Management of postchemotherapy residual mass in patients with advanced seminoma: Indiana University experience.

Thirty-six patients with advanced seminoma treated with cisplatin combination chemotherapy were evaluated to assess the significance of postchemotherapy residual radiographic mass. All patients had a minimum follow-up of 2 years. Of the 36 patients 21 had an evaluable residual radiographic mass after completion of chemotherapy. Twelve of these patients had a less than 3 cm maximal transverse diameter residual mass, and nine had a greater than 3 cm persistent mass postchemotherapy. Only three of these 21 patients underwent postchemotherapy retroperitoneal lymph node dissection, and the histopathology revealed only necrotic fibrous tissue. The remaining patients were followed by close observation including repeat abdominal computed tomography (CT) every 3 months the first year and every 6 months the second year (or until normal); further therapeutic intervention was given only on evidence of progressive disease. Nineteen of these 21 patients have no evidence of disease, including eight of nine with greater than 3 cm persistent radiographic abnormality. The optimal management for advanced seminoma patients with a persistent radiographic mass postchemotherapy remains unresolved. However, based on this small series, we feel that observation is a viable option, reserving radiotherapy or chemotherapy for those patients who subsequently develop progressive disease.

Imaging of lung cancer: old and new.

Lung cancer is the leading cause of cancer death in the United States. Lung cancer is frequently encountered by the radiologist, whether the lung cancer is detected on a chest radiograph obtained in a symptomatic patient, or is an incidental finding. The radiologic workup of pulmonary lesions suspected of being lung carcinoma has evolved as new technology has become available. Current imaging modalities which are useful in the workup of suspected lung cancers include plain radiography, computed tomography, magnetic resonance imaging, with the recent addition of positron emission tomography and endoscopic ultrasound. The following article discusses the merits of these imaging modalities and their role in the workup of patients with lung cancer.

Esophageal fistula complicating mediastinal histoplasmosis. Response to amphotericin B.

A 41-year-old man was admitted for evaluation of hemoptysis, dysphagia, and pleuritic chest pain associated with a mediastinal mass. Esophagography demonstrated a fistula between the mass and the esophagus. Results of histoplasmosis complement fixation serologic testing suggested an active infection. A methenamine silver stain of a lymph node obtained at mediastinoscopy revealed Histoplasmosis capsulatum. The patient was successfully treated with amphotericin B. This is believed to be the first reported case of an esophageal fistula as a complication of mediastinal histoplasmosis successfully treated with amphotericin B.

Treatment of pneumothoraces utilizing small caliber chest tubes.

Pneumothorax is a common problem in both hospitalized and emergency room patients. Eight-four pneumothoraces in 79 patients were treated using a No. 9 French catheter. In 76 cases, the catheter was attached to a flutter valve, and in eight cases, suction was applied. The No. 9 French catheter provided definitive treatment in 73 (87 percent) of the pneumothoraces. Causes of catheter failure included kinking, malposition, inadvertent removal by patient, occlusion of the tube or valve by pleural fluid, and large air leak. No complication attributable to tube placement occurred. When the flutter valve was employed, the patient was able to ambulate allowing for potential outpatient therapy. The tube was found to be easy to use, safe, and efficacious in the treatment of pneumothoraces.

Thoracic needle biopsy. Improved results utilizing a team approach.

Transthoracic needle aspiration biopsy (TNAB) is a useful diagnostic technique in the evaluation of thoracic disease. Previous reports have shown that this technique has a high positive but a low negative predictive value. The latter has limited the clinical usefulness of a negative biopsy. To improve the reliability of a negative TNAB, a series of thoracic needle biopsies was done using a team approach, having a cytopathologist, with the necessary equipment to examine the biopsy specimens, in attendance at the biopsy. As biopsy specimens were obtained, they were reviewed to ensure an adequate and representative sampling. The positive predictive value was 98.6 percent and the negative predictive value was 96.7 percent. The high negative predictive value obtained using this approach allows clinical decisions to be based on the results of a negative TNAB.

Ioversol 320: a new nonionic, water-soluble contrast medium for body computed tomography clinical trial.

