Autofluorescence bronchoscopy improves staging of radiographically occult lung cancer and has an impact on therapeutic strategy.

BACKGROUND: The ability of conventional CT scans and fiberoptic bronchoscopy to localize and properly stage radiographically occult lung cancer (ROLC) in the major airways is limited. High-resolution CT (HRCT) scanning and autofluorescence bronchoscopy (AFB) may improve the assessment of ROLC before the most appropriate therapy can be considered. PATIENTS AND METHODS: We prospectively studied 23 patients with ROLC, who were referred for intraluminal bronchoscopic treatment (IBT) with curative intent. Additional staging with HRCT and AFB was performed prior to treatment. Twenty patients were men, 9 patients had first primary cancers, and 14 patients had second primary cancers or synchronous cancers. RESULTS: HRCT scanning showed that 19 patients (83%) had no visible tumor or enlarged lymph nodes. With AFB, only 6 of the 19 patients (32%) proved to have tumors < or = 1 cm(2) with visible distal margins. They were treated with IBT. In the remaining 13 patients, abnormal fluorescence indicated more extensive tumor infiltration than could be seen with conventional bronchoscopy alone. Six patients underwent radical surgery for stage T1-2N0 (n = 5) and stage T2N1 (n = 1) tumors. Specimens showed that tumors were indeed more invasive than initially expected. The remaining seven patients technically did not have operable conditions, so they were treated with external irradiation (n = 4) and IBT (n = 3). The range for the time of follow-up for all patients has been 4 to 58 months (median, 40 months). The follow-up data underscore the correlation between accurate tumor staging and survival. CONCLUSIONS: Our data showed that 70% of patients presenting with ROLC had a more advanced cancer than that initially diagnosed, which precludes IBT with curative intent. Additional staging with HRCT and AFB enabled better classification of true occult cancers. Our approach enabled the choice of the most appropriate therapy for each individual patient with ROLC.

Herpes simplex virus 1 pneumonia: conventional chest radiograph pattern.

The aim of this study was to describe the findings on plain chest radiographs in patients with herpes simplex virus pneumonia (HSVP). The study was based on 17 patients who at a retrospective search have been found to have a monoinfection with herpes simplex virus. The diagnosis was established by isolation of the virus from material obtained during fiberoptic bronchoscopy (FOB) which also included broncho-alveolar lavage and tissue sampling. Fourteen patients had a chest radiograph performed within 24 h of the date of the FOB. Two radiographs showed no abnormalities of the lung parenchyma. The radiographs of the other 12 patients showed lung opacification, predominantly lobar or more extensive and always bilateral. Most patients presented with a mixed airspace and interstitial pattern of opacities, but 11 of 14 showed at least an airspace consolidation. Lobar, segmental, or subsegmental atelectasis was present in 7 patients, and unilateral or bilateral pleural effusion in 8 patients, but only in 1 patient was it a large amount. In contradiction to the literature which reports a high correlation between HSVP and acute respiratory distress syndrome (ARDS), 11 of 14 patients did not meet the pathophysiological criteria for ARDS. The radiologist may suggest the diagnosis of HSVP when bilateral airspace consolidation or mixed opacities appear in a susceptible group of patients who are not thought to have ARDS or pulmonary edema. The definite diagnosis of HSV pneumonia can be established only on the basis of culture of material obtained by broncho-alveolar lavage.

[Added value of positron emission tomography with fluoro-18-deoxyglucose as the tracer (FDG-PET) in clinical problem cases in oncology]. / Meerwaarde van positronemissietomografie met als tracer fluor-18-deoxyglucose (FDG-PET) bij klinische probleemgevallen in de oncologie.

Positron emission tomography with fluoro-18-deoxyglucose as tracer molecule (FDG-PET) is a relatively new imaging technique used in oncology to study tumour metabolism in vivo. Both qualitative and quantitative data obtained by PET provide unique information to the clinician and may guide the therapeutic approach in selected patients, where conventional diagnostic tests like CT or MRI yield equivocal results. According to the experience obtained in the Vrije Universiteit Medical Centre in Amsterdam, the additional value of FDG-PET can be explained by the sensitivity and the specificity of the technique, combined with the visualization of the whole body. FDG-PET may reveal metastases and tumour tissue may be differentiated from scar tissue and necrosis. PET is expensive and its effects on patient outcome has yet to be established.

Severe acute lung injury induced by gemcitabine.

