Plasma D-dimer levels and ischaemic lesions in multiple vascular regions can predict occult cancer in patients with cryptogenic stroke.

BACKGROUND AND PURPOSE: Cancer patients with cryptogenic stroke often have high plasma D-dimer levels and lesions in multiple vascular regions. Hence, if patients with cryptogenic stroke display such characteristics, occult cancer could be predicted. This study aimed to investigate the clinical characteristics of cryptogenic stroke as the first manifestation of occult cancer and to determine whether plasma D-dimer levels and lesions in multiple vascular regions can predict occult cancer in patients with cryptogenic stroke. METHODS: Between January 2006 and October 2015, data on 1225 patients with acute ischaemic stroke were extracted from the stroke database of Osaka University Hospital. Among them, 184 patients were classified as having cryptogenic stroke, and 120 patients without a diagnosis of cancer at stroke onset were identified. Clinical variables were analyzed between cryptogenic stroke patients with and without occult cancer. RESULTS: Among 120 cryptogenic stroke patients without a diagnosis of cancer, 12 patients had occult cancer. The body mass index, hemoglobin levels and albumin levels were lower; plasma D-dimer and high-sensitivity C-reactive protein levels were higher; and lesions in multiple vascular regions were more common in patients with than in those without occult cancer. Multiple logistic regression analysis revealed that plasma D-dimer levels (odds ratio, 3.48; 95% confidence interval, 1.68-8.33; P = 0.002) and lesions in multiple vascular regions (odds ratio, 7.40; 95% confidence interval, 1.70-39.45; P = 0.01) independently predicted occult cancer. CONCLUSIONS: High plasma D-dimer levels and lesions in multiple vascular regions can be used to predict occult cancer in patients with cryptogenic stroke.

18fluorodeoxyglucose positron emission tomography to detect mediastinal or internal mammary metastases in breast cancer.

PURPOSE: To determine the prevalence of suspected disease in the mediastinum and internal mammary (IM) node chain by 18fluorodeoxyglucose (FDG) positron emission tomography (PET), compared with conventional staging by computed tomography (CT) in patients with recurrent or metastatic breast cancer. PATIENTS AND METHODS: We retrospectively evaluated intrathoracic lymph nodes using FDG PET and CT data in 73 consecutive patients with recurrent or metastatic breast cancer who had both CT and FDG PET within 30 days of each other. In reviews of CT scans, mediastinal nodes measuring 1 cm or greater in the short axis were considered positive. PET was considered positive when there were one or more mediastinal foci of FDG uptake greater than the mediastinal blood pool. RESULTS: Overall, 40% of patients had abnormal mediastinal or IM FDG uptake consistent with metastases, compared with 23% of patients who had suspiciously enlarged mediastinal or IM nodes by CT. Both FDG PET and CT were positive in 22%. In the subset of 33 patients with assessable follow-up by CT or biopsy, the sensitivity, specificity, and accuracy for nodal disease was 85%, 90%, and 88%, respectively, by FDG PET; 54%, 85%, and 73%, respectively, by prospective interpretation of CT; and 50%, 83%, and 70%, respectively, by blinded observer interpretation of CT. Among patients suspected of having only locoregional disease recurrence (n = 33), 10 had unsuspected mediastinal or IM disease by FDG PET. CONCLUSION: FDG PET may uncover disease in these nodal regions not recognized by conventional staging methods. Future prospective studies using histopathology for confirmation are needed to validate the preliminary findings of this retrospective study.

Diagnosing pneumonia by physical examination: relevant or relic?

