Normal lymph node size in the mediastinum: a retrospective study in two patient groups

Role of EBUS-TBNA in Non-Neoplastic Mediastinal Lymphadenopathy: Review of Literature

Mediastinal lymphadenopathy is a condition in which one or more mediastinal lymph nodes are enlarged for malignant or benign causes, generally more than 10 mm. For a long time, the only way to approach the mediastinum was surgery, while in last decades endoscopic techniques gained their role in neoplastic diseases. At the present time, EBUS is the technique of choice for studying the mediastinum in the suspicion of cancer, while there are not strong indications in guidelines for the study of benign mediastinal lymphadenopathy. We reviewed the literature, looking for evidence of the role of EBUS in the diagnostics of non-neoplastic mediastinal lymphadenopathy, with special regard for granulomatous disease, both infectious and non-infectious. EBUS is a reliable alternative to surgery in non-neoplastic mediastinal lymphadenopathy, even if more evidence is needed for granulomatous diseases other than tuberculosis and sarcoidosis.

Incidental Non-cardiac Findings in Cardiovascular Imaging

Improvements in imaging techniques have led to an expansion in the number of cross-sectional cardiac studies being performed. This means that incidental non-cardiac findings (INCF) identified on cardiac imaging have become an important clinical concern. The majority of INCF are not clinically significant. However, some INCF will require follow-up or changes in management. Differentiating clinically significant from non-significant INCF can be challenging, particularly given the breadth of potential findings and the range of organ systems involved. Following up INCF also has economic implications. Recent changes to the lung nodule follow-up guidelines will reduce the cost of following up incidental lung nodules. In this manuscript, we discuss the common and important INCF which may be identified in cardiovascular imaging and explore potential implications of these findings.

Tuberculous Pericardial Effusion: Features, Tamponade, and Computed Tomography

The clinical features with particular reference to tamponade and mediastinal adenopathy were studied in tuberculous pericardial effusion. Tamponade is a frequent complication and the recognition of tuberculous etiology can be difficult. Involvement of the pericardium is mostly from mediastinal lymph nodes that have not been studied. This was a prospective cohort study. All patients had large effusions, and underwent pericardiocentesis and chest computed tomography. Patients with tuberculosis had specific therapy. Others with viral/idiopathic effusion served as controls for the computed tomography studies. There were 26 patients with tuberculosis: 18 had tamponade on echocardiography. All had symptoms. Fever (n=23) and dyspnea (n=20) were the most frequent presenting symptoms. Pericardial rub was heard in 14, and 3 had enlarged cervical or axillary nodes. Pulmonary tuberculosis was present in 6. Tuberculin skin test measured 17 ±3.3 mm. The biopsy specimen showed a granuloma in 22 of 24. All 26 had mediastinal lymph nodes >10 mm with a mean size of 19.5 ±8.6 mm that disappeared (81%) or regressed (19%) on treatment (p<0.001). Aortopulmonary nodes were most frequently enlarged (65.4%) and hilar the least. Three required pericardiectomy. At follow-up all were doing well. None with viral/idiopathic effusion had lymph node enlargement. Fever, dyspnea, and tamponade were frequent with tuberculosis. The prognosis was good with specific therapy. Mediastinal nodes were enlarged in all and only with tuberculosis and not with viral/idiopathic effusion. Nodes disappeared or regressed with treatment. In the appropriate clinical context, mediastinal lymph node enlargement on chest computed tomography along with a strongly positive skin test results could help in the diagnosis of a tuberculous etiology of pericardial effusion.

Reactive Mediastinal Lympadenopathy in Bronchiectasis Assessed by CT

Mediastinal lymphadenopathy is commonly detected on CT. It is a non-specific finding, but because of its significance in the treatment in lung carcinoma it is important to know with which other disease states it is associated. We present a series of 42 patients in whom CT of the chest was used to confirm a clinical diagnosis of bronchiectasis. The size, number and distribution of mediastinal lymph nodes is documented. Lymph nodes were visible in 81% of patients. Nodes larger than 10 mm, the recognised maximum size for normal nodes in the U. K., were detected in 29%. In the absence of other recognised causes of lymphadenopathy in these patients, these findings confirm “reactive” mediastinal lymph node enlargement in bronchiectasis.

