Biomedical subjects
Publications and source records attributed to R D Pugatch.
The radiographic appearance of metastatic disease is classic, but nonspecific. The differentiating characteristics of radiographic patterns of metastatic disease are discussed in this article, as well as the relative advantages of different imaging modalities. Recommendations for radiologic evaluation are also presented.
PURPOSE: To evaluate the histopathologic findings of pulmonary nodules 1 cm or smaller detected at computed tomography (CT) that were removed at video-assisted thorascopic surgery. MATERIALS AND METHODS: Clinical, radiologic, and histopathologic findings were retrospectively reviewed in 64 patients (48 women, 16 men; aged 22-85 years) who underwent video-assisted thorascopic surgical resection of small pulmonary lesions present on CT scans. RESULTS: Sixty-four patients had a total of 65 lesions resected. Of the 64 patients, 37 (58%) patients had no known previous malignancy and 27 (42%) had previous malignancy. Overall, 58% (38 of 65 [95% confidence interval = 0.45, 0.73]) of these lesions were malignant. Among the patients without previous malignancy, 14 (38%) had lung carcinoma (10 [27%], primary bronchogenic carcinoma; four [11%], carcinoid). In patients with a previous malignancy, malignant lesions were diagnosed in 81% (22 of 27). This included seven (26%) patients with bronchogenic carcinoma as a second primary carcinoma. In patients without previous malignancy, benign lesions were diagnosed in 59% (22 of 37); in patients with previous malignancy, benign lesions were diagnosed in 18% (five of 27). CONCLUSION: A considerable number of the malignant lesions were primary bronchogenic carcinoma. In addition, diagnosis in patients with a previous malignancy other than suspected metastatic disease can substantially alter treatment. For these reasons, early biopsy with an acceptable technique for diagnosis of these lesions is recommended.
PURPOSE: To determine the radiologic features, pathogenesis, and prognostic importance of sarcoidlike reaction in patients with malignancy. MATERIALS AND METHODS: Radiographs and computed tomographic (CT) scans of the chests of 10 patients with known malignancy and either concurrent or subsequent development of noncaseating granulomas (NCG) were reviewed and correlated with histopathologic reports and pertinent clinical data. RESULTS: Ten patients with malignancy were found to have either mediastinal or hilar lymph node enlargement (n = 4) or parenchymal lung disease (n = 6). The presumptive diagnosis was metastatic disease. In eight of 10 histopathologic specimens, no tumor was found, but innumerable NCGs were present. They were thought to be consistent with sarcoidlike reaction. In the other two specimens, only a small focus of tumor cells was found amidst innumerable NCGs. On CT scans of the chests, parenchymal lung disease took the form of either ground-glass attenuation (n = 1) or nodules following perivascular and peribronchial distributions (n = 5). CONCLUSION: Lymph node enlargement and parenchymal lung nodules may not indicate metastatic disease. Sampling of all abnormal areas may be helpful in staging the disease and in treating and determining the prognosis of patients. Likewise, the discovery of NCG does not necessarily indicate sarcoidosis and may represent sarcoidlike reaction.
Radiologic evaluation of the patient with non-small cell lung cancer (NSCLC) includes chest radiographs for detecting nodules, computed tomography (CT) for further characterizing them, CT and magnetic resonance imaging (MRI) to evaluate the mediastinum, and extrathoracic imaging of bones, the adrenal gland, the central nervous system, and liver. The current practice standards for each are reviewed. Asymptomatic solitary pulmonary nodules, which are usually detected on chest radiographs obtained for other indications, inevitably require a precise diagnosis. The radiologic characteristics that differentiate benign from malignant pulmonary lesions are given. Mediastinal CT is the preferred modality for examining the mediastinum in patients with NSCLC. Magnetic resonance imaging is used selectively, eg, in patients with superior sulcus tumors who are candidates for surgery. When evaluation for N2/N3 disease is requested, mediastinoscopy should replace CT using the latter as a "roadmap." The role of extrathoracic imaging in evaluating asymptomatic patients with NSCLC at initial presentation is equivocal. Computed tomographic scanning of the head is reasonable in most patients with lung cancer, given the significant incidence of occult brain metastases in this population and that solitary brain lesions may be resected in some protocol settings. Routine liver and adrenal gland scanning is similarly controversial. Bone scans do not appear to be useful in patients with NSCLC unless they have clinical signs, symptoms, or laboratory findings to indicate possible metastases. Although heavily affected by local practice, radiologic evaluation of the patient with NSCLC should attempt to provide accurate determination of local disease and a search for distant metastases.
