Hilar and mediastinal adenopathy in sarcoidosis as detected by computed tomography

CT of the chest was performed in 25 patients with chest radiographs suspicious for hilar or mediastinal adenopathy, who subsequently proved to have sarcoidosis. In each case, CT detected more extensive adenopathy than suspected on chest radiographs. Adenopathy greater than 1.0 cm was present in the right paratracheal and pretracheal regions in all cases. Adenopathy was also frequently seen in the hilar (92%), anteroposterior window (88%), subcarinal (64%), anterior mediastinal (48%), and posterior mediastinal (16%) lymph node groups. The adenopathy occurred in multiple and varying combinations without a consistent identifiable pattern suggestive of sarcoidosis. It is concluded that while CT detects adenopathy more consistently, it does not offer a clear advantage over chest radiography in confirming a diagnosis of mediastinal and hilar involvement by sarcoidosis.     

Kaposi's sarcoma. CT-radiographic correlation

The role of CT in the diagnosis of intrathoracic Kaposi's sarcoma (KS) was evaluated retrospectively in 24 patients, in the absence of coexistent opportunistic infections. In all cases the diagnosis of KS was initially established by histologic evaluation of extrathoracic disease: 15 patients had verified parenchymal KS and nine patients endobronchial KS. (Chest roentgenograms were analyzed separately for each group: in 14 patients serial films were available for review. The predominant radiographic findings was the presence of nonspecific, bilateral, perihilar infiltrates in 22 of 24 cases (92 percent). Corresponding CT scans documented the presence of abnormal hilar densities characteristically extending into the adjacent pulmonary parenchyma along distinctly perivascular and peribronchial pathways. Discrete, poorly marginated nodules were identified radiographically in ten cases (42 percent); these proved to be randomly distributed throughout the parenchyma on CT. Radiographic evidence of mediastinal adenopathy was distinctly unusual, seen in only two cases (8 percent). While CT typically demonstrated shotty adenopathy, significantly enlarged nodes (greater than 1 cm) were rarely identified. We concluded that CT is more specific than routine roentgenograms for identifying pulmonary KS. While not pathognomonic, peribronchial and perivascular disease is sufficiently characteristic to obviate more invasive diagnostic procedures, especially in patients with established KS.     

Bronchoscopic and roentgenographic correlates of a positive transbronchial needle aspiration in the staging of lung cancer

A study was conducted to determine the bronchoscopic and chest roentgenographic findings associated with a positive TBNA. One hundred fifty-seven of 465 patients who were diagnosed for the first time as having carcinoma of the lung had a positive aspirate. Bronchoscopic findings associated with a positive TBNA of N2 nodes were carinal widening and endobronchial disease, especially of the right upper lobe. Mediastinal adenopathy noted on chest roentgenograms and subcarinal nodes on CAT scans were associated with a positive aspirate as well. In 34 of 465 patients, TBNA was the only means of establishing the diagnosis of pulmonary malignancy. A useful, simple and safe procedure, TBNA can be used to stage the mediastinum in patients with lung cancer and is most likely to be positive with endobronchial and nodal disease. It can also facilitate therapeutic decision-making in patients whose surgical candidacy is marginal.     

Value of gallium imaging in the evaluation of tattoo granulomas due to sarcoidosis

We report the case of a patient who developed granulomas in a ten-year-old tattoo. Total body gallium scanning detected the presence of bilateral hilar adenopathy not apparent on routine chest roentgenograms and thus established a diagnosis of systemic sarcoidosis.     

Computed chest tomography in the evaluation of hemoptysis. Impact on diagnosis and treatment

The results of computed chest tomograms (CT) and chest roentgenograms (CR) were compared in 32 patients who presented with hemoptysis. The CT demonstrated roentgenographic abnormalities more often than CR (p less than 0.01), providing new diagnostic information in 15 patients (46.9 percent), and clarifying CR abnormalities in five (15.6 percent) others. In addition, CT correctly localized sources of bleeding in 23 (88.5 percent) of the 26 patients in whom a site was identified at bronchoscopy, while CR localization was correct in 17 (65.4 percent) (p less than 0.05). Despite this augmentation of roentgenographic yield, information derived from CT scans influenced the management of only six patients, did not obviate the need for bronchoscopy, and supplemented the combined diagnostic yield of CR and bronchoscopy in only two. Outcome was changed in one patient in whom CT had demonstrated an otherwise unrecognized malignant solitary pulmonary nodule. The chest roentgenogram and fiberoptic bronchoscopy provided all the information essential for diagnosis and therapeutic recommendations in 93.7 percent of these patients. Although the CT provided additional information in over one half of our patients, its overall impact on clinical management was small and does not support routine use of this imaging procedure in evaluation of hemoptysis. The possible role of chest CT in evaluating carefully selected patients with hemoptysis requires further study.     