Extra-cardiac findings in cardiovascular magnetic resonance: what the imaging cardiologist needs to know

Cardiovascular magnetic resonance (CMR) is an established non-invasive technique to comprehensively assess cardiovascular structure and function in a variety of acquired and inherited cardiac conditions. A significant amount of the neck, thorax and upper abdomen are imaged at the time of routine clinical CMR, particularly in the initial multi-slice axial and coronal images. The discovery of unsuspected disease at the time of imaging has ethical, financial and medico-legal implications. Extra-cardiac findings at the time of CMR are common, can be important and can change clinical management. Certain patient groups undergoing CMR are at particular risk of important extra-cardiac findings as several of the cardiovascular risk factors for atherosclerosis are also risk factors for malignancy. Furthermore, the presence of certain extra-cardiac findings may contribute to the interpretation of the primary cardiac pathology as some cardiac conditions have multi-systemic extra-cardiac involvement. The aim of this review is to give an overview of the type of extra-cardiac findings that may become apparent on CMR, subdivided by anatomical location. We focus on normal variant anatomy that may mimic disease, common incidental extra-cardiac findings and important imaging signs that help distinguish sinister pathology from benign disease. We also aim to provide a framework to the approach and potential further diagnostic work-up of incidental extra-cardiac findings discovered at the time of CMR. However, it is beyond the scope of this review to discuss and determine the clinical significance of extracardiac findings at CMR.

Study to determine the repeatability of supra-sternal Doppler (ultrasound cardiac output monitor) during general anaesthesia: effects of scan quality, flow volume, and increasing age

BACKGROUND

The ultrasound cardiac output monitor (USCOM) is a continuous wave Doppler system designed to measure cardiac output (CO) non-invasively and intermittently either from the pulmonary or from the aortic valve. USCOM scan quality is critical to obtaining reliable data and during anaesthesia it is said to deteriorate with increasing age. The aim of this study was to investigate the effect of age on supra-sternal USCOM scan repeatability during anaesthesia.

METHODS

We performed a series of 6 USCOM scans in 180 patients of all ages after induction for routine surgery. A 12-point Cattermole (CS) score and 10-point insonation (IS) score were used to evaluate scan quality and ease of insonation. The coefficients of variation (CVs) of USCOM variables [CO, peak velocity, stroke volume index (SVI) and the corrected flow time] were derived from the series of six readings.

RESULTS

In >95% of young patients (age <50 yr), it was easy to obtain a good-quality USCOM scan (CS>8). In these patients, repeatability of serial readings was good with CVs<5% and precision of less than ±10%. In older patients (>50 yr), scan quality and ease of insonation declined, with >25% of patients >60 yr having unreliable USCOM scans (CS<5). In these patients, the CV was >5-10%. In several elderly patients (>65 yr), we failed to locate the USCOM signal. Average scan time increased with age (30 to >60 s). SVI was also strongly correlated with scan quality (R(2)=0.77).

CONCLUSIONS

Increasing age has a significant effect on USCOM scan quality and data reliability.

The role of popliteal lymph nodes in differentiating rheumatoid arthritis from osteoarthritis by using CE 3D FSPGR MR imaging: relationship of the inflamed synovial volume

Objective

We wanted to assess the role of the popliteal lymph nodes for differentiating rheumatoid arthritis (RA) from osteoarthritis (OA), and we also wanted to investigate the relationship between the popliteal lymph nodes and the inflamed synovial volume (ISV) by using contrast enhanced (CE), fat suppressed, three dimensional-fast spoiled gradient echo (3D-FSPGR) MR imaging.

Materials and Methods

Contrast enhanced 3D-FSGPR MR imaging of 94 knees (21 with RA and 73 with OA) was analyzed. A lymph node was defined as being 'observed' if it could be seen in at least two planes of the three orthogonal reformatted planes. The number of observed lymph nodes, the mean of the smallest dimension of each lymph node and the existence of central fatty change were recorded. The OA group was graded according to the ISV calculated by a segmentation method: grade I was < 20 cm³; grade II ranged from 20 cm³ to 40 cm³; and grade III was > 40 cm³. Statistical analysis of the number and the mean size of the popliteal lymph nodes among the four groups (the RA group and the grade I-III OA groups) was performed.