An open-label noncomparative clinical study was conducted to evaluate the safety, tolerance, and efficacy of ioversol (Optiray 320), a new low-osmolality nonionic contrast medium used in contrast-enhanced computed tomographic (CT) scanning. Forty-two adult patients who required contrast-enhanced body CT scanning participated in the study. Ioversol was administered to patients undergoing CT of the chest, abdomen, and pelvis. Most of the patients received a dose of 150 mL, with smaller doses administered if a patient weighed less than 50 kg or if a patient had only one functioning kidney. The quality of the CT scans was judged to be diagnostic in all 42 patients in the study, with the quality assessed as excellent in 35 patients and good in seven patients. Ioversol was considered well tolerated by patients in the study, with none reporting any pain from the contrast agent. Only mild or moderate sensations of heat were reported. There were no clinically significant changes in vital signs, and only one mild adverse reaction (determined to be procedure-related) was reported. Ioversol was found to be safe, well tolerated, and efficacious for use in body CT scanning.

Aberrant locations and complications in initial placement of subclavian vein catheters.

The subclavian vein approach is frequently used in the placement of catheters into the great intrathoracic veins. Central venous catheters are associated with complications that may be related to the insertion of the catheter or the location of its tip. A retrospective review of 500 subclavian vein catheterizations was undertaken to determine initial catheter tip position and identify complications associated with the initial placement of the catheter. Catheters were properly positioned in 68% of successful placements. The incidence of complications associated with initial catheter placement was 1.6%. The postplacement chest roentgenogram identified clinically useful information in approximately 33% of the cases.

Patient positioning for subclavian vein catheterization.

The subclavian vein is a commonly used venous access route. Percutaneous cannulation is associated with complications and malpositioning of the catheter. We studied the potential effect of various body positions on subclavian vein catheterization using gross anatomic dissection and magnetic resonance imaging. Findings show that traditional recommendations for patient positioning with the shoulders retracted and the head turned away can act to distort the subclavian vein anatomy and make successful cannulation more difficult. Positioning the patient flat with the head and shoulders in a neutral position is suggested.

Assessing the feasibility of bronchoplastic surgery with magnetic resonance imaging.

Bronchoplastic surgical techniques may allow resectional therapy for non-small cell lung carcinoma in select patients in whom preoperative pulmonary function demonstrates prohibitive risk for pneumonectomy. We report an otherwise poor candidate for pneumonectomy in whom coronal magnetic resonance imaging demonstrated the potential for distal bronchial salvage.

Surgical management of pulmonary carcinoma secondary to recurrent respiratory papillomatosis.

Recurrent respiratory papillomatosis is a rare, but acknowledged, risk factor for pulmonary squamous cell carcinoma. Although previous reports suggest a poor prognosis for lung cancer associated with papillomatosis, we have successfully treated 1 such patient, who presented with three synchronous pulmonary malignancies, using parenchyma-sparing resection techniques.

Interventional chest radiology.

Interventional radiology has important applications for the diagnosis and treatment of chest diseases. Fine-needle aspiration biopsy of a lung nodule is the most commonly performed procedure, but lesions in the mediastinum, hilum, and chest wall also can be biopsied. Needle aspiration and catheter drainage help in treating pleural effusion, empyema, and lung and mediastinal abscesses. Emphasis on teamwork and patient care is essential. In this article, the authors offer practical advice on how and when to undertake these procedures and how to manage any associated complications.

Cardiac manifestations of noncardiac tumors. Part II: Direct effects.

Cardiac manifestations of secondary tumors of the heart exert their effects directly by endocardial, myocardial, epicardial or cavitary deposits (metastatic lesions); indirectly via tumor products such as carcinoma; or mediated by therapy (chemotherapy, radiation) to treat the primary neoplasm. Part II of this review summarizes certain direct effects of noncardiac tumors on the heart including superior and inferior vena cava syndromes, pulmonary artery and vein obstruction or compression, myocardial implants, and intracavitary metastases. Many of these direct effects may be noninvasively diagnosed by computed tomography, magnetic resonance imaging and/or two-dimensional echocardiography.

Cardiac manifestations of noncardiac tumors. Part I: Direct effects.

Cardiac manifestations of secondary tumors of the heart may exert their effects directly by endocardial, myocardial, epicardial, or cavitary deposits (metastatic lesions), indirectly via tumor products such as in carcinoma, or mediated by therapy (chemotherapy, radiation) to treat the primary neoplasm. Part I of this review summarizes the frequency of metastatic cardiac involvement by various tumors and discusses pericardial manifestations (effusion, tamponade, constriction), one of the most common consequences of direct cardiac involvement by secondary tumors.

Pulmonary infections in immunocompromised patients who do not have acquired immunodeficiency syndrome: a systematic approach.

