Computed tomography in bronchogenic carcinoma

As was indicated at the beginning of this review, a concensus does not exist regarding many aspects of the use of CT in evaluating bronchogenic carcinoma. When and how CT is used, therefore, becomes a function of the beliefs of the physician caring for the patient. The radiologist must be familiar with this philosophy to be able to advise when CT will be of value. Despite all of the variables considered on the preceding pages, there are some facts. (1) Normal mediastinal lymph nodes may be larger than 1 cm in maximal transverse diameter; the majority are not. (2) An enlarged node (independent of definition) need not harbor metastases. Histologic proof is necessary, especially if this information will preclude surgery. (3) CT less frequently offers usable information in small peripheral cancers. The use of CT in peripheral cancers is very much dependent on the surgeon's philosophy. (4) Important information for patient care is more frequently obtained in patients with central lesions or peripheral lesions associated with abnormal hili or mediastinums. This is also closely related to surgical philosophy. (5) Prediction of either chest wall or mediastinal invasion is treacherous and should only be diagnosed when the findings are certain.

Ductal carcinoma-in-situ of the breast: fine-needle aspiration cytology of 12 cases

Aspiration specimens from 12 patients with histologically documented ductal carcinoma-in-situ (DCIS) of the breast (seven patients) or DCIS with minute foci of stromal invasion (five) were evaluated. Five patients presented with palpable masses, 1.5-4.0 cm, and four patients presented with localized thickening, associated with nipple erosion and discharge in two of them. One patient had nipple inversion, and one patient had bilateral nipple discharge. In one patient, no apparent abnormality of the breast was present. Mammography was either suspicious for or strongly suggestive of carcinoma in 10 patients and negative in two. Aspirates from all patients were composed of fragments of atypical ductal epithelium and numerous single epithelial cells. In nine cases, the smears were hypercellular and similar to aspirates of typical invasive ductal carcinoma. Calcifications were present in six cases. In four of these, associated tumor necrosis was evident. Cytologic features separating DCIS patients from those showing minimal stromal invasion or common types of invasive ductal carcinoma (IDC) were not identified. We conclude that fine-needle aspiration cytology of DCIS is identical to that of IDC. If preoperative radiotherapy or chemotherapy is considered in the management of invasive breast carcinoma, cutting-needle biopsy for confirmation of tumor invasion is necessary.

Angiosarcoma arising in an irradiated breast. A case report and review of the literature

The authors discuss an angiosarcoma that developed in a 50-year-old woman's breast 10 years after she underwent conventional postoperative irradiation with cobalt 60 teletherapy. Although angiosarcoma developing in a lymphedematous arm after radical mastectomy is a well-known phenomenon, and several cases of angiosarcoma are known to have occurred in the chest wall after mastectomy with or without irradiation, only one other case of angiosarcoma in an irradiated breast has been reported. The possible role of therapeutic irradiation in inducing this malignancy is discussed.

Radiation-induced sarcoma of bone: CT findings in 19 cases

We reviewed the CT findings in 19 cases of radiation-induced sarcoma of bone. The latent period before development of the sarcoma ranged from 5 to 50 years (mean, 17 years). In all 19 lesions, a soft-tissue extraosseous component was seen on CT, and 18 of them had associated bone destruction. Expansion of the affected bone and tumor-matrix mineralization each were present in 10 patients, but occurred together in only five patients. Periosteal reaction was seen in five patients, one of whom had an associated fracture. Radiation osteitis could not be identified on CT scans in the affected bone of any of the patients when tumor was present, but it was present in contiguous bone in two patients and had been shown 6 years before tumor became apparent in the affected bone in one other patient. Radiation-induced sarcoma of bone should be considered when bone destruction and an associated soft-tissue mass are shown on CT, or when changes occur in the appearance of previously stable irradiated bone.

MR imaging of malignant pleural mesothelioma

The magnetic resonance (MR) findings in three patients with malignant pleural mesothelioma are described. All patients had a circumferential pleural mass surrounding the lung on the affected side. These tumors had a signal of intermediate intensity on T1-weighted images. The T2-weighted images showed a slight increase in signal intensity of the mass, with focal areas of very high signal intensity due to pleural fluid. Adenopathy was demonstrated by CT and MR in two patients. The extent of the tumor and its effects on adjacent structures were well appreciated on the coronal MR images.

Computed tomography of hepatic oil embolism following lymphangiography

Computed tomographic (CT) findings in two cases of hepatic oil embolism following lymphangiography are described. Both patients had lymphatic obstruction and opacification of the liver due to collateral flow of lymphangiographic contrast. Computed tomography of the liver showed a distinctive branching pattern due to the intrahepatic ethiodol.

The chest radiograph after resection of pulmonary nodules with a neodymium-YAG laser

We studied the chest radiographs of 30 patients (39 thoracotomies) after resection of pulmonary nodules with a neodymium-YAG laser. New "nodules" were often visible in the resected areas. These gradually evolved into linear scars with or without a small, nodular component or disappeared. In 11 of 39 thoracotomies, postresection cavities developed at the site of the lesion. Familiarity with the typical radiographic findings after laser resection and their normal evolution is necessary to avoid confusing these expected findings with residual or recurrent disease or with infection following surgery.

