Transthoracic hilar and mediastinal biopsy.

TNB of the mediastinum is an accurate, safe, and cost-effective diagnostic tool for the evaluation of mediastinal masses and lymphadenopathy. The technique is most useful in the staging of carcinoma, where it serves as a less expensive and minimally invasive alternative to mediastinoscopy for establishing unresectability. With recent advances in immunohistochemical and core biopsy techniques, TNB has become more accurate for establishing the initial diagnosis of lymphoma and for confirming recurrent disease. Core-needle biopsy has improved the accuracy of TNB and is particularly useful when fine-needle aspiration fails to yield a specific diagnosis, or when lymphoma or a noncarcinomatous lesion is suspected.

Impact of filmless radiology on frequency of clinician consultations with radiologists.

OBJECTIVE: The purpose of the study was to determine the impact of filmless operation on the relative frequency of in-person consultations in the radiology department between radiologists and clinicians. CONCLUSION: The transition to filmless operation at the Baltimore Veterans Affairs Medical Center was associated with an 82% reduction in the in-person consultation rate for general radiography and a 44% reduction for cross-sectional imaging despite an increase in the volume of studies. The major reason for this decrease was the convenient access to current and prior images provided by the PACS (picture archiving and communication system). Radiology departments contemplating a transition to filmless operation should prepare for communication with clinicians to shift from being mostly in person to being conducted more and more through electronic forms of communication.

Impact of filmless imaging on the frequency of clinician review of radiology images.

The purpose of this study was to determine the impact of filmless imaging on the frequency with which physicians access radiology images and to assess clinician perception of image accessibility using a hospital-wide Picture Archival and Communication System (PACS). Quantitative data were collected at the Baltimore VA Medical Center (BVAMC), prior to and after conversion to filmless imaging, to determine the frequency with which clinicians access radiology images. Survey data were also collected to assess physician preferences of image accessibility, time management, and overall patient care when comparing filmless and film-based modes of operation. In general, there was a significant increase in the average number of radiology images reviewed by clinicians throughout the hospital. However, the one are in the hospital where this trend was not observed was in the intensive care unit (ICU), where the frequency of image assess was similar between film and filmless operations. Ninety-eight percent of clinicians surveyed reported improved accessibility of images in a filmless environment resulting in improved time management. The mean clinician estimate of time saved due to the use of PACS was 44 minutes. The study documented a combination of clinician perception of improved accessibility and substantial time savings with the use of a hospital-wide PACS, which was supported by objective measurements. The increased frequency of image review by clinicians and rapid image access should provide a further impetus to radiologists to decrease report turnaround time to provided "added value" for patient care.

Incidental lung carcinoma detected at CT in patients selected for lung volume reduction surgery to treat severe pulmonary emphysema.

PURPOSE: The authors present their experience with previously unsuspected carcinoma of the lung detected at preoperative computed tomography (CT) in patients with severe pulmonary emphysema who were scheduled to undergo lung volume reduction surgery. MATERIALS AND METHODS: Preoperative chest CT was performed in 148 patients (84 men, 64 women; mean age, 65 years +/- 8 [standard deviation]) with advanced pulmonary emphysema before lung volume reduction surgery. At surgery, an attempt was made to excise any pulmonary nodule considered suspicious for carcinoma at CT. RESULTS: Eighteen pulmonary nodules suspicious for lung cancer were found at CT in 17 (11%) of the 148 patients. Sixteen of these 148 nodules were resected at lung volume reduction surgery. Nine non-small cell carcinomas (adenocarcinoma, n = 4, including three with bronchioloalveolar differentiation; poorly differentiated, n = 3; squamous cell carcinoma, n = 2) were found in eight (5%) patients. Eight of the cancers were stage I, and one was unstaged surgically. Maximum diameters of the cancers ranged between 1.0 and 3.8 cm (median, 1.6 cm). The seven (5%) other resected nodules were all benign. CONCLUSION: A 5% rate of stage I primary lung cancer in patients selected for lung volume reduction surgery suggests that performance of chest CT in candidates for lung volume reduction surgery is appropriate not only to identify patterns of pulmonary parenchymal destruction but also to search for stage I lung cancer.

