Plasma D-dimer levels and ischaemic lesions in multiple vascular regions can predict occult cancer in patients with cryptogenic stroke.

BACKGROUND AND PURPOSE: Cancer patients with cryptogenic stroke often have high plasma D-dimer levels and lesions in multiple vascular regions. Hence, if patients with cryptogenic stroke display such characteristics, occult cancer could be predicted. This study aimed to investigate the clinical characteristics of cryptogenic stroke as the first manifestation of occult cancer and to determine whether plasma D-dimer levels and lesions in multiple vascular regions can predict occult cancer in patients with cryptogenic stroke. METHODS: Between January 2006 and October 2015, data on 1225 patients with acute ischaemic stroke were extracted from the stroke database of Osaka University Hospital. Among them, 184 patients were classified as having cryptogenic stroke, and 120 patients without a diagnosis of cancer at stroke onset were identified. Clinical variables were analyzed between cryptogenic stroke patients with and without occult cancer. RESULTS: Among 120 cryptogenic stroke patients without a diagnosis of cancer, 12 patients had occult cancer. The body mass index, hemoglobin levels and albumin levels were lower; plasma D-dimer and high-sensitivity C-reactive protein levels were higher; and lesions in multiple vascular regions were more common in patients with than in those without occult cancer. Multiple logistic regression analysis revealed that plasma D-dimer levels (odds ratio, 3.48; 95% confidence interval, 1.68-8.33; P = 0.002) and lesions in multiple vascular regions (odds ratio, 7.40; 95% confidence interval, 1.70-39.45; P = 0.01) independently predicted occult cancer. CONCLUSIONS: High plasma D-dimer levels and lesions in multiple vascular regions can be used to predict occult cancer in patients with cryptogenic stroke.

Specificities in human cell-mediated cytotoxicity.

Specificity of natural cell-mediated cytotoxicity was investigated through selective reactions detected by direct cell-mediated cytotoxicity and by inhibition of cytotoxicity through competition. Assuming that target cells reacting alike in direct cytotoxicity shared common antigens, we classified 10 target cells into three groups by target antigens: TA (target antigen) 1, 2, and 3. Partial confirmation of the three groups was achieved in the cross-competition assay. The distinction of TA 1 as a group was clear but some cross-reactivity existed between TA 2 and TA 3 cells.

Decline of natural nonselective cell-mediated cytotoxicity in patients with tumor progression.

Lymphocytes isolated from the blood of patients and healthy donors include a population of cells that destroy target cells in the direct cell-mediated cytotoxic assay with little indication of specificity. This natural reaction is the dominant feature of most cell-mediated cytotoxic tests and, although it appears to be mostly nonselective, it possesses some selective activity. The observed cytotoxicity from these reactions depends mostly on the reactivity of the effector cell; when several effector cells are tested on different target cells, the relative order of activity is usually maintained on the different target cells. When this natural cytotoxicity was analyzed without regard to the type of cancer of the patient or of the target cells, a weak decline in the average reactivity was observed with increasing tumor involvement.

18fluorodeoxyglucose positron emission tomography to detect mediastinal or internal mammary metastases in breast cancer.

PURPOSE: To determine the prevalence of suspected disease in the mediastinum and internal mammary (IM) node chain by 18fluorodeoxyglucose (FDG) positron emission tomography (PET), compared with conventional staging by computed tomography (CT) in patients with recurrent or metastatic breast cancer. PATIENTS AND METHODS: We retrospectively evaluated intrathoracic lymph nodes using FDG PET and CT data in 73 consecutive patients with recurrent or metastatic breast cancer who had both CT and FDG PET within 30 days of each other. In reviews of CT scans, mediastinal nodes measuring 1 cm or greater in the short axis were considered positive. PET was considered positive when there were one or more mediastinal foci of FDG uptake greater than the mediastinal blood pool. RESULTS: Overall, 40% of patients had abnormal mediastinal or IM FDG uptake consistent with metastases, compared with 23% of patients who had suspiciously enlarged mediastinal or IM nodes by CT. Both FDG PET and CT were positive in 22%. In the subset of 33 patients with assessable follow-up by CT or biopsy, the sensitivity, specificity, and accuracy for nodal disease was 85%, 90%, and 88%, respectively, by FDG PET; 54%, 85%, and 73%, respectively, by prospective interpretation of CT; and 50%, 83%, and 70%, respectively, by blinded observer interpretation of CT. Among patients suspected of having only locoregional disease recurrence (n = 33), 10 had unsuspected mediastinal or IM disease by FDG PET. CONCLUSION: FDG PET may uncover disease in these nodal regions not recognized by conventional staging methods. Future prospective studies using histopathology for confirmation are needed to validate the preliminary findings of this retrospective study.