Transbronchial needle aspiration cytology of subcarinal lymph nodes for the staging procedure in the diagnosis of lung cancer

OBJECTIVE AND BACKGROUND: The aim of this study was to improve the staging of lung cancer with or without lymphadenopathy on chest CT by using transbronchial aspiration cytology (TBAC). METHODS: TBAC of the subcarinal lymph nodes was performed on 153 consecutive patients with lung cancer, with or without subcarinal lymphadenopathy on chest CT. RESULTS: Thirty-four patients had enlargement of the subcarinal lymph nodes (>1 cm). Eighteen of these had TBAC confirmation of metastases. Another seven patients with no mediastinal involvement on CT were positive for metastases on TBAC. TBAC was the only way to confirm lung cancer in two patients. Therefore, routinely performed subcarinal TBAC contributed to an improved non-operative staging of the patients and diagnosis in 16% (25/153) of the patients with lung cancer. Forty-nine patients with NSCLC had surgical resection of the tumour. Surgical procedure revealed metastases to the subcarinal lymph nodes in three patients in whom the preoperative TBAC diagnosis was normal. No significant complications due to TBAC occurred in any of the patients. CONCLUSION: TBAC of the subcarinal lymph nodes is a minimally invasive technique for staging of lung cancer and can provide useful information for the diagnosis of metastases to the subcarinal lymph nodes.     

The chest roentgenogram in pulmonary tuberculosis patients seropositive for human immunodeficiency virus type 1

To determine the impact that co-infection with HIV has on the radiographic presentation of pulmonary tuberculosis, we examined the chest roentgenograms obtained before treatment in 225 HIV-tested adult Haitians with bacillary (smear or culture or both) positive pulmonary tuberculosis. There were 67 HIV-seropositive and 158 HIV-seronegative patients. Intrathoracic adenopathy alone was more common and parenchymal infiltrates less common in HIV-seropositive patients (p less than 0.05). Although a parenchymal infiltrate was less likely to be cavitating in the HIV-seropositive group (p less than 0.05) when cavitary parenchymal disease was present, HIV seropositivity did not affect the number of cavities (single or multiple) or the size of the largest cavity. Patients with AIDS were significantly more likely to have a chest radiographic pattern consistent with primary tuberculosis (80 percent) than HIV-seropositive patients without AIDS (30 percent), and the latter were significantly more likely to have such a pattern than HIV-seronegative patients (11 percent) (p less than 0.05). The HIV-seropositive patients were equally infectious, regardless of the pattern of disease (primary vs postprimary). Even though pulmonary tuberculosis in an HIV-seropositive adult probably results from reactivation of dormant foci or reinfection, the pattern on the chest roentgenogram often suggests primary disease, especially if the patient has AIDS.     

Usefulness of routine preoperative chest roentgenograms in elderly patients

One hundred thirty-six charts of preoperative patients over the age of 59 years were reviewed to determine whether clinical criteria alone are sufficient to identify patients who would not benefit from preoperative chest roentgenograms. Thirty-four percent of the patients without risk factors and 62% of those in the high-risk group were found to have significant abnormalities on chest roentgenograms (P less than 0.05). Postoperative complications occurred in 20% of patients in the high-risk group compared to 11% complication-rate in patients without clinical risk factors. The difference is not statistically significant. The prevalence of abnormal preoperative chest roentgenograms among those over the age of 70 years (49%) was not significantly different from the prevalence in those between the ages of 60 and 70 years (59%); however, the incidence of major postoperative complications was significantly higher in the older group (17 v 4%, P less than 0.01). Because of the substantial prevalence of abnormal chest roentgenograms and postoperative complications, it is concluded that in the elderly preoperative patients, in particular those over the age of 70 years, chest roentgenograms should be done on all patients regardless of clinical history.     

