Computed tomography to assess pulmonary injury associated with concurrent chemo-radiotherapy for inoperable non-small cell lung cancer.

OBJECTIVE: To characterize serial computed tomography (CT) findings of pulmonary injury after a uniform regimen of concurrent chemo-radiotherapy in inoperable non-small cell lung cancer, and to compare the radiation-induced lung toxicity with other concurrent chemo-radiation regimens. METHODS: Twenty-four patients with advanced non-small cell lung cancer received 2 induction cycles of cisplatin and vinblastine, followed by 2 further cycles of cisplatin and vinblastine, concurrent with 60 Gy radiation at 2 Gy per fraction. Radiation-induced lung injury in the acute and chronic phases was assessed by serial CT scans and compared with preradiation baseline scans. Acute radiation pneumonitis was evaluated using the Common Toxicity Criteria, and chronic radiation fibrosis was graded according to the European Organisation for Research and Treatment of Cancer--Radiation Therapy Oncology Group Scale. RESULTS: Seventeen (81%) patients had characteristic CT findings of radiation-induced pulmonary damage, which were confined to the radiation ports. Although patchy nonhomogeneous and air-space opacities characterized acute radiation pneumonitis, and homogeneous opacities with loss of volume were typical for chronic fibrosis, ground-glass opacities were found frequently in both phases. Acute radiation pneumonitis grade 1 was seen in 29% and grade 2 in 9.5%. Chronic radiation fibrosis grades 1, 2 and 3 were found in 14%, 33% and 19% of the patients respectively. Median survival time was 13 months. CONCLUSION: CT enables detailed evaluation of radiation-induced pulmonary injury after concurrent chemo-radiation for inoperable non-small cell lung cancer. Although survival time with the present regimen is comparable to other concurrent chemo-radiation regimens, a high incidence of radiation injury was found, though the severity was not life threatening.

A prospective randomized clinical trial comparing two film-screen systems for chest radiography.

OBJECTIVE: To compare conventional and asymmetric film-screen chest radiography systems in a prospective, randomized trial. PATIENTS AND METHODS: Posteroanterior and lateral films were obtained with each system for one healthy volunteer and 49 consenting patients referred from pulmonary clinics and wards (for a total of 27 male and 23 female subjects ranging in age from 16 to 82 [mean 58] years). The radiographs, obtained and presented in random order, were reviewed and rated independently by two experienced radiologists and one resident in radiology; all observers were blinded to patient identification and film type. The Wilcoxon signed rank sum nonparametric test for paired samples was used to test for significant differences between the two film-screen systems. A second evaluation involving direct (blinded) comparison of the two types of films was then performed for each of the 25 patients in whom abnormality was noted during the first evaluation. RESULTS: For the posteroanterior radiographs, the asymmetric film-screen system was significantly better for assessing the trachea and mainstem bronchi, the descending thoracic-aortic edge, the left paraspinal line, the thoracic vertebral body interspace and the azygo-esophageal line (p < 0.05), whereas the conventional system had superior conspicuity in the lateral subpleural zones (p < 0.05). For the lateral radiographs, the asymmetric system was superior for assessing retrosternal lung markings (p < 0.05) but inferior for assessing fissures (p < 0.05). CONCLUSIONS: In general, the asymmetric system was superior for assessing mediastinal features and inferior for assessing the lateral subpleural zones in the posteroanterior radiographs. The asymmetric system was superior for assessing retrosternal lung markings and inferior for assessing fissures in the lateral radiographs. The results for the posteroanterior radiographs were consistent with the results of nonblinded studies reported elsewhere.

Accuracy of portable chest radiography in the critical care setting. Diagnosis of pneumonia based on quantitative cultures obtained from protected brush catheter.

Sixty-six supine portable chest radiographs done on the day of bronchoscopy in 62 critical care unit patients suspected of having pneumonia were examined in a blinded fashion by two radiologists. Quantitative culture results obtained from protected brush catheter (PBC) specimens were compared with chest radiograph scores. For one observer, the sensitivity of the chest radiograph for predicting the presence of positive culture results was 0.60, specificity was 0.29, overall agreement was 0.41, positive predictive value was 0.34, and negative predictive value was 0.55. For the second observer, the values were as follows: sensitivity, 0.64; specificity, 0.27; overall agreement, 0.41; positive predictive value, 0.35; and negative predictive value, 0.55. The kappa statistic was calculated at 0.27 indicating marginal interobserver reproducibility. We conclude the portable chest radiograph in the critical care setting is not accurate in predicting the presence of pneumonia when the diagnosis is based on quantitative cultures obtained from protected brush catheter specimens.

