The role of bronchoscopy and needle aspiration in the diagnosis of peripheral lung masses.

Sixty patients underwent flexible fiberoptic bronchoscopy and percutaneous needle aspiration of peripheral lung lesions with fluoroscopic monitoring. A single general anesthetic was used. We found that percutaneous needle aspiration was the more accurate of the two procedures in establishing a diagnosis but that flexible fiberoptic bronchoscopy proved complementary in some instances. The incidence of pneumothorax was 27% but aspiration was needed in only 8%. There were no other complications. In 84% of patients with primary carcinoma of the lung presenting as a peripheral lesion, the diagnosis was established by these procedures. The accuracy was less in metastatic lesions and considerably less in benign lesions.

Diagnostic imaging in the initial staging of mycosis fungoides and Sézary syndrome.

Four imaging examinations-gallium citrate Ga 67 scintigraphy, liver-spleen scans, lymphangiography, and computed tomography-were used in the initial staging of mycosis fungoides and Sézary syndrome in 62 patients (85% with stage I or II disease). None of the imaging modalities added significantly to the information already available from physical examinations and routinely performed lymph node biopsies. The results of this investigation did not support routine performance of imaging studies in patients with early stages of cutaneous T-cell lymphoma.

Radiologic investigation of thoracic metastases from unknown primary sites.

When a patient presents with thoracic metastases from a tumor whose site of origin is not apparent from the initial history, physical examination, and routine laboratory studies, there is a considerable likelihood that the individual will be subjected to an extensive and frequently unrewarding series of radiologic examinations. An analysis of the "behavior" of so-called tumors of unknown origin suggests that these tumors metastasize to distant sites with a frequency that is different from the more common tumors, that is to say, those whose primary site is readily apparent. While compulsive testing should unquestionably be eschewed, certain radiologic tests are still appropriate. These studies should be supplemented, when necessary, by newer pathologic studies, primarily those that involve the rapidly developing field of immunocytochemistry.

Preliminary experience with portable digital imaging for intensive care radiography.

A digital radiography system based on reusable, photostimulable phosphor technology was evaluated in approximately 3,500 portable chest radiographs of patients in an intensive care unit. The system functioned well in this application. No major problems were encountered in the visualization of tubes or catheters or in the detection of pneumothoraces. Assessment of fluid volume status or the presence of small pleural effusions, especially when these were bilateral, was initially somewhat difficult but became easier as investigators became familiar with the system. Radiologists were quicker than nonradiologists to accept the minimized two-on-one display format. Critical evaluation of the overall performance of digital systems such as this one is needed for a better definition of the system's strengths and weaknesses. Specifically, statistical analyses of the ability to detect disease states such as pneumothoraces, interstitial lung disease, lung nodules, and pleural abnormalities need to be performed.

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.

Radiologic assessment of head trauma.

We have endeavored through the use of an actual clinical scenario to emphasize that reliance on skull radiographs for assessing the acutely traumatized patient is both unwarranted and unwise. Not only are these films fundamentally useless, but they have the potential to lull us into a false sense of security. A negative skull examination cannot and does not imply that the brain substance is normal. If there is a legitimate indication for any examination, that examination should be computed tomography. To reinforce this notion, we offer for your consideration the following algorithm for the management of head trauma (Table 1: see text).

Severe pulmonary hemorrhage following lymphography.

The hemoptysis which occurs following lymphography typically consists of one or more episodes of blood-tinged sputum, and generally requires no treatment. In contradistinction to this "mild" form of hemoptysis, the current report describes a case of hemoptysis following lymphography--hemoptysis so severe as to require multiple transfusions. Time course and possible etiologic factors are discussed.

Computed tomography of rabbit V2 carcinoma after intraarterial contrast enhancement.

Changes in X-ray attenuation of rabbit V2 carcinoma, as determined by computed tomography (CT) scanning, were assessed following the intraarterial and intravenous administration of a water soluble contrast agent. After intraarterial contrast medium administration, a significant increase in CT attenuation values occurred in both blood and V2 carcinoma, and the attenuation values remained above control values for at least 120 min. A similar, although less pronounced, increase in VA attenuation values occurred following intravenous contrast medium administration. Comparison of V2 CT enhancement values after intraarterial and intravenous administration suggested that tumor enhancement was greater after intraarterial administration.

Pulmonary lymphangitic carcinomatosis: chronicity of radiographic findings in long-term survivors.

OBJECTIVE: Long-term survival after development of pulmonary lymphangitic carcinomatosis is considered unusual. However, modern chemotherapy can result in surprising stability or only gradual progression of lymphangitic carcinomatosis. We evaluated the course of radiographic findings in 10 patients with chronic lymphangitic carcinomatosis. MATERIALS AND METHODS: Ten patients met our criterion of having lymphangitic carcinomatosis for at least 6 months. The primary tumor was a carcinoma of the breast in six cases, the ovary in two, the pancreas in one, and the skin in one. Serial radiographs (all cases) and CT scans (eight cases) were analyzed retrospectively. RESULTS: Survival with lymphangitic carcinomatosis ranged from 11 to 30 months (median, 13 months). With chemotherapy, the radiographic abnormalities and pulmonary symptoms initially regressed in six patients, progressed in two, and remained unchanged in two; the radiographic findings of lymphangitic carcinomatosis were progressing at the time of death in four patients. All patients had periods of at least 4 months of relative stability or slow progression of pulmonary radiographic abnormalities. Serial transbronchial biopsies in one case confirmed persistent lymphangitic carcinomatosis despite therapy, and autopsy disclosed persistent lymphangitic tumor in two others. CONCLUSION: Stability or slow progression of radiographic findings can occur in some patients with lymphangitic carcinomatosis. Therefore, chronicity of radiographic findings should not be taken as evidence against lymphangitic carcinomatosis as the cause of an interstitial abnormality in a patient with cancer.

Preservation of normal lung regions in the adult respiratory distress syndrome. Analysis by computed tomography.

In this report, we challenge the commonly held assumption that the adult respiratory distress syndrome (ARDS) is a homogeneous process associated with generalized and relatively uniform damage to the alveolar capillary membrane. We studied 13 patients with ARDS, comparing the pulmonary parenchymal changes seen by standard bedside chest roentgenograms with those seen by computed tomography of the chest. Three patients demonstrated generalized lung involvement by both radiologic techniques. In another eight patients, despite the appearance of generalized involvement on the standard chest x-ray film, the computed tomographic scans showed patchy infiltrates interspersed with areas of normal-appearing lung. Two patients showed patchy involvement by both techniques. The fact that ARDS spares some regions of lung parenchyma is useful knowledge in understanding the gas-exchange abnormalities of ARDS, the variable responsiveness to positive end-expiratory pressure, and the occurrence of oxygen toxicity. The problem of regional inhomogeneity should also be kept in mind when interpreting lung biopsy specimens or bronchoalveolar lavage fluid in patients with ARDS.