Diagnosing pneumonia by physical examination: relevant or relic?

BACKGROUND: The reliability of chest physical examination and the degree of agreement among examiners in diagnosing pneumonia based on these findings are largely unknown. OBJECTIVES: To determine the accuracy of various physical examination maneuvers in diagnosing pneumonia and to compare the interobserver reliability of the maneuvers among 3 examiners. METHODS: Fifty-two male patients presenting to the emergency department of a university-affiliated Veterans Affairs medical center with symptoms of lower respiratory tract infection (cough and change in sputum) were prospectively examined. A comprehensive lung physical examination was performed sequentially by 3 physicians who were blind to clinical history, laboratory findings, and x-ray results. Examination findings by lung site and whether the examiner diagnosed pneumonia were recorded on a standard form. Chest x-ray films were read by a radiologist. RESULTS: Twenty-four patients had pneumonia confirmed by chest x-ray films. Twenty-eight patients did not have pneumonia. Abnormal lung sounds were common in both groups; the most frequently detected were rales in the upright seated position and bronchial breath sounds. Relatively high agreement among examiners (kappa approximately 0.5) occurred for rales in the lateral decubitus position and for wheezes. The 3 examiners' clinical diagnosis of pneumonia had a sensitivity of 47% to 69% and specificity of 58% to 75%. CONCLUSIONS: The degree of interobserver agreement was highly variable for different physical examination findings. The most valuable examination maneuvers in detecting pneumonia were unilateral rales and rales in the lateral decubitus position. The traditional chest physical examination is not sufficiently accurate on its own to confirm or exclude the diagnosis of pneumonia.

Selective reactions in antibody-dependent cell-mediated cytotoxicity.

Selective reactions associated with HLA specificity were sought in antibody-dependent cell-mediated cytotoxic tests against HLA-typed lymphoblastoid lines using operationally monospecific HLA sera and effector cells from healthy individuals. Precise detection of HLA specificities was disturbed by the presence of natural antibodies in HLA antiserum and the effect of the serum and cells on target cell viability. Detection of HLA specificity was improved by absorption of the serum to remove natural antibodies and correction of the results for extraneous cell and serum effects.

Computed tomographic evaluation of lesions in the thoracic apex.

Fifty patients with clinically suspected lesions of the chest apex underwent computed tomography (CT) and plain film (PF) examinations in an attempt to define the underlying etiology as benign or malignant. CT was slightly more sensitive in diagnosing malignancy (90%) compared with PF (77%), with a higher predictive value of a negative test (85% vs. 70%), although the differences were not statistically significant. The specificity and predictive value of a positive test were similar for CT and PF. CT's advantage was better elucidation of the soft tissues of the chest apex. CT provided additional information beyond PF in 17/20 patients with benign conditions and in 29/30 patients with cancer. In 21 of these 29 cancer patients, CT findings significantly altered subsequent management.

Radiology of chronic obstructive pulmonary disease.

This article reviews the radiologic manifestations and complications of chronic obstructive pulmonary disease, particularly those seen in association with emphysema. Current concepts on the pathogenesis of chronic obstructive pulmonary disease are discussed and related to findings on high-resolution CT scan and histologic examinations. Controversial issues concerning the detection and grading of emphysema using radiologic and physiologic tests are also addressed.

Computed tomography of air-space disease.

Although computed tomography (CT) has not been used as often in air-space diseases as in interstitial ones, it often provides useful information. Diseases such as early opportunistic pneumonia may be detected by CT before becoming visible on plain radiographs. Also, extent and location are often better defined by CT than by plain radiographs. Accompanying abnormalities such as abscess, lymphadenopathy, and pleural effusion are often clearly demonstrated by CT. This article reviews the CT findings in a variety of air-space diseases, including pneumonia and other infections, radiation pneumonitis and fibrosis, embolism, eosinophilic pneumonia, alveolar proteinosis, bronchioloalveolar carcinoma, lipoid pneumonitis, sarcoidosis, and trauma.