Workload and sources of remuneration for radiologists at a tertiary-care teaching hospital in Ontario.

Detailed information about workload and sources of remuneration for radiologists at a large tertiary-care teaching hospital was reviewed for the calendar year 1991 as part of an assessment of medical professional resources. Radiologists at this facility worked an average of about 50 hours per week. When the intensity of the cases was taken into consideration, there was only a small variation among individual radiologists in terms of workload and income earned for the group. Ninety-three percent of the radiologists' remuneration came as payment for clinical patient care. The radiologists were poorly remunerated for the time they spent teaching, conducting research and performing administrative duties, but this low level of remuneration was partially compensated by the activity of senior residents, who did some work without supervision.

Anthropometric and computed tomographic assessment of the thigh in young and old men.

Anthropometric (AP) and computed tomographic (CT) methods of determining limb and muscle-plus-bone cross-sectional area (CSA) and volume (Vol) were compared in 13 young (M = 24.5 yrs) and 11 old (M = 71.0 yrs) men. CSA of total thigh, muscle-plus-bone, quadriceps, and hamstring muscle compartments and muscle were measured from CT scans. Corresponding muscle Vol were estimated from anthropometric equations. Prediction equations for CT measures were developed from AP measures using multiple linear regression. AP and CT techniques produced different values for thigh component CSA and Vol, especially in the old men. AP overestimated muscle-plus-bone CSA and Vol (4-6%) and underestimated skin and subcutaneous tissue CSA and Vol (17-33%). Prediction equations for quadriceps CSA and Vol (R2 = 80-96%) were more accurate than equations for hamstrings (R2 = 42-65%). Specific thigh muscle CSA and Vol can be predicted from AP measures (SEE 5-15%). These findings may have clinical significance when normalizing strength per unit of muscle size.

Thigh composition in young and elderly men determined by computed tomography.

Computed tomography (CT) was used to quantify components of the thigh in young (n = 13) and elderly (n = 11) men. Cross-sectional areas (CSA) of the total limb, total muscle plus bone, quadriceps compartment, hamstring compartment and bone were measured at each of five scan sites along the length of the thigh. Non-muscle tissue (NMT) areas within the muscle compartments were measured using changes in density based on Hounsfield units. Skin plus subcutaneous fat areas and quadriceps and hamstring lean muscle areas were calculated by subtraction. Geometric formulae were used to calculate related volumes for each thigh component. Volumes were also predicted from regression equations employing thigh length and component CSA from single mid-limb CT scans. The results showed that while total thigh CSA was not different in elderly men, they had significantly smaller total muscle plus bone (13.0%), and quadriceps (26.4%), and hamstring (17.9%) muscle areas. The elderly men also had significantly greater CSA for skin plus subcutaneous fat (37.6%), and for NMT in the quadriceps (59.4%) and hamstring (127.3%) muscle compartments. These results suggest that comparisons of relative leg muscle strength between young and elderly men may be misleading due to the decrease in actual muscle tissue associated with ageing. Appropriate quantification of muscle size and CSA must be carried out before such comparisons can be meaningful.

Knee extensor and knee flexor strength: cross-sectional area ratios in young and elderly men.

The relationships between isometric and isokinetic-concentric knee extensor and knee flexor strength, and quadriceps and hamstring cross-sectional area (CSA) were determined in young (n = 13, M = 24.5y) and elderly (n = 12, M = 70.7y) men. Quadriceps and hamstring CSA was determined by computed tomography. Knee extensor and flexor strength at 0 degree/s and 120 degree/s was determined on a Kin-Com isokinetic dynamometer. Compared to the young men, elderly men had significantly smaller quadriceps muscles and were weaker (22-32%) in knee flexion and knee extension at both angular velocities. Strength:CSA ratios were similar at 0 degree/s, but elderly men had decreased ratios for both extensors and flexors at 120 degree/s. Correlations of knee extensor and flexor strength with muscle CSA were significant at both velocities in elderly men, but not at either velocity for the knee flexors in young men. The decrease in isometric strength in elderly men can be accounted for by their decrease in muscle CSA, but their decrease in isokinetic-concentric strength was greater than their loss of CSA. Further study is required to determine the reason for this nonproportional loss of isokinetic-concentric strength.

A comparison of anthropometry with computed tomography in limbs of young and aged men.