CT of interpectoral lymph nodes

The presence of lymph nodes between the pectoralis major and minor muscles (Rotter's nodes) has been noted in the anatomic and surgical literature. We analyzed the appearance of the interpectoral space and nodes on chest CT scans of 25 patients without known chest wall abnormalities or causes for lymphadenopathy. In some of these cases small structures were detected in the interpectoral fat that could be either vessels or nodes. In addition we studied chest CT scans in six patients with interpectoral adenopathy due to metastases from breast cancer. The nodes were oval soft-tissue densities ranging from 1.5 X 1 cm to 3.5 X 3 cm in diameter.

Pulmonary metastatic disease: radiologic-surgical correlation

Radiologic-surgical correlative studies were performed for new pulmonary parenchymal nodules in 100 lungs of 84 patients with previously treated extrathoracic malignancies. Ten patients with radiographically typical bronchogenic carcinomas were excluded from analysis. Of 237 nodules resected, 173 (73%) were identified with computed tomography (CT) and 64 (27%) were not. Two hundred seven (87%) were of metastatic origin, 21 (9%) were benign, and nine (4%) were bronchogenic carcinomas. Of those nodules seen with CT and not with radiography of the chest, 84% were of metastatic origin. Between patients with carcinoma and those with sarcoma or melanoma, there was little difference in the percentage of nodules found with CT. More resected nodules were metastases in the sarcoma-melanoma group (93%) than in the carcinoma group (77%). New bronchogenic carcinomas and benign lesions were more common in the carcinoma group. Chest radiography disclosed all nodules resected in 44% of cases, whereas CT disclosed 78%. Of 65 nodules detected as solitary nodules with chest radiography, only 35 (54%) proved to be truly solitary, whereas 35 of 44 (80%) detected with CT were truly solitary.

The postlobectomy chest: anatomic considerations

The authors present a systematic review of the changes that occur in pulmonary and extrapulmonary anatomy as the result of lobar collapse or resection. Differences in the changes produced by lobectomy and lobar collapse are noted.

Thymic lesions. Experience with computed tomography in 24 patients

The value of computed tomography in the treatment of 24 patients with thymic lesions was analyzed. These included 21 patients with thymomas, and one each with thymic carcinoid, thymic lymphoma, and thymic cyst. Twelve patients were seen before therapy and 12 after treatment elsewhere. Computed tomography gave additional information in 14 of 24 cases and management was altered in two. The presence or absence of invasion of adjacent structures was predicted in 16 of 17 patients in whom computed tomographic-surgical correlation was available.

Urachal carcinoma: evaluation with computed tomography

The computed tomographic (CT) findings in 7 patients with urachal carcinoma were reviewed. Computed tomography was useful in establishing an initial diagnosis, determining the tumor extent, and visualizing tumor recurrence. The embryology, histology, and clinical course of urachal carcinoma are reviewed.

Primary central nervous system lymphoma: CT and pathologic correlation

CT findings of 15 patients with histologically proven primary central nervous system (CNS) lymphoma were reviewed with pathologic correlation in order to evaluate variable CT patterns. There were a total of 32 lesions. Of the 15 patients studied, seven had acquired immunodeficiency syndrome (AIDS), all diagnosed within the past 3 years. The CT observations of eight non-AIDS patients were consistent with findings reported previously. Most of the lymphomatous lesions were either hyper- or isodense, round or oval masses with homogeneous contrast enhancement and variable surrounding edema. Pathologic examination showed tightly packed preserved lymphoma cells without necrosis. In AIDS patients, rim or ring enhancement of lymphoma, indistinguishable from brain abscess, was frequently seen. Histologic examination consistently showed extensive tumor necrosis with preservation of viable tumor cells at the periphery. A third and infrequent CT pattern was multiple infiltrative nonnodular solid enhancement with extensive edema. Pathologic correlation showed infiltrating viable tumor cells without necrosis. The rim- or ring-enhancing brain lesion seen in AIDS patients can either be an abscess or a primary lymphoma; proper tissue collection is essential for correct diagnosis and appropriate treatment.

Superior vena caval syndrome in primary mediastinal germ cell tumors

Upon examination, nine of 45 patients (20%) with primary mediastinal germ cell tumors were found to have superior vena caval syndrome. All patients were men (average age, 27). Superior vena caval syndrome was found with all mediastinal germ cell tumor cell types except mature teratoma. Primary mediastinal germ cell tumors should be strongly considered in the diagnosis of young men with a mediastinal mass and superior vena caval syndrome.

Patterns of mediastinal metastases in bronchogenic carcinoma

The location and frequency of metastases to the lymph nodes were documented in a review of 200 patients with bronchogenic carcinoma who underwent pulmonary resection and total lymph node resection. No nodal metastases were found in 120 patients (60 percent). Metastases were present in only lobar or hilar nodes (or both) in 32 patients (16 percent), and 34 (17 percent) had metastases in mediastinal nodes as well as in lobar or hilar nodes. Only mediastinal nodal metastases were found in 14 patients (7 percent). Previously described lymphatic pathways can explain the presence of metastases in mediastinal nodes alone. Unexplained findings were the higher prevalence of mediastinal nodal metastases in adenocarcinoma vs squamous cell carcinoma and a much higher frequency of mediastinal metastases without lobar or hilar involvement (or both) in patients with adenocarcinoma compared to those with squamous cell carcinoma.

