Predicting therapeutic response and degree of pituitary tumour shrinkage during treatment of acromegaly with octreotide LAR.

BACKGROUND/AIMS: The efficacy of transsphenoidal surgery in the treatment of patients with acromegaly is largely dependent on tumour size. A reduction in pituitary tumour volume by medical therapy might therefore improve subsequent surgical cure rates. This study prospectively determined the effects of the depot somatostatin analogue octreotide LAR on pituitary tumour size, GH and IGF-I levels and clinical symptoms in a cohort of previously untreated patients with acromegaly. METHODS: Six patients newly diagnosed with acromegaly (mean age 53 years; range 42-76 years) received intramuscular octreotide LAR every 28 days for 6 months. The initial dose of LAR was 20 mg, but increased to 30 mg after the initial 3 injections if mean GH levels were >5 mU/l. Prior to commencing LAR therapy, each patient received 3 injections of subcutaneous octreotide (50, 100 and 200 mug) in a randomized order on separate days, and the serum GH response was measured. Pituitary tumour volume was calculated from MRI or computed tomography scans at baseline, then 3 and 6 months after initiation of treatment, and assessed by a 'blinded' radiologist in random order. At baseline, 4 patients had a macroadenoma and 2 patients had a microadenoma. For the latter, the whole gland volume was measured. RESULTS: Serum GH levels decreased from 29.6 +/- 19.2 mU/l (mean +/- SD) at baseline to 12.1 +/- 10.5 mU/l at 3 months and 10.4 +/- 9.3 mU/l at 6 months. Three patients achieved a mean serum GH level of <5 mU/l. In these patients, the serum GH had declined to <5 mU/l in response to a single 100 mug subcutaneous octreotide injection. Serum IGF-I levels decreased by a mean of 45 +/- 7.4%. Tumour volume decreased in all patients: mean baseline volume 2,175 mm(3) (range 660-6,998) decreasing to 1,567 mm(3) (range 360-4,522) at 3 months (p < 0.05) and 1,293 mm(3) (range 280-4,104) at 6 months (p < 0.002). The mean percentage decrease in size was 29% (range -54 to +4%) at 3 months (p < 0.02) and 47% (range 21-97%) at 6 months (p < 0.002). There was no statistically significant correlation between GH response and tumour shrinkage. CONCLUSIONS: A single test dose of subcutaneous octreotide may be useful in predicting the subsequent efficacy of octreotide LAR. Octreotide LAR results in significant shrinkage of pituitary tumours of newly diagnosed patients with acromegaly. Whether its administration to such patients for 6-12 months can improve the efficacy of subsequent transsphenoidal surgery will require further study.

A comparison of serial computed tomography and functional change in bronchiectasis.

In bronchiectasis the morphological determinants of (marginal) fluctuations in pulmonary function tests are uncertain. The aim of the present study was to evaluate serial computed tomography (CT) changes in relation to pulmonary function trends in patients with bronchiectasis. The relationships between pulmonary function indices and CT scans in 48 adult patients with bronchiectasis were evaluated at baseline and at follow-up, at a median interval of 28 months (range 6-74 months). Two independent observers semiquantitatively scored CT features of bronchial and small airways disease. At initial assessment, the severity of airflow obstruction was linked primarily to the extent of mosaic attenuation. However, serial changes in pulmonary function indices were only associated with serial changes in mucous plugging scores. Alterations in mucous plugging on serial CT were associated with changes in the severity of bronchiectasis and bronchial wall thickness. Greater severity of all three morphological abnormalities at baseline CT were predictive of significant declines in forced expiratory volume in one second, with severe bronchial wall thickness being the most adverse prognostic determinant. Variations in mucous plugging on computed tomography correlate with minor fluctuations in pulmonary function tests in bronchiectasis. However, the severity of bronchial wall thickness is the primary determinant of subsequent major functional decline.

Pleural effusions in patients with AIDS.