Gemcitabine is a nucleoside analog that is active in the treatment of various solid tumors. In general it is well tolerated and has few side effects. Pulmonary toxicity reported with gemcitabine use is usually mild and self-limiting. We present a case of severe pulmonary dysfunction after intravenous administration of a single dose of gemcitabine in a 58-year-old female patient with metastatic carcinoma of the pancreas. She developed tachypnea, marked hypoxemia, and an interstitial infiltrate on chest radiograph consistent with pulmonary edema, 4 days after receiving this drug. Diuretics and corticosteroids were beneficial in treating the acute respiratory failure. Pulmonary damage was completely resolved by means of clinical and radiological assessment. Because of the severity of this side effect, no further treatment with gemcitabine was given. Eventually, the patient died because of obstruction of the bowel due to progression of tumor growth. Publications concerning severe pulmonary toxicity due to gemcitabine are sparse. Pathophysiology and treatment are considered and a review of the literature is presented.

A phase I-II study of gemcitabine and paclitaxel in advanced non-small-cell lung cancer patients.

Thirty patients with chemotherapy-naïve advanced non-small-cell lung cancer (NSCLC) were given escalating doses of paclitaxel (150, 175, 200 mg/m2) on day 1 in three consecutive cycles, together with a fixed dose of gemcitabine 1000 mg/m2 on days 1 and 8; cycles were repeated every three weeks. The dose escalation of paclitaxel was feasible in the majority of patients. Subsequently, 30 other NSCLC patients received a dose of 200 mg/m2 paclitaxel with gemcitabine 1000 mg/m2 in a phase II study. The major side effect was mild myelosuppression. A response rate of 24% was achieved in 49 fully evaluable patients. This regimen proved to be safe and easy to administer on an out-patient setting, and constitutes now one of the arms of the current EORTC randomized study for advanced NSCLC.

High-resolution CT in patients with intraluminal typical bronchial carcinoid tumors treated with bronchoscopic therapy.

STUDY OBJECTIVE: To evaluate the extent to which high-resolution CT (HRCT) can predict the clinical outcome of bronchoscopic treatment with curative intent in patients with intraluminal typical bronchial carcinoid tumors. DESIGN: An observational study. SETTING: Bronchoscopy unit and radiology department of a university hospital. PATIENTS AND INTERVENTIONS: Eighteen patients with intraluminal typical bronchial carcinoid tumors in the absence of nodal and distant disease were treated with bronchoscopic electrocautery or Nd-YAG laser as an alternative to surgical resection. Prior to treatment, HRCT was performed. RESULTS: In 10 patients, HRCT showed no peribronchial tumor extension, and 9 of these patients were found to be tumor free after bronchoscopic treatment. So far during follow-up, none of these patients has had a recurrence of the tumor. The median duration of follow-up was 33 months (range, 13 to 68 months). In five patients, HRCT showed signs of peribronchial tumor extension. In three of these patients, specimens taken from biopsies performed after bronchoscopic treatment showed residual tumors, and salvage surgery was carried out. In three patients, HRCT was unable to assess peribronchial tumor extension: in two because of insufficient connective tissue contrast between the hilar structures and in one patient because of suboptimal scan technique. CONCLUSION: HRCT findings were complementary but not conclusive in patients with intraluminal typical bronchial carcinoid tumors treated with bronchoscopic therapy. However, in a category of patients in whom HRCT showed strictly intraluminal tumors, bronchoscopic resection as an alternative for surgical resection seems justified.

Radiographically occult lung cancer treated with fibreoptic bronchoscopic electrocautery: a pilot study of a simple and inexpensive technique.

The curative potential of bronchoscopic intervention, e.g. photodynamic therapy (PDT) and brachytherapy, for resectable radiographically occult lung cancer has been reported previously. Bronchoscopic electrocautery is currently feasible using an insulated flexible bronchoscope to coagulate and vaporize tumour tissue. Since the lesions are usually small, noninvasive bronchoscopic electrocautery may be able to eradicate radiographically occult lung cancer completely. In a prospective study, 13 patients with 15 radiographically occult lung cancer lesions were treated with bronchoscopic electrocautery. The duration of follow-up was > or = 16 months. The median age of the patients was 69 yrs (range 48-79 yrs). Fibreoptic bronchoscopy under local anaesthesia was used to coagulate the occult lung cancer. Approximately 30 W of energy was applied until visible necrosis of the tumour area became apparent. There were no immediate complications. In 10 patients with 12 lesions, a complete response (CR) was obtained (CR rate 80%; 95% confidence interval (95% CI) 52-96%). Median duration of follow-up was 21 months (range 16-43 months). Bronchoscopic electrocautery did not obtain a CR in the remaining three patients, but PDT also failed to achieve CR. Two patients underwent radical resection, and the tumours were histologically confirmed to be more invasive. One patient received external radiotherapy. Three patients with a CR died during follow-up, two as a result of myocardial infarction and apoplexy, and one because of metastasis from his previously resected T3N1 primary large cell cancer. Current data show bronchoscopic electrocautery to be equally effective and potentially as curative as photodynamic therapy for treating patients with radiographically occult lung cancer. Obvious advantages are that it is an inexpensive and simple procedure, which does not cause photosensitivity.