Results

The prevalence of the observed popliteal lymph nodes was significantly different between all the OA groups or between the grade III OA group and the RA group (p < 0.0001, 0.0001, respectively). The popliteal lymph node was observed in 32 out of 73 OA cases, whereas it was visible in all of the 21 RA cases. The number (mean ± standard deviation) of lymph nodes in the grade I OA group, the grade II OA group, the grade III OA group and the RA group was 1.2 ± 0.4, 1.2 ± 0.4, 1.3 ± 0.5, and 2.7 ± 1.1, respectively. The mean size (mean ± standard deviation) of the lymph nodes was 3.8 ± 1.0 mm, 3.6 ± 1.1 mm, 4.1 ± 0.8 mm, and 5.4 ± 1.3 mm, respectively. The incidence of central fatty changes was significantly lower in the RA group than in all the OA groups and the grade III OA group. When differentiating RA from OA, and when the differentiation was confined to the RA group and grade III OA group, respectively, the criteria of the number of lymph nodes, their size, their central fatty change and a combination of all these three criteria showed statistical significance (Az values for the former were 0.869, 0.847, 0.776, and 0.942; Az values for the latter were 0.855, 0.799, 0.712, and 0.916). The number and mean size of the lymph nodes correlated with the ISVs (r = 0.49, p < 0.001; 0.50, 0.001, respectively).

Conclusion

The number, size and central fatty changes in the popliteal lymph nodes observed on the MR images might serve as simple and useful markers in differentiating RA disease from OA disease. These markers would be particular helpful in cases of severe synovial enhancement where the ISVs of both RA and OA overlap. The number and mean size of the lymph nodes also correlated well with the ISV.

Diagnosis of tuberculous aetiology in pericardial effusions

The diagnosis of tuberculous aetiology in pericardial effusions is important since the prognosis is excellent with specific treatment. The clinical features may not be distinctive and the diagnosis could be missed particularly with tamponade. With the spread of HIV infection the incidence has increased. The diagnosis largely depends on histopathology of the pericardial tissue or culture of Mycobacterium tuberculosis from this tissue or fluid, but patients without haemodynamic compromise do not require pericardiocentesis. Histopathology may, however, show non-specific findings in a significant number. This review is an update on the diagnostic difficulties, current research, and criteria for diagnosis.

Cost-minimization analysis of alternative diagnostic approaches in a modeled patient with non-small cell lung cancer and subcarinal lymphadenopathy

OBJECTIVE

To evaluate the costs of alternative diagnostic evaluations of enlarged subcarinal lymph nodes (SLNs) in modeled patients with non-small cell lung cancer (NSCLC).

METHODS

A cost-minimization model was used to compare 5 diagnostic approaches in the evaluation of enlarged SLNs in modeled patients with NSCLC. Values for the test performance characteristics and prevalence of malignancy in patients with SLN were obtained from the medical literature. The target population was adult patients known or suspected to have NSCLC with SLNs with a short axis length of at least 10 mm on thoracic computed tomography (CT).

RESULTS

The lowest-cost diagnostic work-up was by initial evaluation with endoscopic ultrasonography-guided fine-needle aspiration (EUS FNA) biopsy ($11,490 per patient) compared with mediastinoscopy (with biopsy) ($13,658), transbronchial FNA biopsy ($11,963), CT-guided FNA biopsy ($13,027), and positron emission tomography ($12,887). The results were sensitive to rate of SLN metastases and EUS FNA sensitivity. The EUS FNA biopsy remained least costly if the probability of SLN metastases exceeded 24% or EUS FNA sensitivity was higher than 76%. Primary mediastinoscopy was the most economical if not.

CONCLUSIONS

Which testing strategy is least costly for SLN evaluation in a modeled patient with NSCLC may be determined by the pretest probability of nodal metastases. Use of EUS FNA biopsy minimizes the cost of diagnostic evaluation in most cases.

The characteristics and significance of thoracic lymphadenopathy in parapneumonic effusion and empyema

The occurrence of significant mediastinal lymphadenopathy together with pleural effusion or empyema inevitably raises concern about the presence of intrathoracic malignancy or granulomatous disease. Lymph node enlargement may also occur when pneumonia is accompanied by a parapneumonic effusion or empyema. Features that allow "benign" lymph node enlargement to be distinguished from malignant causes have not previously been determined. The present study aims to establish the CT characteristics of enlarged nodes in parapneumonic effusion. The appearances of mediastinal lymph nodes were recorded in 50 consecutive patients with parapneumonic effusion/empyema. 18 (36%) had mediastinal lymphadenopathy (node size greater than 1 cm). The mean number of enlarged nodes was 1.9 (range 1-3) and the mean size was 1.4 cm (2 cm maximum). Seven patients had a single involved site, nine patients two sites and two patients three sites. The right paratracheal area was most commonly involved and the subcarinal area contained the largest nodes. The presence of enlarged nodes did not correlate with biochemical and microbiological stage of pleural infection, length of history, or extent of consolidation. This study shows that mediastinal lymphadenopathy is commonly associated with parapneumonic effusion and that multiple sites may be involved. The degree of enlargement is moderate although lymphadenopathy of greater than 2 cm size should raise the possibility of other pathology.