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PURPOSE: To characterize the radiologic features of thymolipoma. MATERIALS AND METHODS: Twenty-seven cases of thymolipoma were reviewed. Clinical, radiologic, and pathologic findings were noted. RESULTS: The masses occurred in 15 male and 12 female patients (mean age, 26.7 years). All 27 tumors were in the anterior mediastinum; 22 were in the anterior inferior mediastinum. On frontal radiographs, 12 tumors simulated cardiomegaly. On lateral radiographs, 12 tumors draped over the ipsilateral hemidiaphragm, simulating diaphragmatic elevation. Computed tomographic scans (n = 11) demonstrated a mixture of fat and soft-tissue attenuation in 10 tumors corresponding to adipose and thymic elements found at microscopy. Magnetic resonance images (n = 2) demonstrated fat and soft-tissue signal intensity characteristics. Both types of studies showed a connection between tumor and thymus. CONCLUSION: Thymolipomas are anterior mediastinal masses that may conform to the shape of adjacent structures. The diagnosis is supported by imaging studies that demonstrate fat and soft tissue within the tumor.
The authors describe the radiologic features of precision electrocautery excision of pulmonary lesions (Perelman technique). Thin-walled cavities were seen on chest radiographs obtained in three patients at the site of the resected lesion subsequent to this surgical procedure. Knowledge of these findings can avoid a false diagnosis of abscess, septic emboli, or additional metastasis.
The article describes eight patients with enlarged internal mammary lymph nodes visualized on the frontal plain chest radiograph. Enlarged internal mammary lymph nodes cast shadows that initially may be mistaken for a mediastinal or pleural abnormality. Although the lateral film alone may suggest these nodes, the findings on the frontal film help lateralize the abnormality.
OBJECTIVE: Our objective was to determine if CT or MR imaging findings could be used to accurately predict resectability in patients with biopsy-proved malignant pleural mesotheliomas. SUBJECTS AND METHODS: CT and MR findings in 41 consecutive patients with malignant mesotheliomas who were referred to the thoracic surgery clinic for extrapleural pneumonectomy were studied by thoracic radiologists before surgery. Review of radiologic studies focused on local invasion of three separate regions: the diaphragm, chest wall, and mediastinum. Results of all imaging examinations were carefully correlated with intraoperative, gross, and microscopic pathologic findings. RESULTS: After radiologic and clinical evaluation, 34 patients (83%) had thoracotomy; 24 of these had tumors that were resectable. The sensitivity was high (> 90%) for both CT and MR in each region. Specificity, however, was low, probably because of the small number of patients with unresectable tumors. CONCLUSION: CT and MR provided similar information on resectability in most cases. Sensitivity was high for both procedures. Because CT is more widely available and used, we suggest it as the initial study when determining resectability. In difficult cases, important complementary anatomic information can be derived from MR images obtained before surgical intervention.
An elderly woman was seen with a left mediastinal mass in the region of the aortic arch on chest roentgenography. Further imaging with computed tomography, angiography, and magnetic resonance demonstrated a highly vascular neoplasm adjacent to the aortic arch. Pathological analysis of the resected specimen showed a leiomyoma. A brief review of the 10 previous reported cases of primary mediastinal leiomyoma is provided.
Small pulmonary nodules can be difficult to examine with routine computed tomographic techniques, primarily because of inconsistent levels of inspiration on sequential scans. However, with the patient performing a breathing technique that involves three rapid maximal inspirations and expirations followed by a final maximal inspiration, an average of six images that cover a 12-mm section of lung can be obtained during a single breath. The technique has been used in 10 patients, with encouraging results.