BACKGROUND: The reliability of chest physical examination and the degree of agreement among examiners in diagnosing pneumonia based on these findings are largely unknown. OBJECTIVES: To determine the accuracy of various physical examination maneuvers in diagnosing pneumonia and to compare the interobserver reliability of the maneuvers among 3 examiners. METHODS: Fifty-two male patients presenting to the emergency department of a university-affiliated Veterans Affairs medical center with symptoms of lower respiratory tract infection (cough and change in sputum) were prospectively examined. A comprehensive lung physical examination was performed sequentially by 3 physicians who were blind to clinical history, laboratory findings, and x-ray results. Examination findings by lung site and whether the examiner diagnosed pneumonia were recorded on a standard form. Chest x-ray films were read by a radiologist. RESULTS: Twenty-four patients had pneumonia confirmed by chest x-ray films. Twenty-eight patients did not have pneumonia. Abnormal lung sounds were common in both groups; the most frequently detected were rales in the upright seated position and bronchial breath sounds. Relatively high agreement among examiners (kappa approximately 0.5) occurred for rales in the lateral decubitus position and for wheezes. The 3 examiners' clinical diagnosis of pneumonia had a sensitivity of 47% to 69% and specificity of 58% to 75%. CONCLUSIONS: The degree of interobserver agreement was highly variable for different physical examination findings. The most valuable examination maneuvers in detecting pneumonia were unilateral rales and rales in the lateral decubitus position. The traditional chest physical examination is not sufficiently accurate on its own to confirm or exclude the diagnosis of pneumonia.

Radiology of chronic obstructive pulmonary disease.

This article reviews the radiologic manifestations and complications of chronic obstructive pulmonary disease, particularly those seen in association with emphysema. Current concepts on the pathogenesis of chronic obstructive pulmonary disease are discussed and related to findings on high-resolution CT scan and histologic examinations. Controversial issues concerning the detection and grading of emphysema using radiologic and physiologic tests are also addressed.

Lung-volume reduction surgery for diffuse emphysema: radiologic assessment of changes in thoracic dimensions.

Patients with severe, diffuse emphysema may be candidates for pneumectomy (lung-volume reduction surgery, LVRS) to improve lung and respiratory muscle function. To identify candidates who might benefit from this surgery, it is necessary to understand how lung volumes and respiratory function are effected. In this article, the authors demonstrate a significant difference in lung size on chest radiographs obtained before and after surgery. Thirty-five of 71 consecutive patients undergoing LVRS had both preoperative and postoperative chest radiographs and pulmonary function tests available for retrospective review. Preoperative and postoperative measurements of lung height, transthoracic diameters, mediastinal width, heart size, diaphragmatic arc, and intercostal spaces were compared using paired t-tests. Radiographic measurements where also correlated with changes in lung volumes as measured by pulmonary function tests. Lung heights (right, left, mean lateral) and coronal diameter at the aortic arch were reduced after surgery (all p < 0.05). Forced vital capacity, forced expiratory volume in 1 second (FEV1), and vital capacity increased, and total lung capacity and residual volume decreased after surgery (all p < 0.05). Left lung height showed a significant correlation (p = 0.025) with FEV1; all other correlations between radiographic changes and pulmonary function test changes were not significant. The explanation for improved lung function in patients after LVRS is not completely clear and is probably multifactorial. Radiologic alterations reflect anatomic changes caused by surgery and support the theory that modifications of chest wall configuration occur and are likely responsible, in part, for improved symptomatology and respiratory function.

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.

Monitoring changes in cyclosporine dosage by trough level testing.

The concept of a narrow therapeutic window has guided the management of transplant recipients on cyclosporine immunosuppression since its inception more than a decade ago. The need to maintain immunosuppression and avoid toxicity imposed the requirement of monitoring cyclosporine levels within a limited range. The use of circulating trough levels to aid in the adjustment of dosage, however, has also led to controversies. Trough levels did not immediately reflect the dose, and circulating drug levels varied even in the absence of dose changes, indicating the role of factors other than the dose. By introducing a time factor or delay between the dose and trough levels, the sequential delay analysis allows a clearer demonstration of the relationship between doses and trough levels. Using dose adjustments as markers, corresponding changes in the trough levels were observed for most markers after a short delay. The existence of a time factor imposes some restrictions on the scheduling of dose changes and trough level tests. Adjustments in dose need to be separated to avoid interference from each other and the frequency of testing after a change increased to assure its detection. Consideration of the delay should aid in the adjustment of doses and provide an initial step in the understanding of other factors in the relationship between the dose and circulating trough levels.