High-resolution ultrafast chest CT in the clinical management of febrile bone marrow transplant patients with normal or nonspecific chest roentgenograms

Plain chest roentgenograms may be normal or show nonspecific abnormalities during the frequent febrile episodes that occur in patients after bone marrow transplantation. In this group, ultrafast 10-mm and 3-mm high-resolution CT scans were prospectively performed in 33 patients to determine if useful information was provided that either changed the patient's clinical management or added confidence to the clinical diagnosis. The 36 symptomatic episodes that occurred in 33 patients included fever in 20 episodes and fever combined with cough, dyspnea, chest pain, or rales in 16. Fourteen chest roentgenograms were interpreted as normal, and 22 were interpreted as demonstrating nonspecific changes; however, none of the roentgenograms was considered helpful in that they did not provide sufficient information for further management. In 2 of 14 episodes in patients with normal chest roentgenograms and in 9 of 22 episodes in patients with nonspecific chest roentgenograms, CT scanning resulted in a change in clinical management that included performing bronchoscopy, increasing or changing antibiotic coverage, starting white blood cell transfusions, requesting surgical biopsy, or a combination of these. In 1 of 14 episodes in patients with normal chest roentgenograms and in 8 of 22 episodes in patients with nonspecific roentgenograms, CT added confidence to the diagnosis. In the remaining 16 episodes, CT scans provided no additional information. We conclude that in many instances, noncontrast ultrafast chest CT scans can provide information that may either change a patient's clinical management or more clearly establish the extent of pulmonary disease.     

Computed tomography in the etiologic assessment of idiopathic spontaneous pneumothorax

In an attempt to elucidate the origin of the so-called idiopathic spontaneous pneumothorax (ISP), clinical examination, pulmonary function tests, and computed tomography (CT) with visual quantification and density analysis were performed in 20 young patients two months after an ISP episode. Twenty controls were recruited for CT. The chest roentgenograms were normal in the two groups. The results indicated the presence of various types of emphysematous lesions (EL) in the ISP group located predominantly in the apical fields with subpleural location in 16 patients. Interestingly, diffuse but moderate centrilobular emphysema was noted in 12 of 20 patients. The EL visual quantification was always less than 5 percent of the CT slices' total areas. The lung mean density shifted significantly toward the air density in the patient group (patients: -743 +/- 57.5 HU vs controls -713 +/- 59.5 HU, p less than 0.01). These findings suggest that CT may be useful for early assessment of EL in patients with ISP.     

Roentgenographic evaluation of mediastinal nodes for preoperative assessment in lung cancer

Evaluation of mediastinal nodal metastases is a critical step in the assessment of potential surgical candidates with lung cancer. Mediastinal tomography (TOMO) and chest computerized tomography (CT) visualize the mediastinal nodes more clearly than a chest roentgenogram (CXR). A prospective study was undertaken to determine the clinical value of these three tests for mediastinal staging in 102 surgical patients with lung cancer. All patients underwent thoracotomy and mediastinal nodal dissection. The roentgenographic findings were compared with the histologic evaluation of paratracheal, tracheobronchial angle, aortic window, subcarinal, and inferior pulmonary ligament nodes. TOMO, and especially CT, correctly predicted the size and location of mediastinal nodes; however, the overall accuracies were CXR (74 percent), TOMO (74 percent), CT (61 percent). These results demonstrated that the improvement in mediastinal imaging is counteracted by the fact that enlarged nodes need not contain metastases and normal-appearing small nodes may harbor microscopic disease. Computed tomography and TOMO had little clinical impact on the assessment of mediastinal nodes in potential surgical candidates with lung cancer.     

The role of transcarinal needle aspiration in the diagnosis and staging of lung cancer: computed tomographic correlates of a positive result

BACKGROUND: Transbronchial needle aspiration (TBNA) is used most frequently to assess subcarinal nodes because of its technical ease. OBJECTIVES: We conducted a prospective observational clinical study to define the indications for TBNA use for subcarinal nodes (transcarinal needle aspiration, TCNA) related to the nodal size by computed tomography (CT) of the chest. METHODS: One hundred and eight consecutive patients with lung cancer underwent TCNA at the time of initial diagnostic bronchoscopy within a 22-month period. RESULTS: TCNA was positive in 21 of the patients. Only 1 of 75 patients (1%) with subcarinal nodes less than 10 mm in short-axis diameter by CT had a positive result. TCNA for enlarged nodes, 10 mm or greater, had a high positive yield of 61% (20/33). The procedure provided the only evidence of unresectable non-small cell lung cancer (stage IIIA-N2 disease) in 3 patients and the sole pathological evidence for malignancy in 5 patients. CONCLUSIONS: The high yield of positive TCNA results for enlarged subcarinal nodes contributes to the improvement of the overall diagnostic yield of bronchoscopy. We recommend that TCNA for enlarged subcarinal nodes on CT in patients with presumptive lung cancer should be performed routinely at the time of initial diagnostic bronchoscopy.     

