TNM staging of lung cancer: a quick reference chart.

Lung cancer is the leading cause of cancer mortalities. TNM Staging, which has recently been revised, remains an important guide to treatment and prognosis of lung cancer. In this article, we propose a simple chart that can be used as a quick reference consolidating all the information necessary to obtain an accurate staging.

Chest computed tomography and mediastinoscopy in the diagnosis of sarcoidosis-associated uveitis.

PURPOSE: To report the usefulness of chest computed tomography and mediastinoscopy in diagnosing sarcoidosis in elderly patients with uveitis. METHODS: Case reports. Two Caucasian women, aged 73 and 70 years, underwent evaluations for uveitis, which included chest computed tomography and mediastinoscopy. RESULTS: A chest computed tomographic scan of each woman disclosed mediastinal lymphadenopathy and warranted mediastinal lymph node biopsy by mediastinoscopy. In both patients, histopathologic and microbiologic studies demonstrated sterile noncaseating granulomas consistent with the diagnosis of sarcoidosis. CONCLUSIONS: The diagnosis of sarcoid-associated uveitis in the elderly may be facilitated by chest computed tomography, which may be more sensitive than conventional chest roentgenography. Laboratory studies of biopsied mediastinal nodes obtained by mediastinoscopy can confirm the diagnosis.

Postoperative portable chest radiographs: optimum use in thoracic surgery.

PURPOSE: Daily portable chest radiographs are routinely ordered in many institutions after thoracic surgery. Our purpose was to assess the efficacy and cost of this practice and to determine the optimum use of postoperative x-ray studies. METHODS: A prospective review of all portable chest x-ray films after 100 consecutive elective thoracotomies (DRG 75) was conducted. Each x-ray study initiated a three-part survey. First, the surgeon listed whether the x-ray study was routine and the anticipated management had it not been available. The radiologist then interpreted and scored the x-ray study as follows: negative, expected findings; A, minor findings necessitating no intervention; B, minor findings necessitating intervention; or C, major findings necessitating intervention. Finally, the x-ray film and the interpretation were returned to the surgeon. Any interventions necessitated by the x-ray study were recorded. RESULTS: In 6 months, 99 patients underwent 82 pulmonary resections and 18 other major procedures. In the postoperative period, 769 portable chest x-ray studies were ordered, median five per patient (range 2 to 49). Of these, 731 (95%) were routine and 38 (5%), nonroutine. Severity scores were as follows: negative in 106 (13.8%), A in 558 (72.5%), B in 59 (7.7%), and C in 46 (6.0%). X-ray findings altered management in 43 of 769 studies (5.6%): in 33 routine (4.5%), in 10 nonroutine (26.3%), in 13 A (2.3%), in 22 B (37.3%), and in 8 C (17.4%). CONCLUSIONS: These results demonstrate that routine daily portable chest x-ray studies have a minimal impact on management. It is, in fact, nonroutine x-ray studies that more often alter management. Had routine portable chest x-ray studies, which cost $114 each in our institution, been limited to one immediately after the operation, only 133 such studies (100 routine and 33 nonroutine) would have been needed in the care of these patients. Elimination of 636 (82.7%) x-ray studies reduces the cost of care by $725 per patient ($286,000 annually). For major thoracic procedures, it is safe, efficacious, and cost effective to eliminate routine postoperative portable chest x-ray studies and order nonroutine portable studies only when clinically indicated.

Rare pulmonary manifestation of Ehlers-Danlos syndrome.

Ehlers-Danlos syndrome (EDS) is an inherited disorder of connective tissue with multiple thoracic manifestations. We present an unusual thoracic manifestation of EDS consisting of parenchymal cysts and fibrous and fibroosseous nodules. These manifestations may be related to an abnormal attempt at repair of parenchymal or vascular tears.

Pulmonary embolism: increased ventilation in areas of decreased perfusion.

An abnormal finding that is considered characteristic of large or extensive pulmonary embolism has been observed on ventilation-perfusion (V-P) lung scans. This observation is a regional area of increased ventilation radioactivity in the embolized region of the lung that is more than the normal ventilation radioactivity in the adjacent or contralateral normally perfused lung. It has been designated the "enhanced V-P mismatch sign." This sign was noted in 15 cases among approximately 700 routine V-P lung scans interpreted by a nuclear radiologist. Of these, large or extensive emboli were confirmed in only 10 cases, nine by means of angiography and one by means of autopsy studies. The remaining five cases demonstrated clinical correlation only and are not included in this report. Of the 10 confirmed cases with enhanced V-P mismatch sign, increased ventilation radioactivity involved unilateral lung distribution in five and zonal or lobar distribution in five. The Westermark sign was seen in only seven of the 10 cases. It is hoped that this observation will prove useful in the diagnosis of large or extensive pulmonary emboli.