Pulmonary function of patients with spontaneous pneumothorax in relation to the extent of emphysema-like changes.

The aim of the present study was to analyse pulmonary function parameters of patients with spontaneous pneumothorax (SP) in relation to the extent of emphysema-like changes (ELCs). Pulmonary function tests were performed in 85 patients with unilateral SP, 6 weeks after video-assisted thoracoscopy (VAT). In 63 patients, thoracic computer tomography (CT) was obtained. An ELCs score, based on findings of CT and VAT, was used to quantify ELCs, ranging from 0 (expressing no ELCs) to 3 (expressing extensive ELCs). Emphysema-like changes were detected during VAT in 74% of patients, of which 70% were considered larger than 2 cm. An ELCs score > or = 2 was found in 27 patients. Clinical characteristics of the patients grouped according to thoracoscopical findings and ELCs score did not differ, except for age. Patients with large ELCs were significantly older than patients without ELCs or small ELCs (P = 0.0009). In patients with large ELCs and ELCs score > or = 2, increased mean percentages of predicted total lung capacity and decreased diffusing capacity (KCO) were found. None of the patients exhibited all pulmonary function criteria of emphysema, in contrast to 43% of the patients with an ELCs score > or = 2. KCO was the only pulmonary function parameter which was decreased in smokers, especially in patients with large ELCs or ELCs score > or = 2. Static lung compliance (Cstat) was the only pulmonary function parameter which was increased in patients with recurrent SP. The authors concluded that KCO is related to smoking behaviour and ELCs in patients with SP. Cstat is the only parameter which is increased in patients with recurrent SP. The discrepancy between pulmonary function and macroscopical parenchymal changes could be explained by the fact that not all patients with SP are old enough at presentation to show all signs of emphysema with pulmonary function testing. On the other hand, it might be possible that ELCs in SP cause different pulmonary function abnormalities than in centriacinar or panacinar emphysema.

High resolution computed tomography in patients referred for intraluminal bronchoscopic therapy with curative intent.

In patients with so-called roentgenologically occult intraluminal lung tumours, an accurate assessment of tumour size, its location and peribronchial tumour extent is important prior to any intraluminal bronchoscopic therapy (IBT) with curative intent. In twenty patients with so-called occult early-stage lung cancers, clinical outcome was compared to high resolution computed tomography (HRCT) findings prior to IBT. HRCT showed peribronchial tumour extension or nodal enlargement in 7 of the 20 patients (35%), and consequently treatment policy was changed. Five of the seven died 1.5-6 months after diagnosis, one patient underwent a radical pneumonectomy after induction chemotherapy, and the remaining patient is alive with pleural metastasis. HRCT showed intraluminal tumours in 11 of the 20 patients and IBT with curative intent was given. Complete response (CR) was achieved in 10 of the 11 patients, follow-up has been 4-26 months. One patient underwent a radical lobectomy, pathological stage T1NO, after 3 months because of tumour recurrence. HRCT was inconclusive in 2 of the 20 patients with postobstructive infiltrates. IBT was unsuccessful in both these cases. High resolution computed tomography may provide supportive evidence of intra-and extraluminal tumour; thereby, helping in the assessment of patients who were judged to be suitable for intra-luminal bronchoscopic therapy with curative intent. This may lead to a change in the treatment policy. High resolution computed tomography findings are complementary to bronchoscopic, histological and cytological examinations for the proper evaluation of treatment indications in patients with occult lung cancer.

Expiratory chest radiographs do not improve visibility of small apical pneumothoraces by enhanced contrast.

Demonstration of small apical pneumothoraces is supposed to be facilitated by expiratory chest radiographs. This study aimed to analyse the assumed enhancement of visual contrast on expiratory chest radiographs in patients with small apical pneumothoraces. Optical densities (OD) were obtained with a densitometer (X-rite 3001) on 54 paired inspiratory and expiratory chest radiographs of 22 consecutive patients with small apical pneumothoraces. The ODs were measured: at the intervertebral space between the first and second thoracic vertebrae (Area 1); at the peripheral part of the affected lung parenchyma (Area 2); and at the adjacent intrapleural space (Area 3). Excellent correlations of OD of each area were obtained between paired inspiratory and expiratory chest radiographs. The ODs of all areas on expiratory chest radiographs were significantly higher than on inspiratory chest radiographs. Contrast between pulmonary parenchyma and intrapleural air in inspiratory and expiratory films did not differ significantly. Expiratory chest radiographs do not improve visibility of small apical pneumothoraces by enhanced contrast between pulmonary parenchyma and intrapleural air. Expiratory chest radiographs show equally increased OD in the area of lung tissue and intrapleural air, caused by increased extrapulmonary tissue density during expiration, resulting in increased radiation exposure monitored by the ionization chambers of standard radiological equipment. If expiratory chest radiographs are really improving the visibility of apical pneumothoraces, there must be other reasons than contrast enhancement to explain this.