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The authors report a case in which a highly unusual, simultaneous occurrence of a peripheral small cell carcinoma and a central bronchial carcinoid in the right upper lobe and a peripheral adenocarcinoma in the right middle lobe was observed. This is the fourth case of triple lung cancer reported in the literature. The role of computerized tomography in disclosing multiple lung carcinomas and the significance of the concurrence of pulmonary small cell carcinoma and bronchial carcinoid are discussed.
Radiologic imaging of the pleura has undergone dramatic changes in the past 5 years. This can be primarily attributed to the availability and better understanding of computed tomography and, to a lesser extent, ultrasonography. When used in the proper clinical-radiologic environment, abnormalities of the pleural space can be quickly identified, localized, and often diagnosed in a rapid efficient manner.
A 53-year-old man entered the hospital with a large, right chronic pancreatitic pleural effusion. Computed tomographic examination of the abdomen and chest demonstrated a pancreatic pseudocyst that had extended into the mediastinum. After conventional closed-chest tube thoracotomy drainage failed to empty the pleural space, percutaneous abdominal pseudocyst drainage was instituted using computed tomographic guidance. The pleural effusion cleared promptly, and the pancreatic pseudocyst resolved gradually over seven weeks. Following termination of pseudocyst drainage, the patient has remained well for over two years with no recurrence of pancreatitis, pseudocyst, or pleural effusion. In contrast, three earlier patients with a chronic pancreatitic effusion managed conventionally had a complicated hospital course and required surgical intervention; two had recurrent pancreatitis following hospital discharge. Percutaneous catheter placement was unsuccessful in one of these three and, in retrospect, was infeasible in the other two. It is recommended that thoracoabdominal computed tomography be performed in all patients with a chronic pancreatitic pleural effusion, and that percutaneous abdominal catheter drainage be attempted in all patients with an accessible pancreatic or mediastinal pseudocyst. Such treatment may relieve respiratory insufficiency, minimize the risk of empyema or fibrothorax, and may promote pseudocyst closure without the need for surgery.
Because of rapid technologic advances, clearly defined clinical indications, and widespread availability, computed tomography of the lungs, pleura, and chest wall has become increasingly important in the imaging and subsequent management of numerous thoracic disorders. This article describes the current indications, common findings, and potential controversies in CT of the lung, pleura, and chest wall.
Computed tomographic scans of the chest were utilized to stage mediastinal disease in 148 instances of bronchogenic carcinoma considered for resection in 146 patients. Nodes greater than or equal to 1.5 cm in diameter were interpreted as abnormal. All nodes positive by computed tomography were evaluated by mediastinoscopy, anterior mediastinotomy, or thoracotomy. All patients with negative computed tomographic findings underwent thoracotomy without prior surgical staging. Patients undergoing thoracotomy were divided into two groups. In Group I (first 51 instances) routine mediastinal exploration was not carried out; in Group II (last 97 instances) the mediastinum was explored in every patient and nodes were submitted for histopathological study. The computed tomographic and pathological findings on the mediastinal lymph nodes were compared. The sensitivity, specificity, and accuracy of computed tomography in Group I were 88%, 94%, and 92%, respectively, in Group II 75%, 89%, and 86%, and in the combined group, 80%, 91%, and 88%. The positive predictive index in Group I, Group II, and in the combined group was 88%, 69%, and 77%, respectively. It was lower for central than peripheral lesions (74% versus 88%) and was lowest for lesions in the right upper and left lower lobes. The negative predictive index was greater than 90% for all groups and all tumor sites except the left upper lobe, where it was 89%. Ten patients had false-positive scans, three with old mediastinitis and seven with postobstructive pneumonia; nine of the 10 had central lesions, and seven of these lesions were located in the right upper lobe. Eight patients had false-negative scans; six had para-aortic, subaortic, or postsubcarinal nodes. These nodes would not have been accessible to mediastinoscopy. In only one patient with false-negative nodes would routine mediastinoscopy have prevented thoracotomy and resection. Computed tomographic staging of mediastinal disease is indicated for all patients with lung cancer in whom operation is contemplated. Computed tomography directs the most appropriate staging procedure for patients with positive findings and obviates invasive staging for patients with negative findings.
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