Arm and leg composition determined by anthropometry (AP, girths, and skinfolds) were compared with computed tomography (CT) in 7 young (mean age 31.4y) and 13 old (74.8y) males. Five transverse CT scans, girths, and skinfold measurements were made. In each CT image, total cross-sectional area (CSA), bone CSA, muscle compartment CSA, and "pure" muscle CSA within the compartment were measured. Corresponding volumes were also calculated. Total limb and muscle plus bone CSA and volumes were estimated from AP measures. The two methods were compared, and multiple regression analyses were used to predict component CSA and volumes from AP measures. In both groups, AP component measures in the leg provided more accurate values than in the arm. Skin plus subcutaneous tissue in the old was not well estimated by AP. The greater preponderance of nonmuscle tissue in the muscle compartments of the old, as determined from CT images, was not related to any AP estimates. Prediction equations for various component areas and volumes were derived. Some equations derived for the young could not be obtained for the old due to the reduced ability of AP to accurately assess limb composition of aged men.

Fine-needle aspiration of bone lesions.

Percutaneous needle biopsy of bone lesions has been done for over 50 years. Although initially not widely used, it has been increasingly accepted over the past several years. Large-bore needles were used at first. However, as cytopathological techniques have improved, fine-needle biopsy has become feasible, offering the advantage of reduced tissue trauma and increased flexibility in needle positioning. We have retrospectively reviewed our fine-needle bone biopsies performed from January 1985 to May 1988 in 53 patients. Repeat aspirations were required on only five patients. Adequate samples were obtained at initial biopsy in the remainder. Accuracy was 0.94 which is comparable with, or better than, reported results obtained using larger bone needles. Accuracy was not affected by site or number of lesions, nor was it markedly different in patients with and without known primary malignant lesions. Biopsy of bone lesions using a fine needle provides a flexible, accurate, and relatively atraumatic alternative to more invasive methods.

Hypersensitivity pneumonitis: evaluation with CT.

Thirteen chest radiographs and computed tomographic (CT) scans obtained from 11 patients with hypersensitivity pneumonitis were reviewed. The CT findings were correlated with open lung biopsy findings in seven patients. The two patients with acute hypersensitivity pneumonitis showed air-space opacification on CT scans. An open lung biopsy, done in one of these patients, demonstrated noncaseating granulomas and filling of the air spaces with macrophages. The nine patients with subacute hypersensitivity pneumonitis showed small, rounded opacities and patchy air-space opacification on CT scans. These findings reflected the histologic findings, which consisted of interstitial pneumonitis, cellular bronchiolitis, and small, noncaseating granulomas. The six patients with symptoms for 12 months or longer also showed irregular linear opacities on CT scans, corresponding to areas of fibrosis. CT scans were superior to radiographs in helping to assess the type and extent of abnormalities, and high-resolution CT scans were superior to conventional CT scans.

Arm and leg composition determined by computed tomography in young and elderly men.

Five computed tomography (CT) scans were taken at measured intervals of the legs and arms of young (n = 7) and elderly (n = 13) men. Cross-sectional areas (CSA) of the total limb, muscle plus bone and bone were measured in each scan, and skin plus subcutaneous tissue areas were calculated by subtraction. In addition, in the arm scans the CSA of the extensor and flexor compartments were measured, and in the leg the CSA of the plantar flexor compartment. A value for lean muscle within these compartments was calculated by excluding non-muscle tissue using density measurements based on Hounsfield units. Related volumes for the various components were also calculated using geometric formulae. The results showed that elderly limbs were of a similar overall size as the young, but elderly muscles were smaller (28-36%) with greater amounts of non-muscle tissue located within a muscle, particularly in the plantar flexors (81% more than in the young). Elderly arms had a greater amount of skin plus subcutaneous tissue than the young, but there was no difference in the legs. Muscle volumes were similar to in vitro results reported from cadaver studies and can be predicted from single mid-limb CT scans using regression equations. These results illustrate that, due to the substantially reduced amount of 'pure' muscle tissue in the elderly, comparisons of relative strength with other populations may be misleading unless appropriate measurements of muscle size are considered. Methods to estimate in vivo physiological CSA, which is considered the best means of normalizing strength, have been demonstrated in this study.

Digital teleradiology: Seaforth--London network.

A total digital teleradiology system using a prototype DuPont laser beam scanner (DTR 2000) and a Bell Canada digital transmission network was evaluated. A total of 489 radiographic and ultrasonographic examinations were transmitted for interpretation from a 41-bed rural community hospital in Seaforth to the University Hospital in London, Ontario, 80 km away. There was concurrence in 98% of these examinations, i.e. the laser-sensitive facsimile film clearly duplicated the original film findings and allowed a confident interpretation to be made. We conclude that this system could readily serve the needs of family physicians in rural communities for radiologic consultation, diagnosis, management, and triage of patients 24 hours per day.