OBJECTIVE: To describe the range of pathology causing pleural effusions in HIV infected patients with acute respiratory episodes and to attempt to identify whether any associated radiological abnormalities enabled aetiological discrimination. METHODS: Prospective study of chest radiographs of 58 consecutive HIV infected patients with pleural effusion and their microbiological, cytological, and histopathological diagnoses. RESULTS: A specific diagnosis was made in all cases. Diagnoses were Kaposi's sarcoma, 19 patients; para-pneumonic effusion, 16 patients; tuberculosis, eight patients; Pneumocystis carinii pneumonia, six patients; lymphoma, four patients; pulmonary embolus, two patients; and heart failure, aspergillus/leishmaniasis, and Cryptococcus neoformans, one case each. Most effusions (50/58) were small. Bilateral effusions were commoner in Kaposi's sarcoma (12/19) and lymphoma (3/4) than in para-pneumonic effusion (3/16). Concomitant interstitial parenchymal shadowing did not aid discrimination. A combination of bilateral effusions, focal air space consolidation, intrapulmonary nodules, and/or hilar lymphadenopathy suggests Kaposi's sarcoma. Unilateral effusion with focal air space consolidation suggests para-pneumonic effusion if intrapulmonary nodules are absent: if miliary nodules and/or mediastinal lymphadenopathy are detected, this suggests tuberculosis. CONCLUSIONS: A wide variety of infectious and malignant conditions cause pleural effusions in HIV infected patients, the most common cause in this group was Kaposi's sarcoma. The presence of additional radiological abnormalities such as focal air space consolidation, intrapulmonary nodules, and mediastinal lymphadenopathy aids aetiological discrimination.

Pulmonary sequelae of bronchopulmonary dysplasia survivors: high-resolution CT findings.

OBJECTIVE. We examined the high-resolution CT findings of adult survivors of bronchopulmonary dysplasia. CONCLUSION. The cardinal CT features of bronchopulmonary dysplasia survivors include multifocal areas of reduced lung attenuation and perfusion, bronchial wall thickening, and decreased bronchus-to-pulmonary artery diameter ratios.

Spiral computed tomography for pulmonary embolism.

Spiral computed tomography pulmonary angiography is increasingly used in the non-invasive investigation of patients with suspected pulmonary embolism. This review will focus on current techniques and indications with an explanation of the computed tomography signs of pulmonary embolism, possible pitfalls in interpretation and limitations of the technique.

Follicular bronchiolitis: thin-section CT and histologic findings.

PURPOSE: To evaluate the thin-section computed tomographic (CT) findings of follicular bronchiolitis and compare them with the histologic findings. MATERIALS AND METHODS: Thin-section CT scans obtained in 12 patients (age range, 24-77 years; mean age, 47 years) with follicular bronchiolitis proved at open lung biopsy were reviewed by two observers. Underlying conditions included rheumatoid arthritis (n = 8), mixed collagen vascular disorders (n = 2), autoimmune disorder (n = 1), and acquired immunodeficiency syndrome (n = 1). All patients had thin-section CT scans (1.0-1.5-mm collimation, 11 patients; 3.0-mm collimation, one patient; high-spatial-frequency reconstruction algorithm) obtained at 10-mm intervals through the chest. RESULTS: The main CT findings included bilateral centrilobular (n = 12) and peribronchial (n = 5) nodules. All 12 patients had nodules smaller than 3 mm in diameter; six patients also had nodules 3-12 mm in diameter. Areas of ground-glass opacity were present in nine (75%) patients. Histologically, all patients had lymphoid hyperplasia along the bronchioles; eight had peribronchiolar lymphocytic infiltration. CONCLUSION: The cardinal CT feature of follicular bronchiolitis consists of small centrilobular nodules variably associated with peribronchial nodules and areas of ground-glass opacity.

Acute pulmonary embolism in patients with HIV disease.

OBJECTIVES: To determine the incidence, mode of presentation, and outcome of pulmonary embolism (PE) in patients with HIV infection. METHODS: Retrospective review of clinical case records, imaging department database, and necropsy reports of patients admitted to the specialist HIV/AIDS unit at UCL hospitals from April 1993 to August 1997 in order to identify those with a diagnosis of PE. RESULTS: During the study period there were 3792 admissions of whom 10 (0.26%) had PE. All patients with PE presented with fever, seven were dyspnoeic, and seven had cough: all were thought initially to have respiratory infection. Only five patients had pleural pain. All 10 patients had abnormal baseline chest radiographs. The diagnosis in six was made by computed tomograph (CT) pulmonary angiography, in two was made by ventilation perfusion (V/Q) scanning, in one by both techniques, and in one at necropsy. CT angiography in addition to identifying thrombus also showed concomitant lung parenchymal abnormalities in all but one patient. Nine patients with PE had one or more risk factors for venous thromboembolism as did 34/40 case matched controls (odds ratio = 1.67; 95% confidence interval = 0.18-15.5). All patients diagnosed in life were anticoagulated and five survived. CONCLUSIONS: PE was uncommon in this HIV infected population. The diagnosis should be considered in patients with respiratory infection which does not respond to antibiotics. Identifiable risk factors for venous thromboembolism appear to be unhelpful in increasing clinical index of suspicion for PE. As baseline chest radiographs are frequently abnormal, the diagnostic utility of V/Q scanning may be reduced and CT pulmonary angiography is the imaging modality of first choice.

