe infection or bronchial obstruction. Currently, it is more commonly seen in patients with abnormal host defenses including impaired clearance of secretions and disorders of cellular and humoral immunity. Historically, bronchography has been the imaging tool used for the evaluation of bronchiectasis. This procedure has been replaced by high resolution computed tomography, which is currently the modality of choice for imaging patients with bronchiectasis.

Pulmonary aspergillosis in patients with AIDS. Clinical and radiographic correlations.

OBJECTIVE: To evaluate the clinical and radiographic features of pulmonary aspergillosis as they present in AIDS patients; in particular, to determine similarities and differences between Aspergillus infection in patients with AIDS vs those without AIDS. SUBJECTS AND METHODS: Six new cases of confirmed or probable pulmonary aspergillosis were discovered during a search of hospital records. These are reviewed with 30 previously reported cases with special attention to radiographic appearance of disease and how radiographic appearance influences clinical outcome. RESULTS: Symptoms of pulmonary aspergillosis in AIDS were nonspecific, most often including fever, cough, and dyspnea, and less commonly, chest pain or hemoptysis. Major risk factors for the development of pulmonary aspergillosis in patients with AIDS were steroid administration and neutropenia. Neutropenia was often a complication of therapies for AIDS, in particular, ganciclovir and zidovudine. Radiographic appearance of disease could be divided into three general categories. One third of the patients (13/36) presented with cavitary upper lobe disease resembling noninvasive or chronic necrotizing aspergillosis. Fatal hemoptysis occurred in 42 percent of patients with this form of disease. Twenty-two percent (8/36) of the cases presented as a nondescript focal alveolar opacity similar to invasive aspergillosis. In several patients, the focal infiltrate remained stable for several months, a feature that is unusual for aspergillosis in non-AIDS patients. The air crescent sign was present in none of the 36 reported cases. Patients with only focal disease had the best prognosis of patients with pulmonary aspergillosis. Bilateral alveolar or interstitial disease similar to invasive aspergillosis was present in 23 percent (9/36) of the patients. Bilateral disease appears to be a marker for disseminated infection and was associated with a high mortality due to aspergillosis. Two new forms of bronchial aspergillosis (5/36 cases) have been described previously. These patients presented with either obstructing fungal casts or bronchial pseudomembranes demonstrated bronchoscopically. In some patients with the bronchial forms of aspergillosis, transient alveolar opacities were seen on chest radiographs. These opacities may represent regions of atelectasis due to airway obstruction. One patient who had bilateral pneumothoraces without parenchymal opacities did not correspond to any of the three previously mentioned categories. Mortality due to aspergillosis was greater than 50 percent among AIDS patients. Death was subsequent to fatal hemoptysis or widespread pulmonary or systemic infection. CONCLUSION: Unlike other risk groups that tend to contract only one form of pulmonary aspergillosis, AIDS patients can develop the whole spectrum of aspergillosis-related pulmonary disorders, including chronic cavitary, invasive, and bronchial forms of aspergillosis. Clinical symptoms are nonspecific and major risk factors include neutropenia, which is often a side effect of various therapies for AIDS, and steroid administration. Patients with the chronic cavitary form of disease have an unusually high mortality due to fatal hemoptysis. Patients with bilateral pulmonary infiltrates and aspergillosis have a high mortality due to disseminated infection.

Chest radiographic findings in patients with acute pulmonary embolism: observations from the PIOPED Study.

PURPOSE: To determine the sensitivity, specificity, and positive and negative predictive values of chest radiographic findings in patients suspected of having acute pulmonary embolism (PE). MATERIALS AND METHODS: Chest radiographs of 1,063 patients with suspected PE were reviewed. PE was confirmed angiographically in 383 patients and excluded in 680 patients. RESULTS: The chest radiograph was interpreted as normal in only 12% of patients with PE. The most common chest radiographic finding in patients with PE was atelectasis and/or parenchymal areas of increased opacity; however, the prevalence was not significantly different from that in patients without PE. Oligemia (the Westermark sign), prominent central pulmonary artery (the Fleischner sign), pleural-based area of increased opacity (the Hampton hump), vascular redistribution, pleural effusion, elevated diaphragm, and enlarged hilum were also poor predictors of PE. CONCLUSION: Although chest radiographs are essential in the investigation of suspected PE, their main value is to exclude diagnoses that clinically mimic PE and to aid in the interpretation of the ventilation-perfusion scan.

Disseminated nontuberculous mycobacterial infections in immunosuppressed patients.

In summary, DNTM is an uncommon cause of infection in non-AIDS immunocompromised patients, but it is seen with increasing frequency as a late complication in AIDS patients who are severely debilitated. Non-AIDS patients may have pulmonary symptoms and parenchymal abnormalities on chest radiographs. These patients apparently may have clinically significant pulmonary infection. In contrast, AIDS patients with DNTM are unlikely to have clinically significant pulmonary disease. Although the lung is a common site of infection in these patients, they usually do not have pulmonary symptoms related to NTMB infection. Chest radiographs in these patients may show hilar or mediastinal adenopathy and/or pleural effusion. It is uncertain whether the parenchymal infiltrates noted in these patients are caused by NTMB or by coexisting processes. It is suspected that pulmonary NTMB in the AIDS patient is not likely to produce pulmonary parenchymal abnormalities on the chest radiograph.

Chronic beryllium disease.