Transthoracic hilar and mediastinal biopsy.

Transthoracic needle biopsy (TNB) of the mediastinum is an accurate, safe, and cost-effective diagnostic tool for the evaluation of mediastinal masses and lymphadenopathy. The technique is most useful in the staging of carcinoma, where it serves as a less expensive and minimally invasive alternative to mediastinoscopy for establishing unresectability. With recent advances in immunohistochemical and core-biopsy techniques, TNB has become more accurate for establishing the initial diagnosis of lymphoma and for confirming recurrent disease. Core-needle biopsy has improved the accuracy of TNB and is particularly useful when fine-needle aspiration fails to yield a specific diagnosis, or when lymphoma or a noncarcinomatous lesion is suspected.

Search for a primary lung neoplasm in patients with brain metastasis: is the chest radiograph sufficient?

OBJECTIVE: We assessed whether chest CT provided an advantage over chest radiography when diagnosing a primary lung neoplasm in a selected group of patients. MATERIALS AND METHODS: From a retrospective evaluation of 925 patients who had a discharge diagnosis of brain metastasis, we identified 32 patients who presented without a known primary tumor site and who were investigated subsequently with both chest radiography and CT. Reports of chest radiographs were classified as showing a primary lung neoplasm (positive), as abnormal but nonspecific, or as negative. Patients were categorized as having negative chest radiograph, negative CT; positive chest radiograph, positive CT; nonspecific chest radiograph, positive CT; or negative chest radiograph, positive CT. Radiographic technique and clinical and lesion characteristics were compared among these categories. RESULTS: We found negative chest radiograph and negative CT in one patient who ultimately proved to have breast cancer. The remaining 31 patients (97%) had primary lung carcinoma. In 19 (59%) of the 32 patients, chest radiographs and CT were positive. Twelve patients (38%) had a nonspecific or negative chest radiograph and positive CT. In the 31 patients with lung carcinoma, the mean diameter of lesions in patients with positive chest radiographs was 4.2 cm, compared with 2.5 cm in patients with normal or nonspecific radiographs (p < .01). CONCLUSION: Lung cancer is by far the most common cause of a de novo presentation with brain metastasis. Chest CT is valuable to supplement chest radiography in patients with metastatic brain disease in whom a primary lesion is sought. Lesion size appears to be the most important determinant of detectability of a primary tumor on chest radiographs.

Picture archiving and communication systems and vascular surgery: clinical impressions and suggestions for improvement.

The purpose of this study was to determine the acceptance and clinical utility of a large scale picture archiving and communication system (PACS) for vascular surgery. Questionnaires and one-on-one interviews were conducted with physicians and nurses in the department of vascular surgery at the Baltimore VA Medical Center where PACS has been in routine, hospital-wide use for more than 2 1/2 years. The perceptions of the clinical staff were assessed to determine the efficacy of PACS in comparison to the conventional film based alternative for the practice of vascular surgery and suggestions for improvements were solicited. There was consensus among the vascular surgery staff members that the use of PACS enhanced their clinical practices, both in and out of the operating room (OR). Vascular surgeons heavily rely on image display in the OR as a "road map" to help determine their operative approach and to guide their surgery. PACS offers unique intraoperative imaging capabilities including rapid image retrieval and improved archival, cine review, the ability to modify image contrast, and the ability to obtain direct quantitative measurements of the degree of vascular stenosis. The increased accessibility and availability of images throughout the hospital enables improvement in time management and in patient care.

Experience and design recommendations for picture archiving and communication systems in the surgical setting.