The extrapleural fat in empyema: CT appearance.

Pleural empyema can be accompanied by changes in the adjacent chest wall. We examined the chest wall on computed tomographic scans in 24 patients with pleural effusions. Eighteen patients had pleural empyema and six had transudative effusions. Of the 18 empyema patients, 13 had abnormally high attenuation in the extrapleural tissues. In 12 of these 13, the high attenuation was probably caused by reaction to the pleural infection. In two, it was probably caused by haematoma (one patient had haematoma and empyema). In five patients there was either no clear abnormality in the extrapleural space or an insufficient amount of fat to permit detection of an abnormality, or the parietal pleura could not be distinguished from the pleural fluid because intravenous contrast medium was not given. Of the six patients with proven transudative pleural effusions, all had extrapleural fat which appeared normal. Abnormally high attenuation in the extrapleural tissues can be expected to accompany exudative pleural effusion, particularly empyema, but not transudative effusion.

Diagnostic use of inadvertent pneumothorax after CT-guided percutaneous lung biopsy.

Previous studies using artificially induced pneumothorax and post-pneumothorax computed tomography (pCT) have shown that 100% of cancers that fall away from the mediastinum or chest wall are contained within the visceral pleura at that site. This patient demonstrates how an unintentional, postbiopsy pneumothorax can be used to show that a peripheral carcinoma of the lung does not invade the mediastinum.

Lung abscess caused by Rhodococcus equi.

In the immunocompromised patient, early diagnosis of a lung cavity is essential for appropriate treatment. Rhodococcus equi (formerly Corynebacterium equi) is a variably acid-fast bacterium that can produce cavitary disease in an immunocompromised host. The two cases presented here demonstrate the clinical and radiographic features of R equi lung abscess. The first patient was on long-term corticosteroid therapy for rheumatoid arthritis. The second patient had AIDS. The correct diagnosis in both cases was delayed because acid-fast bacilli seen on smears of sputum were presumed to be Mycobacterium tuberculosis.

Inadvertent bucrylate pulmonary embolization: a case report.

Detection of small, dense, rectangular opacities that follow the course of pulmonary vessels on chest radiographs should raise the suspicion of a prior therapeutic occlusion of the blood supply of a mass or of an arteriovenous fistula elsewhere with embolization of the occlusive material to the lungs. This article demonstrates the radiographic findings of such an occurrence in an asymptomatic woman.

Superior sulcus tumors: the role of imaging.

Advances in the treatment of stage 0 to III superior sulcus tumors mandate greater accuracy in establishing tissue diagnosis, assessing tumor extent, and staging. Currently, this is best accomplished by a combination of PA chest radiography, MRI, and needle biopsy. MRI is superior to other single imaging modalities for the overall assessment of local tumor extent, bone invasion, mediastinal invasion, and perhaps in the future, determining radiosensitivity. In patients with superior sulcus tumors, evaluation of the brain, liver, and skeleton for metastases may be advisable prior to treatment with preoperative radiation and radical surgical resection.

Intrathoracic granulocytic sarcomas.

Recent trends in the treatment of intrathoracic granulocytic sarcoma (IGS) call for an overview of its radiographic manifestations. Nine patients from our institution and a review of 41 from the literature provide the basis of our conclusions on the typical and atypical appearance of IGS. Of the nine patients with IGS, all had chest radiographs, five had computed tomographic (CT) scans, and one had magnetic resonance (MR) scans. Radiographic studies and medical records were examined to establish the site and appearance of IGS. Three cases were histologically proved; in the others, the diagnosis was based on clinical presentation and response to chemotherapy. The mediastinum was the most common site of involvement (six of nine cases). A focal mass or mediastinal widening was visible on chest radiographs, and a focal mass or diffuse infiltration or replacement of fat was visible on chest CT. Less common sites of involvement were the lungs (two cases), the pleura (two), the pericardium (two), and the hilar (two). Mediastinal or hilar mass or mediastinal widening is the characteristic finding in IGS. Less common manifestations such as pleural and pericardial effusions and lung opacities should be confirmed histologically, since fluid or tissue is readily accessible.