High resolution computed tomography of the lungs.

High resolution computed tomography has increased the certainty with which diffuse lung disease is detected and often allows a histospecific diagnosis to be made. The technique continues to be refined and further pathophysiological insights can be expected in this challenging area.

Ultrasound-guided compression of femoral pseudoaneurysm: an audit of practice.

OBJECTIVE: To audit the practice of ultrasound-guided compression of femoral pseudoaneurysm in a specialist cardiac hospital. BACKGROUND: Femoral pseudoaneurysm is an important complication of invasive cardiac procedures. This may require surgical repair but more recently ultrasound-guided compression for ablating pseudoaneurysms has been described. We investigated the success of such a procedure. METHODS AND RESULTS: In a 26-month period, 56 patients were referred for ultrasound scanning to exclude the formation of a femoral pseudoaneurysm following transfemoral cardiac procedures. During this period, 5756 diagnostic cardiac catherisations and 1165 coronary angioplasties were performed in our hospital (total of 6921 procedures). Of the 56 patients, 20 patients (0.3% of 6921) were found to have a pseudoaneurysm. Ultrasound-guided compression was attempted in 11 patients and was successful in 7 patients (64%). Of the patients who had failed ultrasound-guided compression, 2 proceeded to surgical closure and 2 were treated conservatively with compression stockings to facilitate thrombosis of the pseudoaneurysm. Of those who did not have an attempted ultrasound-guided compression of the pseudoaneurysm (n=9), a conservative approach consisting of resting the leg was adopted to facilitate spontaneous thrombosis of the pseudoaneurysm; repeat ultrasound scanning was needed for follow-up and 1 patient required surgical closure in this group. CONCLUSIONS: In patients with a femoral pseudoaneurysm following an invasive cardiac procedure, ultrasound-guided compression may be useful as an immediate step to ablate the pseudoaneurysm. This avoids either prolonged leg rest and repeated ultrasound scanning or surgical intervention. However, ultrasound-guided compression is not always successful; in these patients, a period of conservative management with repeat ultrasound scanning is appropriate to allow for the possible spontaneous thrombosis of the pseudoaneurysm. Surgical closure is needed in those patients whose pseudoaneurysm is enlarging, painful or remain patent.

The significance of bronchial dilatation on CT in patients with adult respiratory distress syndrome.

AIMS: Irreversible bronchial dilatation on computed tomography (CT) is seen in patients with interstitial pulmonary fibrosis whereas reversible dilatation of the bronchi is a feature of many conditions. The aim of this study was to determine whether airways dilatation, which is a frequent finding in adult respiratory distress syndrome (ARDS), is reversible and to establish whether persistent airways dilatation is accompanied by other CT signs of established interstitial fibrosis. METHOD: Thin section CT scans of 16 patients with ARDS were analysed at a lobar level in the acute phase of the disease and at follow-up (median interval 6.3 months) for the presence and extent of a ground-glass pattern, reticular or linear opacities and the presence or absence of bronchial dilatation. RESULTS: 95 out of 96 (99%) lobes on the initial CT scan showed ground-glass pattern. Airway dilatation was present in 65 of 95 (68%) of these lobes. On follow-up CT the airways remained dilated in 60 of 65 (92%) lobes and, in the majority of these, 53 of 60 (88%), a reticular and linear pattern with associated distortion had developed. A coexisting ground-glass pattern was present in 12 of 60 (20%) lobes on follow-up CT, but was the sole residual abnormality in only one lobe. CONCLUSION: In patients with ARDS, dilatation of the airways within areas of ground-glass pattern is a frequent observation in the acute phase of the condition and tends to persist at follow-up, usually accompanied by the CT features of supervening pulmonary fibrosis.

Hepatic artery aneurysms: evaluation using three-dimensional spiral CT angiography.

Hepatic artery aneurysms are rare and frequently difficult to diagnose. Computed tomography (CT) and ultrasound rarely make the definitive diagnosis and angiography is usually required. We present three cases of hepatic artery aneurysms in which the definitive diagnosis was made on three-dimensional (3-D) spiral CT angiography-to our knowledge, this has not previously been described. Our experience shows that in many cases of hepatic artery aneurysm, conventional angiography need only be performed as a prelude to embolization.