Chronic necrotizing pulmonary aspergillosis: a discrete clinical entity.

We conclude that chronic necrotizing pulmonary aspergillosis is a clinical entity which has not usually been recognized as one of the forms of pulmonary disease due to Aspergillus species. Patients are middle-aged, and often have some evidence of impairment of host defenses such as diabetes mellitus, a connective tissue disorder, poor nutrition, chronic obstructive lung disease or low dose corticosteroid therapy. They are almost always symptomatic with fever and a productive cough, and their chest roentgenogram shows infiltrative and cavitary disease, typical of a chronic destructive lung process such as tuberculosis or anaerobic infection. Cavity formation is often accompanied by the development of a mycetoma. The disease is usually of 1 to 6 months duration but can be present for years prior to diagnosis. The diagnosis is suggested by the clinical course and the isolation of the fungus from pulmonary secretions; negative cultures for other pathogens and failure to respond to antibacterial or antimycobacterial therapy are characteristic. The diagnosis is confirmed by pathologic evidence of tissue invasion by the fungus or a response to specific antimycotic therapy. The symptomatic response to antifungal chemotherapy, at times combined with surgical drainage or resection, is favorable. However, roentgenographic resolution is not uniform, and many patients have residual cavitary disease. The long-term prognosis is uncertain.

Treatment of chronic pancreatitic pleural effusion by percutaneous catheter drainage of abdominal pseudocyst.

A 53-year-old man entered the hospital with a large, right chronic pancreatitic pleural effusion. Computed tomographic examination of the abdomen and chest demonstrated a pancreatic pseudocyst that had extended into the mediastinum. After conventional closed-chest tube thoracotomy drainage failed to empty the pleural space, percutaneous abdominal pseudocyst drainage was instituted using computed tomographic guidance. The pleural effusion cleared promptly, and the pancreatic pseudocyst resolved gradually over seven weeks. Following termination of pseudocyst drainage, the patient has remained well for over two years with no recurrence of pancreatitis, pseudocyst, or pleural effusion. In contrast, three earlier patients with a chronic pancreatitic effusion managed conventionally had a complicated hospital course and required surgical intervention; two had recurrent pancreatitis following hospital discharge. Percutaneous catheter placement was unsuccessful in one of these three and, in retrospect, was infeasible in the other two. It is recommended that thoracoabdominal computed tomography be performed in all patients with a chronic pancreatitic pleural effusion, and that percutaneous abdominal catheter drainage be attempted in all patients with an accessible pancreatic or mediastinal pseudocyst. Such treatment may relieve respiratory insufficiency, minimize the risk of empyema or fibrothorax, and may promote pseudocyst closure without the need for surgery.

Radiologic evaluation in chest malignancies. A review of imaging modalities.

Radiologic evaluation of the patient with non-small cell lung cancer (NSCLC) includes chest radiographs for detecting nodules, computed tomography (CT) for further characterizing them, CT and magnetic resonance imaging (MRI) to evaluate the mediastinum, and extrathoracic imaging of bones, the adrenal gland, the central nervous system, and liver. The current practice standards for each are reviewed. Asymptomatic solitary pulmonary nodules, which are usually detected on chest radiographs obtained for other indications, inevitably require a precise diagnosis. The radiologic characteristics that differentiate benign from malignant pulmonary lesions are given. Mediastinal CT is the preferred modality for examining the mediastinum in patients with NSCLC. Magnetic resonance imaging is used selectively, eg, in patients with superior sulcus tumors who are candidates for surgery. When evaluation for N2/N3 disease is requested, mediastinoscopy should replace CT using the latter as a "roadmap." The role of extrathoracic imaging in evaluating asymptomatic patients with NSCLC at initial presentation is equivocal. Computed tomographic scanning of the head is reasonable in most patients with lung cancer, given the significant incidence of occult brain metastases in this population and that solitary brain lesions may be resected in some protocol settings. Routine liver and adrenal gland scanning is similarly controversial. Bone scans do not appear to be useful in patients with NSCLC unless they have clinical signs, symptoms, or laboratory findings to indicate possible metastases. Although heavily affected by local practice, radiologic evaluation of the patient with NSCLC should attempt to provide accurate determination of local disease and a search for distant metastases.