Lung-volume reduction surgery for diffuse emphysema: radiologic assessment of changes in thoracic dimensions.

Patients with severe, diffuse emphysema may be candidates for pneumectomy (lung-volume reduction surgery, LVRS) to improve lung and respiratory muscle function. To identify candidates who might benefit from this surgery, it is necessary to understand how lung volumes and respiratory function are effected. In this article, the authors demonstrate a significant difference in lung size on chest radiographs obtained before and after surgery. Thirty-five of 71 consecutive patients undergoing LVRS had both preoperative and postoperative chest radiographs and pulmonary function tests available for retrospective review. Preoperative and postoperative measurements of lung height, transthoracic diameters, mediastinal width, heart size, diaphragmatic arc, and intercostal spaces were compared using paired t-tests. Radiographic measurements where also correlated with changes in lung volumes as measured by pulmonary function tests. Lung heights (right, left, mean lateral) and coronal diameter at the aortic arch were reduced after surgery (all p < 0.05). Forced vital capacity, forced expiratory volume in 1 second (FEV1), and vital capacity increased, and total lung capacity and residual volume decreased after surgery (all p < 0.05). Left lung height showed a significant correlation (p = 0.025) with FEV1; all other correlations between radiographic changes and pulmonary function test changes were not significant. The explanation for improved lung function in patients after LVRS is not completely clear and is probably multifactorial. Radiologic alterations reflect anatomic changes caused by surgery and support the theory that modifications of chest wall configuration occur and are likely responsible, in part, for improved symptomatology and respiratory function.

Resection of advanced stage neuroblastoma with the cavitron ultrasonic surgical aspirator.

Current protocols for the treatment of neuroblastoma emphasize total or near total resection of tumor to improve survival. This is preferentially performed as a primary procedure, or is attempted at a second-look operation. Unfortunately, this tumor often grows to large size with invasion of the spinal canal, or encasement of major vascular or other retroperitoneal structures. A primary attempt at complete removal may result in difficult-to-control hemorrhage or injury to, or loss of, vital organs. A second-look procedure carries other intrinsic risks. It often must be performed during a period of chemotherapeutically induced hematologic and immunologic suppression. The presence of adhesions and dense scar tissue increases the complexity of the dissection. The Cavitron Ultrasonic Surgical Aspirator (CUSA) combines continuous fragmentation, irrigation, and aspiration in one instrument. Tissues high in water content are selectively fragmented and aspirated, while tissues high in collagen and elastin (such as blood vessels and pseudocapsular walls) are selectively spared. Five patients, two with large pelvic dumbell tumors, two with large intrathoracic tumors, and one with a seemingly unresectable large right adrenal tumor (crossing the midline with extensive aortocaval nodal involvement) had total or near-total resection accomplished using the CUSA. In these patients, initial resection of the relatively soft inner part of the tumor left a collapsed pseudocapsule, which was then removed under greatly improved exposure in a relatively small field. The constant aspiration virtually eliminated tumor spillage. Since most vessels were skeletonized without penetration, total blood loss was minimized. There were no intraoperative or postoperative complications.

Reconstitution of natural cell-mediated cytotoxicity with specific antibodies.

The apparent nonselective reactions of natural cell-mediated cytotoxicity (NCMC) are selective when tested by inhibition of cytotoxicity with competitor cells indicating a recognition of specificities by the effector cell. N cells that mediate this NCMC in humans have most of the characteristics of K cells that mediate antibody-dependent, cell-mediated cytotoxicity (ADCC) and possess Fc receptors. IgG antibodies attached loosely to N cells through their Fc region, form part of the class of lymphocytes with surface immunoglobulin. We hypothesized that ADCC and NCMS involved similar mechanisms but with the specificity of NCMC directed by the natural IgG antibodies already attached to N cells. Removal of the antibodies with trypsin and reconstitution with specific anti-HLA antibodies produced specific effector cells supporting the role of antibodies on N cells as directors of specificity in NCMC.