Chronic beryllium disease is a multisystem granulomatous disease caused by industrial exposure to beryllium dust or fumes. It is thought to represent a hypersensitivity disorder rather than a true pneumoconiosis. The lung is the primary organ of involvement, and many of the radiographic features resemble sarcoid.

Drug-induced pulmonary disease: an update.

The review provides an update of drug-induced pulmonary disorders, focusing on newer agents whose effects on the lung have been studied recently. Included among these drugs are cyclosporine, cytosine arabinoside (Ara-C), amiodarone, interleukin-2 (IL-2), OKT3, tricyclic antidepressants, and bromocriptine. A brief review of the most common cytotoxic and noncytotoxic agents causing pulmonary toxicity is also included.

CT of mediastinal lymph nodes in patients with non-small cell lung carcinoma.

What is the "bottom line" for the role of CT in staging mediastinal involvement in patients with non-small cell bronchogenic carcinoma? On the basis of their studies, Libshitz and McKenna question whether CT has any utility in evaluating mediastinal lymph nodes. Staples et al believe that CT and mediastinoscopy are complementary, and that many patients who are considered candidates for surgical resection should have both. It is clear that the overall sensitivity and specificity of CT are variable from study to study. In recent studies that have subjected patients to exhaustive lymph node dissection, and in which there has been meticulous correlation between the lymph nodes identified on CT and those removed at surgery, it seems clear that the sensitivity of CT in predicting the absence of metastatic disease is unacceptably low. However, there is another way to approach these statistics. Recent studies have shown that patients with mediastinal microscopic metastasis discovered at the time of thoracotomy have improved survival rates if the primary tumor and mediastinal metastases are all resected. Patients with macroscopic metastases in mediastinal nodes have a worse prognosis. Therefore, CT may be useful for screening patients to rule out the presence of macroscopic metastatic disease. If the mediastinal CT scan shows no enlarged lymph nodes, it seems reasonable to bypass the surgical staging procedure and proceed directly to thoracotomy. However, in order to determine the true pathologic stage of disease in the patient, a thorough mediastinal dissection must be carried out in these patients at the time of thoracotomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Cavitary pulmonary metastases in angiosarcoma. Diagnosis by transthoracic needle aspiration.

An unusual case of cavitary pulmonary metastases from an angiosarcoma of the scalp is described. Transthoracic needle aspiration biopsy of one of the cavitary nodules was successful in establishing the diagnosis.

Lung cancer in childhood.

A 16-year-old boy had unresolving right lower lobe consolidation due to primary adenocarcinoma of the lung. Lung cancer is rare in children, is usually adenocarcinoma or undifferentiated histology, and frequently presents with advanced disease. It may be confused with atelectasis attributable to a foreign body or bronchial adenoma, plasma cell granuloma, pulmonary sequestration, or chronic infection. We review the clinical features of pediatric lung cancer and differences in lung cancer between children and adults.

Recurrent esophageal carcinoma at thoracotomy incisions: diagnostic contributions of CT.

Three cases of surgical implantation of esophageal carcinoma during esophagogastrectomy are presented. The CT and radiographic appearance is demonstrated. A possible etiology and method for decreasing the risk of surgical spread of tumor are discussed.

Chronic traumatic diaphragmatic hernia: the significance of pleural effusion.

Five patients with chronic traumatic diaphragmatic hernia presented with symptoms of acute intestinal obstruction and unilateral pleural effusion. In each case, infarcted herniated abdominal structures were found at surgery. The presence of an ipsilateral pleural effusion is an important radiographic sign, which may indicate strangulation in patients with chronic traumatic diaphragmatic hernia.

Clinical evaluation of a medical image management system for chest images.

The clinical efficacy and physicians' assessment of a medical image management system (MIMS) for chest images that involved the medical intensive care unit (MICU) and the radiology department were evaluated. A token-passing fiber-optic network was implemented to connect display stations in the MICU and in the chest reading area in the radiology department with a laser film digitizer and an archiving system. To study the clinical efficacy of this system, blocks of 8 weeks during which portable chest images were digitized and immediately made available in the MICU were alternated with blocks of 8 weeks during which film images only were available. Approximately 3000 portable chest examinations were tracked; patients were entered into the study at a rate of 65 per month. Data on time intervals associated with the examination process were collected from MICU physicians, radiologists, radiographers, and film librarians. The time from the completion of an examination to the time an action was taken that was based on radiographic findings showed significant reductions during the digital periods for certain actions. For example, the time to begin drug therapy decreased from a mean of 4.7 hr when films were viewed to a mean of 3.3 hr when digital images were viewed. In conclusion, if prompt action by the MICU physician improves a patient's outcome, a positive effect on patient care will result from the immediate availability of radiographic images.

Chronic beryllium disease: diagnosis, radiographic findings, and correlation with pulmonary function tests.

Patients with suspected chronic beryllium disease underwent bronchoscopy and bronchoalveolar lavage. Their bronchoalveolar lymphocytes were incubated with beryllium salts, and quantitative lymphocyte transformation was measured. Seventeen patients with a positive lymphocyte proliferation test were evaluated radiographically with the International Labour Office classification. The most common radiographic abnormalities included diffuse small round and reticular opacities. Hilar adenopathy, linear scars, lung distortion, bullae, and pleural thickening were found less commonly. Specific radiographic findings were compared with pulmonary function abnormalities. The extent of radiographic profusion of small opacities and the presence of linear scars did not correlate with pulmonary function abnormalities. There was, however, a significant correlation between extensive pleural disease and reduced vital capacity in this small group of patients.