Chest roentgenogram in pulmonary tuberculosis. New data on an old test

The utility of routine admission chest roentgenograms (CXRs) was evaluated in detecting pulmonary tuberculosis and the relationship between roentgenographic patterns and the likelihood of finding acid-fast bacilli (AFB) on sputum smear. Of 58 patients whose chief complaints were unrelated to pulmonary tuberculosis, the CXR suggested tuberculosis in 52 cases (90 percent). In 45 cases, the emergency room physician failed to elicit the patient's respiratory symptoms and did not consider tuberculosis as a diagnostic possibility. In 18 individuals, the diagnosis was missed in the emergency room because of failure to obtain a CXR. Among patients whose roentgenograms showed cavitation or extensive alveolar infiltrate, sputum smears showed AFB in 98 percent of cases. If alveolar infiltrate was absent, or if the roentgenographic pattern was not that of adult reactivation disease, sputum smears revealed AFB in only one half of the cases. We conclude that routine admission CXRs are useful in hospitals serving populations where tuberculosis is still common, and the probability of detecting AFB on sputum smear is greatly influenced by the roentgenographic findings.     

Exogenous lipoid pneumonia: serial chest plain roentgenography and high-resolution computerized tomography findings

Between May 1988 and July 2002, six patients with pneumonia due to diesel, animal, or vegetable oil aspiration were admitted to Kaohsiung Medical University Hospital. The purpose of this study was to demonstrate distinctive radiographic findings of oil-induced lipoid pneumonitis on initial serial chest roentgenograms and high-resolution computerized tomography (CT) scans. Initial chest roentgenograms (n = 6), CT scans (n = 6), and roentgenography and CT follow-up studies were analyzed retrospectively by two chest radiologists and two surgeons, focusing on the pattern and distribution of parenchymal abnormalities. The most common location was the right middle lobe, followed by the right lower lobe, the left lower lobe, and the lingular lobe. Follow-up chest roentgenograms (n = 6) showed complete disappearance of the parenchymal lesions in only one patient and partial decrease in the extent of lesions in five patients. Lipoid pneumonia presents non-specific findings on chest roentgenography. It is commonly located in both lower and the right middle lobes. On high-resolution CT, the lesions appear most commonly as areas of consolidation, ground-glass attenuation mixed with paving pattern, and poorly defined nodules.     

The use of follow-up chest roentgenograms among hospitalized patients

Follow-up chest roentgenograms are a commonly performed test. We prospectively evaluated their diagnostic and therapeutic influence at a tertiary care teaching hospital. When a follow-up chest roentgenogram was ordered, physicians indicated their reason for ordering the test, the likelihood that the roentgenogram would show changes, and expected alterations in therapy. After the roentgenogram was obtained, physicians described the help provided by the roentgenogram and what changes in therapy were performed. Using receiver operating characteristic curves, we have shown that physicians have difficulty in predicting which roentgenograms will show important changes. Unexpected findings are frequent (25.4%) and highly valued by the physician. Fifty-seven percent of these roentgenograms had a definite or possible influence on patient treatment. Further studies are indicated to define when follow-up chest roentgenograms are likely to be of benefit.     

Pneumothorax following transbronchial biopsy. Low diagnostic yield with routine chest roentgenograms

A chest roentgenogram is commonly obtained after a transbronchial biopsy to exclude a pneumothorax. We hypothesized that these routine chest roentgenograms rarely demonstrate a pneumothorax in patients who have neither symptoms nor fluoroscopic findings of lung collapse. To test this hypothesis, we studied 305 consecutive patients undergoing bronchoscopy with fluoroscopically guided TBB. No patient without symptoms and fluoroscopic findings suggesting lung collapse had a pneumothorax demonstrated on the post-biopsy chest roentgenogram. At the University of Virginia, routine chest roentgenograms failed to demonstrate a single unsuspected pneumothorax among all patients undergoing TBB during a period of nearly six years. Given this low incidence of unsuspected pneumothorax, we conclude that routine chest roentgenograms have a low diagnostic yield and may not be necessary in all patients after fluoroscopically guided TBB.     