The implantable pace-maker-cardioverter-defibrillator: radiographic aspects.

Safer and easier placement, recent approval by the U.S. Food and Drug Administration of several models, and increasing availability have expanded the use of implantable cardioverter-defibrillators (ICDs) for treatment of life-threatening ventricular tachyarrhythmia. Modern ICDs generally use a combination of two transvenously placed electrodes and one subcutaneous electrode; therefore, they do not require a thoracotomy for placement. The authors evaluated the radiographic aspects of one particular ICD--the pacemaker-cardioverter-defibrillator (PCD)--including the normal appearance and variations, confusing findings, and such complications as deformity of the subcutaneous patch electrode, lead fracture, and electrode malposition and migration. The PCD can also be combined with a preexisting, surgically placed automatic ICD or with a pacemaker. Familiarity with the PCD and other ICDs is essential, since the radiologist may be the first to recognize a complication that can render the device inoperative and leave the patient vulnerable to sudden death.

Radiographic changes in acute exacerbations of cystic fibrosis in adults: a pilot study.

OBJECTIVE: We set out to determine whether specific findings can be seen on chest radiographs of adult patients with cystic fibrosis who are having acute exacerbation of respiratory disease. MATERIALS AND METHODS: Over a 2-year period, 22 adults with cystic fibrosis had both a baseline chest radiograph and a radiograph obtained either because of acute exacerbation or for some other reason (nonexacerbation). Fourteen radiographic features, including mucous plugs, air-space disease, peribronchial thickening, bronchiectasis, fluid levels, and lymphadenopathy, were scored retrospectively by two radiologists, who did not have knowledge of the patient's clinical condition, as being present, absent, increased, decreased, or unchanged. An overall assessment (better, worse, or no change) was also given for each radiograph. Data were analyzed in two ways (per individual episode and per individual patient) by using contingency tables, with statistical significance determined by exact permutation testing. RESULTS: Of the 22 patients, 13 had 29 exacerbations and eight had 11 nonexacerbations. The remaining patient had radiographs showing both an exacerbation and a nonexacerbation. With the exception of overall change (p = .06), none of the radiographic variables showed a statistically significant association with exacerbation (mean p value, .66; range, .19-.90). CONCLUSION: The 14 specific radiographic findings studied, including peribronchial thickening, mucous plugs, air-space disease, and fluid levels, were not useful in determining whether an adult patient with cystic fibrosis was having acute exacerbation of the disease. With regard to these individual variables, chest radiographs are not helpful in the management of acute exacerbation of cystic fibrosis in adults. However, overall change approached statistical significance (p = .06). The value of chest radiography lies more in excluding the rare major complication, such as pneumothorax, than in diagnosing the usual exacerbation.

Diagnostic use of inadvertent pneumothorax after CT-guided percutaneous lung biopsy.

Previous studies using artificially induced pneumothorax and post-pneumothorax computed tomography (pCT) have shown that 100% of cancers that fall away from the mediastinum or chest wall are contained within the visceral pleura at that site. This patient demonstrates how an unintentional, postbiopsy pneumothorax can be used to show that a peripheral carcinoma of the lung does not invade the mediastinum.

Computed tomography of air-space disease.

Although computed tomography (CT) has not been used as often in air-space diseases as in interstitial ones, it often provides useful information. Diseases such as early opportunistic pneumonia may be detected by CT before becoming visible on plain radiographs. Also, extent and location are often better defined by CT than by plain radiographs. Accompanying abnormalities such as abscess, lymphadenopathy, and pleural effusion are often clearly demonstrated by CT. This article reviews the CT findings in a variety of air-space diseases, including pneumonia and other infections, radiation pneumonitis and fibrosis, embolism, eosinophilic pneumonia, alveolar proteinosis, bronchioloalveolar carcinoma, lipoid pneumonitis, sarcoidosis, and trauma.