Magnetic resonance appearance of normal inguinal nodes

AIM

To identify adult inguinal lymph node anatomical subgroups using magnetic resonance imaging (MRI), to derive a normal range for nodal number and size and to describe their morphology.

MATERIALS AND METHODS

Eighty-three oncology patients with low stage pelvic tumours had inguinal lymph node assessment by MRI. Nodes were divided into proximal superficial (PS), distal superficial (DS) and deep inguinal (DI) subgroups, their number counted in two planes, and their transaxial short axis diameter recorded. Consistency of the largest node was recorded for each anatomical subgroup and two vertical distances measured, between the skin surface and the ipsilateral pubis, and between the skin surface and the deepest node.

RESULTS

Transaxial plane maximum nodal number at the three sites was: PS 5, DS 8, DI 3; and in the coronal plane: PS 7, DS 5, DI 3. Nodal size ranges were: PS 3-10 mm (mean 4 mm), DS 3-15 mm (mean 6 mm) and DI3-10 mm (mean 6 mm). There was no correlation between nodal size or number and age or gender. Nodes were usually uniformly solid (PS 44%; DS 37%, DI 45%), or fatty (PS 39%; DS 33%; DI 25%). The range of distances between the skin and deepest lymph node was 2.5-16 cm depending on patient fatness.

CONCLUSION

The mean number of nodes counted in the axial plane was six and in the coronal plane five. A maximum short axis diameter of 15 mm was recorded for inguinal lymph nodes.

Mediastinal lymphadenopathy in cryptogenic fibrosing alveolitis: the effect of steroid therapy on the prevalence of nodal enlargement

PURPOSE

To determine the prevalence of enlarged mediastinal lymph nodes in cryptogenic fibrosing alveolitis (CFA) and to assess whether this frequency was related to steroid administration.

MATERIAL AND METHODS

Retrospective review of chest radiographs and high-resolution computed tomography (CT) of 54 patients with proven cryptogenic fibrosing alveolitis (CFA). Twenty-two of the 54 patients received oral steroids up to 2 months before the time of high-resolution CT examination (group 1); the remaining 32 patients had not taken steroids for at least 6 months before study entry (group 2). The prevalence, distribution, and size of enlarged mediastinal lymph nodes was determined in all groups. The diagnosis of CFA was histologically established in 44 patients. In 10 patients the diagnosis of CFA was based on clinical and high-resolution CT findings.

RESULTS

Mediastinal lymphadenopathy was present in 26 of 54 patients with CFA. The prevalence of enlarged nodes was 14% (three of 22) in patients who had received oral steroids up to 2 months before the time of CT examination, and 71% (23 of 32) in patients that had not taken steroids for at least 6 months before study entry.

CONCLUSION

We conclude that patients with CFA on steroid therapy had a significantly lower prevalence of mediastinal adenopathy (P < 0.001) than patients who had not taken steroids.

Clinical impact of adrenal expansive lesions in bronchial carcinoma

PURPOSE

To estimate the prevalence of adrenal expansive lesions in patients with bronchial carcinoma, and assess the relationships among adrenal masses, TNM classification, and histology of the bronchial carcinoma, and to reveal other signs of inoperability in these patients.

MATERIAL AND METHODS

CT findings of the thorax and upper abdomen in 96 patients with bronchial carcinoma were reviewed. Brain- and upper abdominal metastases, together with TNM classification and histology of the bronchial carcinoma, was recorded. CT was performed with 10-mm slice thickness from the thorax aperture to the renal hilum under i.v. contrast medium injection.

RESULTS

Eight adrenal expansive lesions (1.5-10 cm, mean 4.6 cm) were revealed in 6 of the 96 patients (6.3%). Two of these patients, classified as N0, had metastases in other organs; one had brain metastases and the other liver metastases. The bronchial carcinomas in the remaining 4 patients were classified as N3. Three of the patients had adenocarcinoma, one each of small-cell-, large-cell-, and unclassified bronchial carcinoma. Squamous cell carcinoma was most common in the total patient population, but no patient with adrenal masses showed this histologic type.