Severity of pulmonary asbestosis as classified by International Labour Organisation profusion of irregular opacities in 8749 asbestos-exposed American workers. Those who never smoked compared with those who ever smoked.

The profusion of irregular opacities on chest roentgenograms by International Labour Organisation pneumoconiosis criteria was used to assess the severity of asbestosis in 8749 asbestos-exposed active and retired American workers. Seventy-eight percent had no asbestosis (category 0/0 or 0/1), 18.6% had slight asbestosis (1/0 to 1/2), 3% had moderate asbestosis (2/1 to 2/3), and 0.3% had advanced disease (3/2 or greater). Significantly more current smokers had asbestosis than did those who had never smoked, and their average profusion of opacities was higher. The mean age of current smokers with asbestosis was 60 years, whereas subjects with the disease who had never smoked had a mean age of 64 years, a significant difference. Cigarette smoking and asbestosis appear to act synergistically to produce irregular opacities on chest roentgenograms of asbestos-exposed American workers.     

Utility of the Wang 18-gauge transbronchial histology needle in the staging of bronchogenic carcinoma

Use of the Wang 18-gauge histology needle in TBNA was employed as a staging procedure in 29 patients with bronchogenic carcinoma and mediastinal adenopathy demonstrated on chest CT. Twenty patients had malignant aspirates; 12 had both histologic and cytologic specimens demonstrating malignancy; six patients had malignant histologic specimens; two had cancerous cytologic specimens as their only evidence of mediastinal disease. Of the nine negative aspirates, four were true negative at surgery. Five patients had false-negative aspirates. Overall sensitivity of the Wang 18-gauge histology needle in the mediastinal staging of patients with bronchogenic carcinoma was 80 percent. When patients with small cell carcinoma were excluded, sensitivity was 82 percent. The enhanced yield of the 18-gauge histology needle warrants its use in mediastinal staging of bronchogenic carcinoma. We conclude that all patients with bronchogenic carcinoma and mediastinal adenopathy demonstrated on chest CT accessible via TBNA should undergo histology needle aspiration as an initial staging procedure.     

Changing physician test ordering in a university hospital. An intervention of physician participation, explicit criteria, and feedback

To decrease inappropriate test ordering by medical house staff in a university hospital, we examined the feasibility of an intervention that involved physicians in developing explicit criteria for ordering four specific tests and incorporated feedback of tests ordered. We implemented a time series design with measures at 12 and six months before, during, and three weeks after the intervention. During the intervention, orders for initial or admission chest roentgenograms decreased by 22% and repeated orders for routine urinalyses, chest roentgenograms, and leukocyte differential counts decreased by 23%, 30%, and 46%, respectively, compared with the six-month preintervention period. Orders for prothrombin time and/or partial thromboplastin time did not fall. After the intervention, most test ordering remained at the intervention level. These preliminary results suggest that this intervention may be effective and not overly costly.     

The value of portable chest roentgenography in adult respiratory distress syndrome. Comparison with computed tomography

In 17 patients with adult respiratory distress syndrome, we used data derived from computed tomographic (CT) scan densitometric analysis to validate the value of portable chest roentgenograms in objectively estimating the amount of pulmonary edema. Chest roentgenograms and CT scans were taken in the same ventilatory conditions (apnea at 10 cm H2O of positive end-expiratory pressure [PEEP]); blood gas samples and hemodynamic parameters were collected at the same time. Roentgenographic analysis was undertaken by independent observers using two standardized scoring systems proposed in the literature. CT scan analysis was performed using the CT number frequency distribution and the gas lung volume (measured by helium dilution technique) to estimate quantitatively the lung density, the lung weight, and the percentage of normally aerated and nonaerated tissue. Knowing the mean CT number of the pulmonary parenchyma in a group of normal subjects, we also inferred the ideal lung weight expected in the study population and computed the excess tissue mass as the difference between actual and ideal lung weight. Both the roentgenographic scoring systems showed direct correlation with the pulmonary impairment as detected by CT scan densitometric analysis (CT number, percentage of nonaerated tissue, lung weight, and excess tissue mass; p less than 0.01) and inverse relation with the percentage of normally aerated tissue (p less than 0.01). We also found a relationship between roentgenographic scores and the impairment in gas exchange as detected by shunt fraction (p less than 0.05). We conclude that standardized reading of portable chest roentgenograms by means of scoring tables is a valuable tool in estimating the amount of pulmonary edema in a patient with adult respiratory distress syndrome.