Arterial connections of the lung: the inaugural Keith Jefferson Lecture

Coronary tracheal collaterals after heart-lung transplant

Coronary tracheal collaterals are often seen on annual surveillance coronary angiograms in patients with heart-lung transplants and represent a normal postoperative finding.

Ten anomalous patterns of lung cancer spread with a single explanatory hypothesis

Lung cancer is so strategically sited in relation to the pulmonary veins, left heart, and aorta that its disseminating cells have the greatest possible opportunities for being distributed everywhere. Consequently, because scientists need to be ever watchful for the unexpected, this review points out ten topographical patterns of its metastases which are at variance with expectations from blood-borne dispersal. Since a comparative study of disseminated lung cancer cells returning to the lung through the thoracic duct and of those cells carried to the contralateral lung blood vessels revealed that necrotic cancer cells are commoner in blood than in lymph, it is hypothesized that the anomalous patterns occur because of the degree of lethal exposure experienced by these cells during blood-borne transportation. Therefore, in all probability, if the secrets of Nature hitherto hidden in the blood stream are well decoded, a new era will dawn in oncology.

Lobar emphysema due to anomalous aortic origin of the left pulmonary artery

The unusual case of an infant with aortic origin of the left pulmonary artery is presented. The patient developed a rare complication of lobar emphysema due to bronchial compression from the enlarged right pulmonary artery. Operative anastomosis of the left pulmonary artery to the pulmonary trunk was successful, with subsequent resolution of the lobar emphysema.

The effects of congenital heart disease on the lungs

The alterations in anatomy and physiology, which often accompany congenital heart disease, may have a major impact on the child's lungs. These changes in pulmonary blood flow and ventilation are usually demonstrable on chest radiography and should be recognized as manifestations of the underlying lesion and not mistaken for primary lung disease. Correlation with the clinical history and physical examination are essential for correct interpretation, but radiological findings should be viewed objectively and without bias to provide accurate and valuable information to the treating physician.

The pulmonary circulation: the radiology of adaptation

In this George Simon Lecture, I have tried to present a simplistic yet philosophical approach to the physiological processes of adaptation of circulatory and respiratory function in response to pathophysiological challenge. The objective of the body is to achieve a normal ventilation-perfusion ratio of 1 in order to optimise blood-gas exchange in a wide variety of pathological conditions. It is all a question of the right ingredients (oxygen in atmospheric air and reduced haemoglobin in desaturated blood), in the right copious amounts (100 ml/s), in the right proportion (1:1) and in the right place (alveolar capillary membrane). In order to demonstrate the above concepts, a variety of well known conditions, congenital and acquired, have been discussed in the developing infant lung and the adult mature lung; some primarily cardiovascular, others primarily respiratory; some conditions resulting in permanent and others resulting in temporary and reversible major readjustments of the blood supply to the lung. The emphasis has been to illustrate that simple, unsophisticated radiological techniques may provide a substantial amount of valuable information concerning the remarkable capacity of the pulmonary circulation to adapt to varying physiological or pathological demands in order to conserve our precious respiratory resources. George Simon, like all good doctors, had a tremendous respect for the ability of the body to respond to these challenges. He always emphasised the important basic principles rather than fine minutiae. It is hoped that this lecture in his honour follows these principles which he preached so well.

Postoperative haemopneumothorax arising from an anomalous intercostopulmonary artery

Images

Investigating the small lung: which imaging procedure?

Ventilation and perfusion radionuclide lung scans, using krypton 81m and technetium-99m macroaggregates, were performed together with a variety of other imaging procedures in 18 children aged between 1 week and 13 years in whom radiology had shown a small lung. Radionuclide scans provided an assessment of regional ventilation and perfusion unobtainable by other means, and 4 main categories of disturbed function could be seen in the radiological small lung--namely, absence of ventilation and perfusion, absent perfusion with preserved ventilation, generalised or segmental decreases in ventilation, and perfusion and segmental perfusion defects in areas of decreased ventilation. The clinical history and other imaging procedures, including fluoroscopy and penetrated mediastinal views, enabled a firm diagnosis to be made in each of these 18 patients. In 3 main pulmonary arteries were absent, 2 had lung aplasia, 2 had lobar aplasia, 9 had varying degrees of pulmonary hypoplasia (two with additional sequestrated segments), 1 had lobar emphysema, and 1 had post-infective lung mal-development (MacLeod's syndrome).