Laryngeal carcinoma after radiation therapy: correlation of abnormal MR imaging signal patterns in laryngeal cartilage with the risk of recurrence.

PURPOSE: To correlate abnormal magnetic resonance (MR) imaging signal patterns in cartilage with the effectiveness of radiation treatment. MATERIALS AND METHODS: Eighty previously untreated patients underwent MR imaging and radiation therapy with a curative intent. Cartilage was considered to have an abnormal signal pattern if it had intermediate signal intensity on T1-weighted spin-echo (SE) MR images and high signal intensity on T2-weighted SE MR images. The minimum follow-up was 2 years. RESULTS: Abnormal MR imaging signal patterns of the thyroid cartilage (P < .001; P < .04) were more ominous than those of other cartilage. Abnormal signal patterns in cartilage of patients with small tumors (< 5 cm3 and especially < 1 cm3) were less significant. Abnormal signal patterns in cartilage combined with a large tumor (> 5 cm3) worsened the prognosis significantly (P < .05). CONCLUSION: Abnormal MR imaging signal patterns in cartilage may not indicate a poor prognosis in every case. Abnormal signal intensity in the thyroid cartilage combined with a tumor volume of > 5 cm3, however, appears to indicate an adverse prognosis with regard to tumor recurrence.

Predictive value of MR imaging-dependent and non-MR imaging-dependent parameters for recurrence of laryngeal cancer after radiation therapy.

PURPOSE: To determine the predictive value of several clinical and radiologic parameters for recurrence of laryngeal cancer. MATERIALS AND METHODS: Eighty previously untreated patients underwent magnetic resonance (MR) imaging before radiation therapy with curative intent. Tumor volume was calculated from T1-weighted MR images. Cartilage was considered invaded by pathologic tissue if it had intermediate signal intensity on T1-weighted spin-echo (SE) MR images and high signal intensity on T2-weighted SE MR images. The minimum follow-up was 2 years. RESULTS: Parameters such as age, sex, histopathologic findings, and invasion of the vocal muscle or pre-epiglottic space were not significantly correlated with tumor recurrence. Logistic regression analysis showed three relevant contributors: cord mobility, as judged clinically, and tumor volume and, more significantly, cartilage invasion, as seen at MR imaging. CONCLUSION: For untreated laryngeal cancer, MR imaging findings of tumor volume and cartilage invasion allow better patient selection for either radiation therapy or surgery. MR imaging is mandatory for T staging of laryngeal cancer.

Disseminated aspergillosis after near-drowning.

We report a case of invasive pulmonary aspergillosis after near-drowning complicated by systemic disseminated disease to the heart, kidneys, left adrenal gland and brain. Detection of fungal micro-organisms in the sputum of near-drowning patients should be taken seriously.

[Diagnosis of pneumothorax not improved by additional roentgen pictures of the thorax in the expiration phase]. / Diagnostiek van pneumothorax niet gediend door aanvullende röntgenopname van de thorax in expiratiestand.

OBJECTIVE: To evaluate whether an expiratory chest roentgenogram adds anything to the results obtained by a standard inspiratory chest roentgenogram in patients with a pneumothorax. DESIGN: Retrospective analysis and blinded re-evaluation of the radiographs. SETTING: Free University Hospital, Amsterdam. METHOD: Of 59 patients with a proven pneumothorax the chest roentgenograms at the time of the pneumothorax (54 inspiratory and 46 expiratory roentgenograms) were evaluated independently by 4 investigators in random order, as were 28 roentgenograms of the same patients made on different occasions. RESULTS: On all expiratory chest roentgenograms the pneumothorax was seen, of the 54 inspiratory ones two investigators missed one very small apical pneumothorax. All 28 control roentgenograms were scored correctly. No reliable additional information was obtained from the expiratory X-rays with regard to the cause of the pneumothorax. CONCLUSION: Expiratory chest roentgenograms are not indicated as a routine investigation for patients in whom pneumothorax is suspected.

