Diaphragmatic and paradiaphragmatic tumors and pseudotumors.

Primary lesions of the diaphragm are rare and are often difficult to distinguish from a host of other entities. Primary tumors include lipomas, cysts, and sarcomas, while secondary lesions, which can mimic them, include direct extensions from neighboring organs or metastatic implants and adenopathy. In addition, one must exclude a variety of pseudotumors, such as eventrations, diaphragmatic invaginations, and crural thickening. Examples of such primary and nonprimary diaphragmatic lesions are discussed.

Mediastinal involvement in adults with lymphoblastic lymphoma.

Radiologic, clinical, and pathologic findings are described in 6 young adults with lymphoblastic lymphoma (LBL), an aggressive tumor which has recently become recognized as a serious threat to adults as well as to children. Each patient presented with a mediastinal mass, three of them developing cardiac tamponade and one a superior vena cava syndrome. CT scanning and echocardiography were particularly helpful in defining the lesions. The rapid dissemination of LBL, and its early progression to a leukemic phase call for prompt diagnosis and treatment.

Role of CT scanning in the superior vena cava syndrome.

The value of computerized tomographic (CT) studies was compared to other imaging procedures in 18 consecutive patients with the superior vena cava syndrome (SVCS) during a 47-month period. Sixteen of these cases had proved malignancy. In addition to tumor masses, CT findings included effacement, compression, and displacement of the great vessels and the presence of thrombi and collateral blood flow. Significantly, tumor was demonstrated in the region of the superior vena cava in five patients in whom a definite mass could not be diagnosed by other means. CT scanning in a sixth case revealed that although mediastinal tumor was present it was not located in the immediate region of the occluded vessels. CT was corroborative and helpful in planning therapy in all but one of the remaining patients. CT scans appear to be of most value in cases of SVCS in whom other modalities cannot demonstrate tumor and, particularly, in excluding recurrent tumor in previously treated patients.

Hypersensitivity reactions after barium enema examination.

Three patients who developed urticaria shortly after air-contrast barium enema studies of the colon are described. Only a single similar instance was found in the literature. One of the patients had a positive prick skin test to methylparaben, which was the preservative in the barium mixture used and, therefore, is presumed to be the responsible allergen.

Multiple infectious esophageal fistulae.

Acquired fistulous communication between the respiratory tract and the esophagus in the adult are most often posttraumatic or secondary to malignant disease. Infectious fistulae, although uncommon, have been described secondary to primary esophageal, mediastinal, or pulmonary processes. Because of better mucosal definition, double contrast esophagography may help determine the origin of the communication and therefore aid in the differential diagnosis. In addition, near-maximal esophageal distension may demonstrate additional fistulae, which if widely separated, suggest an infectious etiology. To our knowledge, no examples of multiple esophagopulmonary communications have been reported in the English literature. We report two such cases in which the barium study correctly predicted an infectious etiology.

Cervical dysphagia: pharyngeal protrusions and achalasia.

Cervical achalasia, webs, and pharyngeal protrusions, particularly Zenker's diverticula, are prominent sources of upper alimentary tract dysphagia. Since achalasia and webs can secondarily cause pharyngeal protrusions, they may coexist, and must be ruled out before commencing treatment. The nature and origin of these entities and means of radiographic distinction are discussed. Emphasis is placed on the various forms of lateral pharyngeal protrusion, which are the most poorly understood.

Postinflammatory pseudotumors of the lung: fibrous histiocytoma and related lesions.

Three cases of pulmonary fibrous histiocytoma, sometimes known as xanthogranuloma and fibrous xanthoma, are described. The lesion is part of a spectrum of diseases known as postinflammatory pseudotumors of the lung. It is usually discovered on routine radiographic examination on which it appears as a well circumscribed mass, and it usually has a benign course. The microscopic findings upon which diagnosis is based, the theories of origin, and previously reported cases are discussed.

Intrapulmonary metastases from bronchogenic carcinoma and their radiographic detection.

Autopsies on 102 patients dying with bronchogenic carcinoma over an 11-year period revealed that 37.3% had pulmonary metastases. Review of the pathological evidence in questionable cases supported the validity of the diagnosis. This rather high figure is paralleled by the findings of others quoted in the literature. Dissemination in the lungs appears to take place early with respect to the time of diagnosis. Seventeen of 49 patients (34.7%) who died within 1 month of tissue diagnosis already had additional pulmonary foci. It was possible to identify intrapulmonary spread radiographically in over half of the cases despite the prevalence of concomitant pulmonary disease. Hence, x-ray examination is a useful means of establishing the existence of such metastases in pursuing clinical trials.

Erosion of the inferior aspect of the clavicle in secondary hyperparathyroidism.

Erosion of the inferior aspect of the outer third of the clavicle has been found on chest films in 19 out of 100 randomly selected azotemic patients. This important manifestation of secondary hyperparathyroidism compares favorably with other sites of clavicular erosion. Its frequency and degree increase with length of time on dialysis. A review of the local anatomy and of the mechanical stresses imposed on the coracoclavicular ligament explains why anteroposterior and portable chest films are particularly well suited for early detection of these changes.

Pulmonary hemorrhage in renal disease: Goodpasture's syndrome and other causes.

Pulmonary hemorrhage is generally due to neoplasm, tuberculosis, necrotizing pneumonia, or bronchiectasis. If these are not found, kidney diseases, including anti-glomerular basement membrane antibody-induced bleeding (Goodpasture's syndrome), should be considered. Hemoptysis in renal disease is more often due to azotemic hypervolemia than immune reaction. Typically linear immunofluorescent patterns along the glomerular and pulmonary alveolar basement membranes must be demonstrated to confirm the diagnosis of Goodpasture's syndrome.

Posttraumatic osteolysis of the distal clavicle with emphasis on early radiologic changes.

Erosion of progressive resorption of the distal clavicle following trauma has been described but merits greater attention due to its frequency. Six cases of posttraumatic osteolysis of the distal clavicle are reported with emphasis on early radiographic detection. Soft tissue swelling, deminerlization, and loss of the subarticular cortex at the injured clavicular tip antecede the more commonly recognized gross erosion. Recognition of this early stage, with consequent immobilization, may shorten the course of this process and decrease the prolonged disability. The pathogenesis of the process is discussed and illustrated.