Possible spread of bronchogenic carcinoma to the chest wall after a transthoracic fine needle aspiration biopsy. A case report.

Spread of tumor along the needle tract following aspiration biopsy with the so-called "fine" needles (thinner than 18 gauge) is recognized to be an extremely uncommon complication of this technique. A case is presented in which such a spread appears to have occurred to the chest wall 13 months after a transthoracic aspiration biopsy of a bronchogenic tumor.

Choriocarcinoma metastatic to the lung. A cytologic study with identification of human choriogonadotropin with an immunoperoxidase technique.

A case of choriocarcinoma metastatic to the lung following a previous hydatidiform mole is presented. It was possible to make definitive identification of trophoblastic elements on a needle aspiration biopsy using an immunoperoxidase staining technique, thus avoiding diagnostic thoracotomy prior to therapeutic intervention. A method of immunoperoxidase staining of previously fixed and Papanicolaou-stained needle aspiration biopsy specimens is also described, and other uses of the immunoperoxidase technique on needle biopsy specimens are discussed.

Giant-cell carcinoma of the lung. A cytologic study.

A case of giant-cell carcinoma of the lung, confirmed at autopsy, is presented. The cytologic features seen in sputum samples, bronchial washings and brushings and fine needle aspiration biopsy material as well as the histologic findings are described. The possible relationship to bronchioloalveolar carcinoma is discussed. The cytologic features of giant-cell carcinoma of the lung, when seen in the context of the clinical and radiologic setting, should allow the cytologic identification of the tumor prior to surgical intervention.

Clinical studies of measuring extravascular lung water by the thermal dye technique in critically ill patients.

We measured extravascular lung water (EVLW) by the thermal-dye technique in a broad group of critically ill patients who had either acute cardiac or noncardiac illnesses. A portable AP supine chest roentgenogram, reviewed blindly, was used to classify patients as to the presence or absence of pulmonary edema; by clinical history we categorized patients into either a cardiac or noncardiac (ie, ARDS) group. With a normal chest roentgenogram, the mean EVLW was 5.6 +/- 1.8 ml/kg, and the pulmonary capillary wedge pressure (PCWP) was 11.3 +/- 5.3 mm Hg (mean +/- SD). In contrast, patients with pulmonary edema on a cardiac basis had a mean EVLW of 10.2 +/- 3.1 ml/kg (mean PCWP, 20.5 +/- 8.2 mm Hg), while patients with clinically defined noncardiac pulmonary edema and a normal PCWP (11.6 +/- 5.7 mm Hg) had a mean EVLW of 15.8 +/- 4.6 ml/kg, significantly higher than in the cardiac group (p less than 0.001). On a severity system of 014, the EVLW increased in parallel to the severity of the chest radiologic appearance of edema in both the cardiac (r2 = .44; p less than 0.001) and noncardiac (r2 = .59; p less than 0.001) patients. This study defined a normal range of thermal-dye EVLW in critically ill patients without radiologic evidence of pulmonary edema. We further demonstrated the increased pulmonary microvascular permeability of noncardiac pulmonary edema compared with cardiac edema by the greater EVLW at normal microvascular hydrostatic pressures in the former group.

Chronic eosinophilic pneumonia. Diagnosis by fine needle aspiration.

A case of chronic eosinophilic pneumonia in which the diagnosis was established by fine needle aspiration of the pulmonary lesions is presented. The cytologic findings included the presence of an inflammatory exudate consisting of 40% eosinophils, 25% neutrophils and the remaining cells comprised of lymphocytes, histiocytes, atypical columnar cells and cells probably of pneumocyte type II origin. Fine needle aspiration of pulmonary infiltrates can be quite helpful in confirming the diagnosis of chronic eosinophilic pneumonia and in differentiating it from other similar conditions including malignant lymphomas, if the clinical and radiologic appearances are also taken into consideration.

Direct magnification radiography of the chest in diffuse pulmonary disease.

The technique of direct magnification radiography of the lung in diffuse lung disease is very simple to perform. It is probably of value in selected cases where there is clinical suspicion of diffuse lung disease and when the plain radiograph is either normal or inconclusive. It is speculated that the air bronchiologram pattern seen on these radiographs is due to peribronchiolar parenchymal lung disease involving the parenchymal or acinar interstitial space with focal intra-alveolar involvement. An attempt to correlate these morphologic patterns with various pulmonary diseases is also stressed.