Immunocompromised patients are susceptible to infections by organisms that infect individuals with normal immunity and by organisms that affect only those with abnormalities in their immune system. Using the radiographic findings and incorporating clinical information allows for the creation of a useful list differential diagnoses. The nature of the immune defect must be defined because defects in the different parts of the immune system are associated with infections by specific organisms. The time interval since transplantation provides a diagnostic clue because infections tend to occur at certain time intervals after transplantation. An epidemiologic history provides a history of exposure to organisms that may produce pneumonia. Consideration of the therapy the patient has received provides additional clues to the cause of the pneumonia. The physical examination and laboratory studies may provide an indication of the cause of the infection. Organisms tend to produce infections that have a typical rate of clinical development. Classifying the presentation as acute, subacute, or chronic provides additional etiologic clues. Correlating the clinical information with the radiographic findings generates a list of the most likely causative organisms. The list is useful in deciding on additional diagnostic tests and guiding therapy.

Bacterial pneumonia in immunocompromised patients.

Immunocompromised patients develop infections resulting from a wide range of organisms. The most commonly encountered type of infection is bacterial in origin. Many of the infections are community-acquired pneumonias in which most of the infections are caused by organisms that typically produce disease in the healthy person. Hospital-acquired pneumonias are particularly serious, being caused by the highly virulent gram-negative bacilli and Staphylococcus aureus. Immunocompromised patients frequently have indwelling intravascular catheters. These catheters may become infected and seed the lung with septic emboli, producing a hematogenous pneumonia. Underlying conditions and therapy increase the risk for aspiration in the immunocompromised patient. These aspirations can result in the development of an aspiration pneumonia and lung abscess formation. The majority of pneumonias resulting from Legionella and Nocardia occur in immunocompromised patients.

Endemic fungal pneumonia in immunocompromised patients.

The endemic fungi Histoplasma capsulatum, Coccidioides immitis, and Blastomyces dermatitidis tend to reside in specific geographic regions. The organisms are pathogenic in that they are able to produce clinical disease in both immunocompromised patients and in patients with normal immunity. These organisms have a variety of clinical presentations, some of which typically are seen in the normal host and others that are primarily encountered in persons with abnormal immunity. Although most of the cases are seen in endemic regions, they may occur in persons who at some time either resided in or traveled to an endemic region.

Noninfectious lung disease in immunocompromised patients.

Immunocompromised hosts have defects in their immune system that make them at risk of developing a variety of infections. In addition, these persons may develop a wide variety of noninfectious disease processes that involve the lung. These disorders may be caused by the underlying disease process. This may be seen with the development of metastatic disease from the underlying neoplasm, or it may represent the development of a malignancy secondary to therapy, as is seen with posttransplant lymphoproliferative disease. The abnormalities may be a result of the therapy used to treat the patients, as is seen with radiation injury to the lung and drug toxicity. Pulmonary edema may occur and be from a wide variety of causes. All of these disease processes may simulate an infectious process and must be differentiated from infection to allow proper therapeutic intervention.

Noninfectious and nonmalignant pulmonary disease in AIDS.

Infectious and malignant disease processes are responsible for most pulmonary abnormalities seen in patients with acquired immunodeficiency syndrome (AIDS). There are, however, a number of noninfectious and nonmalignant disorders that can involve the lungs of these individuals. Nonspecific interstitial pneumonitis and lymphocytic interstitial pneumonitis may mimic opportunistic infections both clinically and radiographically. Congestive cardiomyopathy may develop and result in pulmonary edema. Other disorders such as alveolar proteinosis and desquamative interstitial pneumonitis are also reported. Bronchoalveolar lavage, a diagnostic technique frequently employed in AIDS patients, may itself produce pulmonary opacities. Knowledge of these disorders may aid in the evaluation of AIDS patients for whom an infectious etiology for pulmonary abnormalities cannot be found.

Tracheoesophageal fistula due to Wegener granulomatosis.

Most acquired tracheoesophageal fistulas (TEFs) are due to malignant disease processes, with nonmalignant causes infrequently encountered. We report a patient with a TEF caused by Wegener granulomatosis. The radiographic findings of this rare cause of TEF are described.

Painful transthoracic needle biopsy: a sign of neurogenic tumor.

Neurogenic tumors most commonly appear initially as posterior mediastinal masses. These tumors, however, may occur in other intrathoracic locations and present a diagnostic challenge. In such cases transthoracic fine-needle aspiration (FNA) often is used to make a definitive diagnosis. This procedure usually does not result in severe pain. We report two patients who experienced severe pain during transthoracic FNA of neurogenic tumors. We believe that severe pain associated with transthoracic needle biopsy of an intrathoracic mass is suggestive of a neurogenic tumor. When pain accompanies this procedure, a cytopathologist should be notified so that specific immunostaining techniques can be performed to confirm the diagnosis.