Appearance of the intact lymphomatous stomach following radiotherapy and chemotherapy

Gastric lymphoma can be treated effectively by a combination of chemotherapy and radiotherapy of the intact stomach; this often eliminates the need for gastrectomy. This article presents 21 patients with gastric lymphoma and compares the radiographic appearance of the intact stomach before and after treatment. There was a variable decrease in lymphomatous involvement of the stomach during the first several months after radiotherapy alone or in combination with chemotherapy. Gastric atrophy with diminished distensibility and constrictive changes was observed, but most remarkable was the appearance of linitis plastica.

Complications of colonic interposition

The roentgenographic and surgical experience with 44 patients treated with colon interpositions was examined. Forty-two of these patients had carcinoma of the esophagus. Staged therapy consisted of mediastinal irradiation, colonic interposition, and total esophagectomy. The more common complications related to luminal patency and conduit integrity. A total of 29.5% developed anastomotic narrowing due to postoperative edema. Anastomotic leaks arose only at the proximal anastomosis and had an incidence rate of 31.8%. Thirty-four percent had fistulous tracts originating in the reconstructed upper gastrointestinal tract. In eighty percent of the patients with leaks or fistulae, their defects healed spontaneously or with simple drainage. Strictures were encountered in 59.1%, and there were 5 instances of colonic graft ischemia. The mortality directly related to surgery was 6.8%. Ischemia, particularly at the cervical anastomosis, is probably the most common cause of complications. Radiographic evaluation is recommended using a single contrast barium examination unless gross extravasation is expected.

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.

Critical evaluation of the gallium-67 scan for surgical patients with lung cancer

Seventy-five patients with lung cancer underwent a gallium scan and thoracotomy with total mediastinal nodal dissection. Evaluation of mediastinal lymph nodes by means of the gallium scan showed a sensitivity of 23 percent (3/13), a specificity of 82 percent (31/38), an accuracy of 67 percent (34/51), a positive predictive valve of 30 percent (3/10), and a negative predictive value of 76 percent (31/41) in those patients whose primary tumors demonstrated uptake of radioactive gallium. The low sensitivity was due to an inability to detect microscopic disease in mediastinal lymph nodes. The specificity was decreased by gallium-67 uptake in enlarged inflamed nodes that contained no metastases. These results do not support the use of the gallium scan in the selection of patients with lung cancer for thoracotomy.

Stages IE and IIE non-Hodgkin's lymphomas of the stomach. Comparison of treatment modalities

Seventy-nine patients with Stages IE and IIE non-Hodgkin's lymphomas of the stomach were treated between 1953 and 1980. The histopathologic classification was as follows: diffuse large cell, 61 (of which 23 were immunoblastic sarcomas [plasmacytoid]); diffuse well-differentiated lymphocytic, 6; diffuse mixed, 1; undifferentiated non-Burkitt's, 1; nodular, 9; and unclassifiable, 1. Thirty-five patients had Stage IE disease and 44 had Stage IIE. Treatment modalities included surgery, radiotherapy, chemotherapy, and combinations thereof. Sixty-six patients had a laparotomy for diagnosis and/or management. Of these, only 42 had a gastrectomy. The stomach was considered to be unresectable in the other 24 patients. There were 5 postoperative deaths among 31 patients who had a laparotomy or gastrectomy at our institution. The overall 5-year actuarial survival was 56%; the disease-free survival was 54%. For patients with Stage IE disease the survival was 76%, and for those with Stage IIE, 42%. Promising results were obtained in 13 patients who were treated on a multimodality program consisting of four cycles of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) plus bleomycin (Bleo), which was alternated with involved field radiotherapy. All 13 patients had no evidence of disease as of this report. Only one patient had a relapse (Waldeyer's ring), and he was salvaged with radiotherapy. Six of these 13 were diagnosed by endoscopic biopsy and did not have a laparotomy, 3 were found to have unresectable disease at laparotomy, and 4 had a resection. Biopsy with the flexible fiberscope and treatment with CHOP-Bleo and radiotherapy can avoid the morbidity and mortality of gastrectomy.

Prophylactic diazepam in prevention of contrast media-associated seizures in glioma patients undergoing cerebral computed tomography

Five milligrams of intravenous diazepam given prior to contrast media injection statistically significantly reduced the incidence of contrast media-associated seizures from 16% to 2% in a prospective, randomized series of glioma patients. Factors related to increased risk of contrast media-associated seizures are (1) prior seizure history due to glioma and/or prior contrast media and (2) prior or concurrent brain antineoplastic therapy. Factors not related to an increased risk of contrast media-associated seizures are (1) contrast media dosage, (2) type or grade of glioma, and (3) computerized tomographic appearance of the glioma. Theories regarding the etiology of contrast media-associated seizures are discussed.