CONCLUSION

The finding of adrenal expansive lesions in bronchial carcinoma has little clinical impact, because these patients usually show other signs of inoperability. Hence, the value of upper abdominal CT as a routine examination is questionable.

Mediastinal lymph node enlargement and splenomegaly in primary hypogammaglobulinaemia

The computed tomography (CT) scans of 37 patients with primary hypogammaglobulinaemia were reviewed to determine the frequency of enlarged mediastinal lymph nodes and splenomegaly in this group. None of the 10 X-linked Agammaglobulinaemia (XLA) patients had enlarged nodes and only one had splenomegaly. Eleven of the 27 Common Variable Immunodeficiency (CVID) group had enlarged nodes (41%) and 13 had splenomegaly (48%). There was no significant correlation between the presence of enlarged nodes and splenic enlargement. Twenty-two patients had bronchiectasis but the presence of bronchiectasis did not correlate with the presence of either splenomegaly or lymphadenopathy. Three to 6 years follow-up is available for 36 of the 37 patients and none of this group have developed lymphoma or other malignancy. Enlarged mediastinal nodes and/or splenomegaly are frequently found in patients with CVID and are usually due to a benign, non-neoplastic, process. Mediastinal lymph node enlargement is not a feature of XLA and splenomegaly is unusual in this condition.

Mediastinal lymph node size in an Asian population

There is a high incidence of respiratory tuberculosis in the British population of Indian subcontinent (Asian) ethnic origin. Granulomatous diseases can cause long term lymph node enlargement. Separate computed tomography (CT) criteria for normal nodal size could therefore be necessary when staging thoracic malignancy in Asian patients. The objective of this study was to measure mediastinal lymph node size in an Asian population, and to correlate nodal size with previous tuberculosis. Chest CT scans on all Asian patients over a 5 year period were reviewed and those with pulmonary disease, malignancy or grossly distorted anatomy were excluded. The study group consisted of 48 patients (26 male, 22 female) aged 10-75 years (mean 47 years). All nodes were measured and the site of those greater than 7 mm was recorded using the American Thoracic Society (ATS) lymph node map. 81.3% of patients had nodes less than or equal to 7 mm at all ATS stations, 10.4% had nodes of 8-10 mm and 8.3% had nodes greater than 10 mm. All nodes measuring more than 7 mm were in regions 4R, 10R and 7. Fourteen patients had signs of previous tuberculosis, and in this group 50% had nodes greater than 7 mm as compared with 6% in the group with no signs of previous tuberculosis (p < 0.001, X2 test). Despite these differences only four of the 48 patients (8.3%) had nodes greater than 10 mm, which is in keeping with other general population studies. Thus the generally accepted size criteria for mediastinal lymph node enlargement (greater than 10 mm) can reasonably be applied to all Asian patients when staging lymphoma or bronchogenic carcinoma.

Mediastinal computed tomography in a British Asian population

We describe a retrospective review of all the thoracic computed tomography (CT) scans performed on British Asian patients at New Cross Hospital, Wolverhampton between January 1989 and April 1992. 39 patients were studied. Of 15 patients with active tuberculosis (TB), 14 showed mediastinal lymphadenopathy. In nine of these 15 patients this adenopathy was the only positive imaging finding, as neither lung parenchymal nor pleural abnormalities were detected on CT or plain chest radiograph (CXR). The patterns of node distribution and enhancement following intravenous contrast are described. We conclude that thoracic CT is useful in Asian or other high risk patients in whom active TB is suspected, but who lack definitive microbiological or CXR proof of diagnosis.