An analysis of the efficacy of a picture archiving and communication system (PACS) in the surgical domain was undertaken at the Baltimore Veterans Affairs Medical Center. Interviews with surgeons and staff were conducted and supplemented by direct radiologist observation in the operating room (OR) and surgical outpatient clinic to determine patterns of routine clinical PACS use, levels of satisfaction both within and outside of the OR, and perceptions of the relative efficacy of the system in comparison to film. These data as well as suggestions from the surgical staff members were used to make recommendations for specific modifications in PACS design and operation to improve the current system and to help prescribe design improvements for future PAC systems. A high level of satisfaction with the system was found and the use of PACS was favored over film by a majority of surgeons and their staff. Findings of this study suggest that the design of a hospital-wide PAC system must have the flexibility to accommodate the specific requirements of a wide variety of end-users in their unique hospital environments.

Picture archiving and communication system training for physicians: lessons learned at the Baltimore VA Medical Center.

Physicians practicing at the "filmless" Baltimore VA Medical Center need to be proficient in the use of the picture archiving and communication system (PACS) to be able to view radiologic images and accompanying reports. PACS training is necessary to assure optimal patient care and to satisfy potential medicolegal requirements. Providing such training is the responsibility of both the Imaging Department and the hospital. Training in the use of the PACS at the Baltimore VA is conducted by an on-site application specialist. Data were collected from interviews with the trainer, training log sheets, and physician surveys. Although 100% of radiologists received formal training, only 22% of nonradiologists were formally trained; 32% of these physicians identified themsleves as having been trained by their peers and 41% stated they were self-trained. We identified two goals of a PACS training program. The first is to teach physicians how to retrieve images and reports from current as well as prior studies and display them on a computer workstation. Secondly, the training should include instruction on the use of the various workstation tools to enhance image interpretation. Imaging requirements and usage by different physician groups vary, and PACS training should be tailored accordingly. Difficulties in the scheduling of training sessions during working hours and the widespread use of a "generic" log-on identification have contributed to the low (22%) compliance of nonradiologists with the formal training program. Although we believe that one-on-one training is most effective and can be best tailored to the needs and computer expertise of an individual particular physician, computer based training (both on and off-line) may provide an acceptable, and in some cases, a preferred alternative.

Evaluation of soft-tissue foreign bodies: comparing conventional plain film radiography, computed radiography printed on film, and computed radiography displayed on a computer workstation.

OBJECTIVE: The study was performed to evaluate detection of soft-tissue foreign bodies using conventional radiography (film-screen radiography), computed radiography printed on films (computed radiography-hard copy), and computed radiography displayed on a computer workstation (computed radiography-soft copy). SUBJECTS AND METHODS: Fifteen foreign bodies of different size, shape, and composition were implanted at different locations in a fresh cadaveric hand, and images were obtained using three radiographic techniques. Images were evaluated by four board-certified radiologists to ascertain the conspicuity of the foreign bodies with the different techniques. A subjective grade was assigned to each image in an attempt to identify the relative conspicuity of foreign bodies when imaged with the three techniques. RESULTS: Computed radiography-soft copy is the preferred imaging technique for the detection of wood and plastic foreign bodies in soft tissue regardless of the size of the wood or the plastic. No significant differences in conspicuity among the three techniques were demonstrated with glass foreign bodies. CONCLUSION: Detection of soft-tissue foreign bodies is best done using computed radiography-soft copy instead of film-screen radiography and computed radiography-hard copy imaging.

Transthoracic needle biopsy of mediastinal lymph nodes for staging lung and other cancers.