Video-Assisted Thoracoscopy is Superior to Standard Computer Tomography of the Thorax for Selection of Patients With Spontaneous Pneumothorax for Bullectomy.

BACKGROUND: Spontaneous pneumothorax (SP) is a common disease of unknown cause often attributed to rupture of a subpleural bulla or bleb [in this study described as emphysema-like changes (ELC)]. Treatment of SP varies from conservative (rest) to aggressive (surgery). Patients with bullae >2 cm diameter, found either by chest roentgenogram or during thoracoscopy, are often treated surgically (bullectomy and pleurectomy, or abrasion). Thoracoscopy is frequently used as the method of choice to select patients for surgery. With the recent introduction of video-assisted thoracoscopy (VAT), it is now possible to combine a diagnostic and therapeutic procedure. However, to do this general anesthesia and a fully equipped operating theater are needed. Proper selection of patients for this costly and time-consuming procedure is necessary. We evaluated whether standard computed tomography (CT) is appropriate for selection of patients with SP who are candidates for surgical intervention. METHODS: In 43 patients with SP, CT was performed after re-expanding the lung by suction through a chest tube if the lung was completely collapsed. After <48 hours VAT under general anesthesia was performed. All CT scans were scored by two investigators who were not informed about the VAT findings or the outcome of the patient. CT findings and VAT findings were compared. RESULTS: In 16 patients (37%), CT scans of the affected lung were considered normal, while in 13 patients (30%) ELCs >/=2 cm were seen and in 14 patients (33%) ELCs <2 cm were found. VAT showed a normal lung in 11 patients (26%), in 24 patients ELCs >/=2 cm were seen, and in 8 patients ELCs <2 cm were present. Of these 32 patients, in 18 bullous degeneration of the apex of the upper lobe was found. Of the 24 patients with ELCs >/=2 cm detected during VAT, 13 were detected by CT. In no patient were ELCs >/=2 cm seen on CT scans that were not detected during VAT. The sensitivity of CT for ELCs >/=2 cm is 54%, and the specificity is 100%. The positive predictive value is 100%; the negative predictive value is 63%. CONCLUSIONS: CT detects ELCs >/=2 cm in 54% of the patients in whom VAT shows these abnormalities. If interventional therapy is deemed appropriate for first time or recurrent SP, VAT should be used since it is superior to CT in demonstrating the presence, number, and size of ELCs.

Comparative evaluation of diagnostic methods in ovarian carcinoma with emphasis on CT and MRI.

A prospective study was performed in 64 patients suspected of having primary or recurrent ovarian epithelial cancer. Physical examination (PE), ultrasonography (US), computer tomography (CT), and magnetic resonance imaging (MRI) were performed and CA 125 serum levels (CA 125) were determined. This evaluation was followed within 3 weeks by laparotomy, which served with the pathology data as the gold standard. Both CT and MRI were, independently, evaluated by two experienced radiologists. The accuracy in diagnosing ovarian carcinoma of both CT (70 and 91%) and MRI (64 and 88%) in patients suspected of primary and recurrent cancer grouped together differed between the two radiologists, but for each radiologist no difference in overall accuracy between CT and MRI was observed. The accuracy of PE was 64%, of US, 67%, and of CA 125, 72%. At surgery, 132 separate tumor locations were present. With CT, 41 and 69% and with MRI, 44 and 56% of these lesions were recognized by the two radiologists, respectively. This was the case in 27% with PE and 34% with US. We conclude that in our setting MRI had no additional value over CT. The interobserver variability was high for both MRI and CT. MRI and CT are both useful diagnostic methods in the diagnosis of ovarian carcinoma.

Modern imaging techniques and ultrasound-guided aspiration cytology for the assessment of neck node metastases: a prospective comparative study.

Although palpation has proved to be an unreliable staging procedure, the indications for and the implications of more reliable radiologic staging methods for the neck in patients with a primary squamous cell carcinoma of the head and neck remain controversial. Only a very accurate imaging technique can replace neck dissection in clinical NO disease. This study compares the value of palpation with computed tomography (CT), magnetic resonance imaging (MRI) and ultrasound (US) with or without guided aspiration cytology for neck node staging. One hundred and thirty-two patients with squamous cell carcinoma of the head and neck were examined radiologically before undergoing a total of 180 neck dissections as part of their treatment. CT, US and MRI proved to be significantly more accurate than palpation for cervical lymph node staging. The accuracy of US-guided aspiration cytology was significantly better than of any other technique used in this study. Modern imaging techniques are essential for appropriate assessment of neck node metastases. In view of advances in the accuracy of contemporary imaging, the need for elective treatment of the neck requires reappraisal.