The extrapleural fat in empyema: CT appearance.

Pleural empyema can be accompanied by changes in the adjacent chest wall. We examined the chest wall on computed tomographic scans in 24 patients with pleural effusions. Eighteen patients had pleural empyema and six had transudative effusions. Of the 18 empyema patients, 13 had abnormally high attenuation in the extrapleural tissues. In 12 of these 13, the high attenuation was probably caused by reaction to the pleural infection. In two, it was probably caused by haematoma (one patient had haematoma and empyema). In five patients there was either no clear abnormality in the extrapleural space or an insufficient amount of fat to permit detection of an abnormality, or the parietal pleura could not be distinguished from the pleural fluid because intravenous contrast medium was not given. Of the six patients with proven transudative pleural effusions, all had extrapleural fat which appeared normal. Abnormally high attenuation in the extrapleural tissues can be expected to accompany exudative pleural effusion, particularly empyema, but not transudative effusion.

Lung abscess caused by Rhodococcus equi.

In the immunocompromised patient, early diagnosis of a lung cavity is essential for appropriate treatment. Rhodococcus equi (formerly Corynebacterium equi) is a variably acid-fast bacterium that can produce cavitary disease in an immunocompromised host. The two cases presented here demonstrate the clinical and radiographic features of R equi lung abscess. The first patient was on long-term corticosteroid therapy for rheumatoid arthritis. The second patient had AIDS. The correct diagnosis in both cases was delayed because acid-fast bacilli seen on smears of sputum were presumed to be Mycobacterium tuberculosis.

CT appearance of the retroaortic anastomoses of the azygos system.

The terminations of the hemiazygos and accessory hemiazygos veins can be mistaken for normal or enlarged posterior mediastinal lymph nodes on CT scans of the chest. These terminations are termed the retroaortic anastomoses by anatomists. We studied the CT appearances of these veins on scans of one cadaver and seven patients. We found that the retroaortic anastomoses usually were clearly recognizable because of their continuity with the hemiazygos or accessory hemiazygos vein. However, it is sometimes possible to mistake these vessels for lymph nodes, especially when only short segments of the vessel are visible on a CT image or when the vessel is not clearly opacified by contrast material. Familiarity with the CT appearances of the hemiazygos and azygous veins can prevent their being mistaken for normal or enlarged lymph nodes.

Inadvertent bucrylate pulmonary embolization: a case report.

Detection of small, dense, rectangular opacities that follow the course of pulmonary vessels on chest radiographs should raise the suspicion of a prior therapeutic occlusion of the blood supply of a mass or of an arteriovenous fistula elsewhere with embolization of the occlusive material to the lungs. This article demonstrates the radiographic findings of such an occurrence in an asymptomatic woman.

Pulmonary histiocytosis X: comparison of radiographic and CT findings.

The authors retrospectively evaluated radiographs, computed tomographic (CT) scans, and results of pulmonary function tests (when available) for 17 patients with biopsy-proved pulmonary histiocytosis X. In 11 patients, high-resolution CT was used. In 12 patients, CT demonstrated cystic air spaces, usually less than 10 mm in diameter. In three of these 12, cysts were the only abnormality, but in six others, nodules (usually less than 5 mm in diameter) were also present. Two patients had only nodules and one, only emphysema. CT showed that many lesions that appeared reticular on plain radiographs were actually cysts. CT showed no central or peripheral concentration of lesions, but it did reveal that many small nodules were distributed in the centers of secondary lobules around small airways. CT findings correlated better with the diffusing capacity (rho = -0.71) than did the plain radiographic findings (rho = -0.57). Thus, CT was better than radiography at showing the morphology and distribution of lung abnormalities.