PURPOSE: To determine the usefulness of transthoracic needle biopsy of mediastinal lymphadenopathy for staging suspected lung and other cancers. MATERIALS AND METHODS: Transthoracic needle biopsy of the hilum or mediastinum was performed in 111 patients with suspected neoplasms. Most biopsy procedures were performed with computed tomographic guidance on an outpatient basis. Forty-eight adult patients had enlarged lymph nodes (defined as < or = 30 mm in the long axis and > or = 10 mm in the short axis). Sixty-three lesions larger than 30 mm were arbitrarily considered to be masses and were excluded. RESULTS: Carcinoma was diagnosed in 40 patients. Four patients had true-negative and one patient had false-negative results. Sensitivity for carcinoma was therefore 98% (40 of 41). One patient with a negative biopsy result did not have surgical confirmation and was excluded from analysis. Lymphoma was excluded from analysis. Lymphoma was diagnosed in two patients (positive in one and suspicious in one). Pneumothorax occurred in 19 (34%) of 56 biopsy procedures. Chest tube treatment was required in eight (14%). CONCLUSION: Transthoracic needle biopsy of mediastinal lymphadenopathy is a safe, accurate diagnostic staging procedure. It can frequently be used as an alternative to mediastinoscopy in patients with lymphadenopathy.

Primary carcinoma of the lung overlooked at CT: analysis of findings in 14 patients.

PURPOSE: To describe the appearances of overlooked lung cancer at computed tomographic (CT) examination and to analyze the reasons for failure to diagnose these lesions. MATERIALS AND METHODS: Fourteen patients with 15 overlooked lung cancers were identified by radiologists at three institutions. Location, shape, and cell type of each cancer were reviewed, and other relevant findings of CT examinations were assessed. RESULTS: The missed tumors manifested as endobronchial lesion (n = 10), solitary parenchymal nodule (n = 2), area of focal peripheral air-space disease (n = 2), or pleural-based thickening (n = 1). Eleven (73%) of the 15 lesions were located in a lower lobe. In six (43%) of 14 patients, major distracting findings were present elsewhere in the thorax. CONCLUSION: Endobronchial location and lower lobe predominance were the most common characteristics of overlooked lung cancer at CT. The presence of unrelated major abnormalities at CT may also have contributed to failure to diagnose the tumor.

Left pulmonic recess of the pericardium: findings at CT and MR imaging.

PURPOSE: To assess the prevalence and appearance of fluid in the left pulmonic pericardial recess (LPR) on computed tomographic (CT) scans and magnetic resonance (MR) images of patients without pericardial effusion. MATERIALS AND METHODS: Eighty consecutive contrast material-enhanced CT scans and 50 consecutive MR images of the thorax were evaluated for the presence of fluid in the LPR, transverse sinus, and superior pericardial recess. RESULTS: Fluid was identified in the LPR in approximately 25% of patients without pericardial effusion (14 of 62 CT scans, eight of 30 MR images). At MR imaging, the LPR and other recesses appeared as a signal void on spin-echo images but demonstrated high signal intensity on gradient-echo flow-sensitive images. CONCLUSION: Recognition that fluid in the LPR can be a normal finding in patients without pericardial effusion should help avert misdiagnoses of lymphadenopathy.

Studies on cholecystokinin-containing neuronal pathways in rat cerebral cortex and striatum.

Lesion experiments were performed to investigate the origin of CCK-containing afferents of the striatum. All the subdivisions of the striatum that were investigated seem to receive CCK afferents from dorsolateral and lateral neocortical areas. However, destruction of these cortical areas alone did not reduce CCK-IRC in the striatum. Only after an additional parasagittal severance of the corpus callosum were significant decreases in CCK-IRC of all striatal subdivisions observed. Thus, CCK neurons in ipsilateral midline areas (such as the cingulate cortex) or, more likely, in contralateral cortical areas, seem to project to the striatum of one side. The CCK fibers seem to enter the striatum via the capsula externa, since a lesion of this structure has been shown to diminish the CCK-IRC in the striatum. In addition, the dorsomedial part of the head of the striatum may receive a projection of CCK fibers from the anterior cingulate area. A series of lesions which severed the afferents of structures caudal to the striatum, that is, the amygdaloid complex and the ventral tegmental area plus substantia nigra, did not reduce CCK-IRC in the striatum. Some of these lesions even significantly enhanced CCK-IRC in several subdivisions of the ipsilateral and contralateral striatum. Further studies will be necessary to cast some light on these caudal CCK afferents to the striatum, which are obviously extremely complex.