High-resolution computed tomography scanning in the assessment of interstitial lung diseases.

The development of high-resolution computed tomography (HRCT) has added a new dimension to the radiographic evaluation of interstitial lung diseases. The article reviews the techniques for HRCT, the normal anatomy seen by HRCT, and the HRCT findings of interstitial lung diseases.

Diagnostic efficacy of digitized images vs plain films: a study of the joints of the fingers.

Four hundred fifteen finger joints from 30 patients were evaluated for the presence of joint-space erosion, narrowing, and degenerative spurring on plain films, low-resolution digitized images (1024 x 840 bytes x 12 bit matrix), and high-resolution digitized images (2048 x 1680 bytes x 12 bit matrix). Three hundred four joints were abnormal. Low- and high-resolution digital images were displayed on a 1K x 1K monitor with the ability to change level, window, orientation, and brightness. Five radiologists interpreted images. The presence or absence of each abnormality was determined by consensus of two skeletal radiologists who did not otherwise participate in the study. Receiver-operating-characteristic analysis was used to obtain an area and a true-positive rate at a 0.10 false-positive rate for each interpreter. Randomized block analysis of variance with interpreters as blocks was used to compare areas and true-positive rates among imaging techniques for each type of abnormality; no statistically significant differences were found. In conclusion, the efficacy of display of digitized images on high- and low-resolution modes is not significantly different from that of plain films in the detection of erosions, joint-space narrowing, or degenerative spurring in small joints of the hands.

New perspective in the imaging of pneumoconioses.

The plain, posteroanterior chest radiograph using the International Labour Office classification has been a critical element in the radiologic diagnosis of pneumoconioses. But advances in imaging technology, including high-resolution computed tomography, assure more objective diagnostic information. High-resolution computed tomography can separate nonpleural structures and abnormalities from true pleural disease; it also leaves little room for false interpretation of suspected parenchymal disease because it permits cross-sectional imaging of the lung parenchyma to the submillimeter level without overlap of the surrounding structures. The value of high-resolution computed tomography is already recognized by some courts involved in litigation over asbestos-related disease.

Comparison of digital and conventional musculoskeletal radiography: an observer performance study.

Interpretations of 122 musculoskeletal radiographs were compared with interpretations of their digital counterparts at a resolution of 1,024 X 840 X 12 bits. Images were evaluated by four readers and included subtle and nonsubtle abnormalities and normal findings. Joint receiver operating characteristic (ROC) analysis results were averaged over all readers and demonstrated no statistically significant difference between the two imaging methods. High interobserver variability limited identifiable differences. Review of cases with subtle findings on the digital system at a resolution of 2,048 X 1,680 X 12 bits (2.5 line pairs per millimeter) revealed adequate visualization of the abnormality in every case. It is concluded that a resolution of 1,024 X 840 X 12 bits is adequate for the interpretation of many musculoskeletal abnormalities but that a resolution of 2,048 X 1,680 X 12 bits is needed for visualization of some subtle abnormalities.

Pulmonary infarction: CT appearance with pathologic correlation.

The CT appearance of 12 proven pulmonary infarcts in 10 patients was analyzed and correlated with pathologic appearance. The diagnosis of pulmonary infarction was clinically suspected in only 2 of the 10 patients. A pleural based parenchymal density with convex, bulging borders and linear strands directed from the apex of the density toward the hilum was noted in each case (n = 12). Other features were a truncated apex (n = 10), a broad pleural base (n = 10), and scattered areas of reduced attenuation within the lesions (n = 7). This distinctive complex of findings on CT should raise a strong suspicion of pulmonary infarction.

High resolution CT of the lung parenchyma with pathologic correlation.

The authors describe a technique for directly correlating high resolution CT scans and gross and histologic sections of the lung. They conclude that HRCT provides anatomic detail comparable to that seen on gross tissue inspection.

High resolution computed tomography of inflation-fixed lungs. Pathologic-radiologic correlation of centrilobular emphysema.