Mediastinal lymph node detection with endosonography

Eighty-two persons with chronic abdominal pain, submucosal or extrinsic masses, or achalasia and 20 volunteers without symptoms were prospectively examined with endosonography to assess the incidence and features of mediastinal lymphadenopathy. In 99 persons without malignant disease, 86% were found to have paraesophageal lymph nodes by endosonography. Overall, 352 lymph nodes were found, with a mean of 3.6 +/- 2.8 SD lymph nodes per person (range, 0 to 14 lymph nodes). Increasing age and chronic pancreatitis were found to correlate with a greater number of lymph nodes. Otherwise, clinical features including quantity of tobacco use, height, weight, sex, and race did not correlate with a greater number of lymph nodes as assessed by regression analysis. The mean width and length among the lymph nodes was 4.9 +/- 2.4 mm (range, 1 to 15 mm) and 9.9 +/- 5.2 mm (range, 1 to 30 mm), respectively, with the largest lymph nodes occurring in the peritracheal and peribronchial regions. Of all subjects, 95% had a maximum lymph node width of 10 mm or less, but only 40% had a maximum lymph node length of 10 mm or less. The most common ultrasound features of these lymph nodes included a triangular or crescent-shaped and homogeneous or centrally echogenic pattern. These ultrasound characteristics were distinct from those previously described in malignant lymph nodes. In summary, a high background prevalence of mediastinal lymph nodes exists as detected by endosonography and must be considered when performing esophageal or lung carcinoma staging examinations.(ABSTRACT TRUNCATED AT 250 WORDS)

The American Thoracic Society lymph node map: a CT demonstration

It is now a decade since the American Thoracic Society (ATS) lymph node map was first described. Recently it has been upgraded to include supraclavicular and superior diaphragmatic lymph nodes. By standardising terminology the map aids in the provision of a more valid data base to evaluate diagnostic techniques and therapeutic protocols. Despite these potential benefits the map has failed to gain widespread use amongst European radiologists. This essay illustrates the relationship of the nodal stations to normal anatomy utilizing calcified nodes on CT scans. The ease with which the map can be applied to cross-sectional anatomy is emphasized. It is hoped that the images will act as a teaching aid to promote greater acceptance and use of the ATS map. The relationship of the nodal stations to the new American Joint Classification of disease extent is also outlined.

Enlarged mediastinal lymph nodes in the fibrosing alveolitis of systemic sclerosis

The aim of this study was to determine the prevalence of enlarged mediastinal lymph nodes in systemic sclerosis (SSc) and relate this to the extent of pulmonary disease and disease activity as judged by high resolution computed tomography (HRCT). The HRCT scans of 78 patients with SSc were reviewed. The extent of lung disease and HRCT pattern were analysed and CT scans examined on soft tissue window settings for evidence of mediastinal lymph node enlargement. Sixty six (85%) patients had evidence of lung involvement on CT. Enlarged mediastinal lymph nodes were present in 21 (32%) patients with lung involvement but in only 1 (8%) patient without. The prevalence of enlarged mediastinal nodes increased with more extensive lung involvement on CT (p < 0.025), but correlated poorly with the type of CT appearance and concurrent erythrocyte sedimentation rate. Mediastinal lymph node enlargement occurs frequently in patients with SSc, particularly if lung involvement is extensive.

The prevalence of enlarged mediastinal lymph nodes in asbestos-exposed individuals: a CT study

Patients with cryptogenic fibrosing alveolitis have a higher prevalence of enlarged mediastinal lymph nodes compared with the normal population. To determine whether or not this observation applies to individuals with asbestos-induced pulmonary fibrosis the high resolution computed tomography (CT) scans of 14 patients with definite asbestosis and 11 age-matched cases with benign asbestos-induced pleural disease, but no lung disease, were re-imaged on soft tissue settings. The site, size and number of mediastinal lymph nodes equal to, or greater than, 1.2 cm were recorded. In the asbestosis group 14 out of 14 patients had at least one enlarged lymph node with an average number per individual of four (range 1-10). In the control group two out of 11 patients each had one minimally enlarged lymph node. We conclude that mediastinal lymph node enlargement occurs frequently in asbestosis: awareness of this is important in the investigation of malignant disease in patients with asbestosis.

Esophageal squamous cell carcinoma: MRI evaluation of mediastinum

Thirty-two patients with esophageal spinocellular (squamous cell) carcinoma were studied with superconductive magnet in order to evaluate local and extraluminal extent, as well as mediastinal lymph node spread of the disease. In the absence of adenopathy, the localized tumors were considered susceptible to surgical treatment. All patients were operated on within 21 days. The resectability criteria were correctly evaluated in 75% of cases; sensitivity and specificity were 86 and 67%, respectively. Unsatisfactory results were obtained in the evaluation of mediastinal adenopathies. We conclude that magnetic resonance imaging (MRI) is useful in the preoperative evaluation of resectability criteria in patients with esophageal squamous cell carcinoma.

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.