Computed tomography of the thorax: a status report.

Computed tomography (CT) of the thorax shows early promise of important diagnostic advances. We believe that CT often provides information superior to that provided by standard roentgenographic techniques, is capable of significantly influencing patient management, and in selected instances, offers unique information not available by other methods. Computed tomography permits the imaging of mediastinal structures not possible with conventional roentgenographic methods and can diagnose with certainty benign mediastinal conditions such as pericardial cysts and focal or diffuse accumulations of fat. It is ideal for detecting pleural abnormalities and for displaying underlying parenchymal disease in patients with complex pleuroparenchymal shadows on conventional films. Pulmonary metastases unseen on the plain chest film can be detected with greater sensitivity than by any other method. Future applications of CT include the staging of mediastinal lymph nodes in bronchogenic carcinoma, the differentiation of benign from malignant solitary pulmonary nodules, and the detection of diffuse diseases involving the lung parenchyma before they are visible on conventional roentgenograms. Additional clinical experience and careful studies will determine CTs final role as a diagnostic aid for disorders of the thorax.

Computed tomography. An effective technique for mediastinal staging in lung cancer.

Computed tomographic scans of the chest were utilized to stage mediastinal disease in 148 instances of bronchogenic carcinoma considered for resection in 146 patients. Nodes greater than or equal to 1.5 cm in diameter were interpreted as abnormal. All nodes positive by computed tomography were evaluated by mediastinoscopy, anterior mediastinotomy, or thoracotomy. All patients with negative computed tomographic findings underwent thoracotomy without prior surgical staging. Patients undergoing thoracotomy were divided into two groups. In Group I (first 51 instances) routine mediastinal exploration was not carried out; in Group II (last 97 instances) the mediastinum was explored in every patient and nodes were submitted for histopathological study. The computed tomographic and pathological findings on the mediastinal lymph nodes were compared. The sensitivity, specificity, and accuracy of computed tomography in Group I were 88%, 94%, and 92%, respectively, in Group II 75%, 89%, and 86%, and in the combined group, 80%, 91%, and 88%. The positive predictive index in Group I, Group II, and in the combined group was 88%, 69%, and 77%, respectively. It was lower for central than peripheral lesions (74% versus 88%) and was lowest for lesions in the right upper and left lower lobes. The negative predictive index was greater than 90% for all groups and all tumor sites except the left upper lobe, where it was 89%. Ten patients had false-positive scans, three with old mediastinitis and seven with postobstructive pneumonia; nine of the 10 had central lesions, and seven of these lesions were located in the right upper lobe. Eight patients had false-negative scans; six had para-aortic, subaortic, or postsubcarinal nodes. These nodes would not have been accessible to mediastinoscopy. In only one patient with false-negative nodes would routine mediastinoscopy have prevented thoracotomy and resection. Computed tomographic staging of mediastinal disease is indicated for all patients with lung cancer in whom operation is contemplated. Computed tomography directs the most appropriate staging procedure for patients with positive findings and obviates invasive staging for patients with negative findings.

Synchronous triple malignant tumors of the lung. A case report of bronchial carcinoid, small cell carcinoma, and adenocarcinoma of the right lung.

The authors report a case in which a highly unusual, simultaneous occurrence of a peripheral small cell carcinoma and a central bronchial carcinoid in the right upper lobe and a peripheral adenocarcinoma in the right middle lobe was observed. This is the fourth case of triple lung cancer reported in the literature. The role of computerized tomography in disclosing multiple lung carcinomas and the significance of the concurrence of pulmonary small cell carcinoma and bronchial carcinoid are discussed.

Primary mediastinal leiomyoma.

An elderly woman was seen with a left mediastinal mass in the region of the aortic arch on chest roentgenography. Further imaging with computed tomography, angiography, and magnetic resonance demonstrated a highly vascular neoplasm adjacent to the aortic arch. Pathological analysis of the resected specimen showed a leiomyoma. A brief review of the 10 previous reported cases of primary mediastinal leiomyoma is provided.