Centrilobular emphysema (CLE) is a disease defined pathologically. Assessment of the accuracy of high resolution computed tomography (CT) in the diagnosis of centrilobular emphysema has been hampered by a lack of pathologic correlation. We applied high resolution computed tomography to 20 postmortem lung specimens fixed by a method that allows for direct one-to-one pathologic-radiologic correlation. The degree of centrilobular emphysema was assessed radiologically on a visual grading system based on nonperipheral low-attenuation areas. The lungs were then sectioned along the plane of the CT image, and the degree of centrilobular emphysema was graded pathologically by scoring against a panel of standards. A significant correlation (r = 0.91, p less than 0.005) was found between the pathologic grade and the in vitro CT score.

Radiologic-pathologic correlation of the CT halo sign in invasive pulmonary aspergillosis.

Invasive pulmonary aspergillosis in the immunocompromised host is difficult to diagnose. Early therapy with amphotericin B improves survival. We correlated early pathologic findings with high-resolution CT of a fixed-inflated air-dried lung obtained from an autopsied patient with invasive pulmonary aspergillosis. Two distinct types of lesions were found radiologically. A large zone of air space consolidation was shown to be a confluent bronchopneumonia, and small halo-like lesions were shown to correspond to a central fungal nodule surrounded by a rim of coagulative necrosis. The halo lesion may represent an early specific sign by which invasive pulmonary aspergillosis can be diagnosed.

Transthoracic needle aspiration biopsy--optimizing the yield.

Transthoracic needle aspiration biopsy (TNAB) is the procedure of choice for the diagnosis of focal pulmonary processes. TNAB can identify the entire spectrum of focal benign or malignant disease. Technique-dependent factors and the underlying pathologic processes that affect the diagnostic yield of TNAB are reviewed.

The solitary pulmonary nodule. Assessment, diagnosis, and management.

We have presented a brief overview of an approach that has been very successful in our hands in the patient with an SPN. Even though the patient who has undergone a thoracotomy is full of gratitude to his physician when told that the resected lesion was benign and does not question the need for the thoracotomy, we have met equally happy and gratified patients when they were told that their lesion is benign be it after CT densitometry or needle biopsy. When properly performed, these techniques demand care and attention to detail much like the surgeon performing a delicate procedure. Without proper care, these procedures can in fact reflect negatively on the physician performing them and fall in disrepute. CT densitometry and transthoracic needle aspiration biopsy allow effective management of the patient with an SPN with prompt documentation of both malignant or benign lesions. With the proper application of these techniques, the majority of patients with benign disease will not need a thoracotomy for diagnosis with resultant benefits to the patient as well as to third-party payers.

Computed tomography of high density renal cysts in adult polycystic kidney disease.

In a review of abdominal CT in patients with adult polycystic kidney disease 24 patients were found to have single or multiple high density renal cysts on nonenhanced studies. All cases showed well defined, homogeneous high density cysts (56-98 HU), with smooth contours, sharp interfaces with renal parenchyma, and lack of contrast enhancement. The benign nature of these lesions was established by tissue examination in five patients and follow-up CT in four others. In the remaining 15 patients the benign nature of these lesions was assumed based on the constellation of CT and clinical findings.

MRI of hemorrhagic renal cysts in polycystic kidney disease.

Nine patients with polycystic kidney disease were examined by MRI, CT, and sonography. MRI distinguished among simple cysts, cysts complicated by prior hemorrhage, and coexistent renal cell carcinoma. On T1-weighted spin-echo images, simple renal cysts appeared as round, homogeneous, low-signal regions with smooth outer margins and a distinct interface with remaining normal renal parenchyma or adjacent cysts. Hemorrhagic cysts were seen as homogeneous medium- to high-signal intensity regions, and about half of them correlated with hyperdense cysts by CT. In five cases, fluid-iron levels were evident by dependent high-intensity layering within the cysts. Renal cell carcinomas occasionally show high intensity because of hemorrhage, but intratumoral fluid-iron levels have not yet been described. These results suggest that MRI is useful in differentiating between simple cysts, hemorrhagic cysts, and neoplasms when CT and sonography are indeterminate.

CT diagnosis of hemopericardium in acute dissecting aneurysm of the thoracic aorta.

Acute hemopericardium was diagnosed preoperatively by computed tomography in three patients with acute dissection of the thoracic aorta. The CT findings consisted of pericardial thickening measuring between 14 and 21 mm, with attenuation values ranging between 26 and 62 Hounsfield units on unenhanced scans. In addition to the hemopericardium, CT also confirmed the diagnosis of Type I or Type II dissection in each case.

Computed tomographic diagnosis of obturator foramen hernia.

Computed tomography was performed on a patient presenting with cryptic small bowel obstruction. A correct preoperative diagnosis of obturator foramen hernia was arrived at based on the recognition of a loop of ileum protruding between the pectineus and external obturator muscles.