Radiology of the pleura.

Radiologic imaging of the pleura has undergone dramatic changes in the past 5 years. This can be primarily attributed to the availability and better understanding of computed tomography and, to a lesser extent, ultrasonography. When used in the proper clinical-radiologic environment, abnormalities of the pleural space can be quickly identified, localized, and often diagnosed in a rapid efficient manner.

Computed tomography of the lung, pleura, and chest wall.

Because of rapid technologic advances, clearly defined clinical indications, and widespread availability, computed tomography of the lungs, pleura, and chest wall has become increasingly important in the imaging and subsequent management of numerous thoracic disorders. This article describes the current indications, common findings, and potential controversies in CT of the lung, pleura, and chest wall.

Transfemoral embolization of an external carotid-cavernous fistula. Case report.

The authors report a case of spontaneous carotid-cavernous fistula in which transfemoral arterial embolization under fluoroscopic control resulted in immediate occlusion of the fistula and dramatic resolution of the patient's signs and symptoms.

Computed tomographic angiography.

Computed tomographic angiography performed by the intravenous administration of contrast medium was evaluated in 86 vascular patients. This experience demonstrates a new approach to the evaluation of patients with symptomatic aortic aneurysms, in whom computed tomographic angiography will aid in evaluating the need for emergency surgery. Nonoperative patients are serially evaluated by computed tomographic angiography to detect significant changes in the geometric configuration of their aneurysms. Computed tomographic angiography was beneficial in the evaluation of the patency of vascular reconstructive procedures such as femoropopliteal bypass, aortoiliac bypass and application of a vena caval device. More clinical experience and possibly a rapid sequence technique are needed to evaluate patients with portasystemic shunts.

The diagnosis of unsuspected esophageal perforation by computed tomography.

The successful management of esophageal perforation requires prompt diagnosis and surgical intervention. The hazards of delayed recognition of esophageal perforation have been recently emphasized. A case of unsuspected esophageal perforation detected by computerized tomography of the chest (CT) is described and illustrated. CT is an effective technique for displaying mediastinal and complex pleural-parenchymal abnormalities and often provides information which is of diagnostic value.

Identification of internal mammary lymph nodes: value of the frontal chest radiograph.

The article describes eight patients with enlarged internal mammary lymph nodes visualized on the frontal plain chest radiograph. Enlarged internal mammary lymph nodes cast shadows that initially may be mistaken for a mediastinal or pleural abnormality. Although the lateral film alone may suggest these nodes, the findings on the frontal film help lateralize the abnormality.

Small pulmonary nodules: dynamic CT with a single-breath technique.

Small pulmonary nodules can be difficult to examine with routine computed tomographic techniques, primarily because of inconsistent levels of inspiration on sequential scans. However, with the patient performing a breathing technique that involves three rapid maximal inspirations and expirations followed by a final maximal inspiration, an average of six images that cover a 12-mm section of lung can be obtained during a single breath. The technique has been used in 10 patients, with encouraging results.

Obscure pulmonary masses: bronchial impaction revealed by CT.

Dilated bronchi impacted with mucus or tumor are recognized on standard chest radiographs because they are surrounded by aerated pulmonary parenchyma. When imaged in different projections, these lesions produce a variety of appearances that are generally familiar. This report characterizes less familiar computed tomographic (CT) findings in eight patients with pathologic bronchial distension of congenital, neoplastic, or infectious etiologies and correlates them with chest films. In seven patients, CT readily revealed dilated bronchi and/or regional lung hypodensity. In four of these cases, CT led to the initial suspicion of dilated bronchi. CT should be used early in the evaluation of atypical pulmonary mass lesions or to confirm suspected bronchial impaction because of the high probability it will reveal diagnostic features.

Imaging characteristics of metastatic disease to the chest.

The radiographic appearance of metastatic disease is classic, but nonspecific. The differentiating characteristics of radiographic patterns of metastatic disease are discussed in this article, as well as the relative advantages of different imaging modalities. Recommendations for radiologic evaluation are also presented.