Dewey J. Conces

Spiral CT evaluation of the trachea and bronchi.

Objective We report two cases in which spiral CT with three-dimensional (3D) reconstruction was used to evaluate abnormalities of the trachea and bronchi. Materials and Methods Two patients with known airway abnormalities, one with a carinal tumor and the other with a postoperative bronchial stenosis, had spiral CT of the chest performed. Images were reconstructed in the coronal plane as well as using a curved planar reformat and shaded surface display. Results Spiral CT with 3D reconstruction provided excellent anatomic definition of the central airway abnormalities. In our two cases the information provided was used in both the clinical assessment and treatment planning of the patients. Conclusion Spiral CT was useful in the evaluation of two patients with central airway abnormalities. Further investigation into applications of spiral CT for the evaluation of the central airways appears warranted.

Imaging the diaphragm and its disorders

Although a radiologic evaluation of the diaphragm is important in many clinical situations, visualization of the diaphragm is difficult because of its thinness, its domed contour, and its contiguity with abdominal soft tissues. Each clinical situation involving the diaphragm presents its own imaging difficulties, and each radiographic technique has advantages and disadvantages. No one modality is best for all situations. Often, several imaging modalities must be used to resolve the clinical question. The particular difficulties in diaphragmatic imaging are (1) distinguishing eventration from paralysis or hernia, (2) distinguishing lipoma from herniated omental fat, and (3) distinguishing unilateral paralysis from weakness and bilateral paralysis from respiratory fatigue. By selecting and applying the appropriate radiographic techniques, the radiologist can serve an essential role in assessing the disorders of the diaphragm.

Imaging of intrathoracic metastases of nonseminomatous germ cell tumors

Radiologic imaging is crucial in the evaluation of intrathoracic metastatic nonseminomatous germ cell tumors. Helical CT is the workhorse of radiologic staging and is sensitive in the detection of parenchymal nodules and mediastinal lymphadenopathy. CT may also demonstrate other less common sites of metastatic disease. Although, currently, no radiologic procedure is effective in distinguishing viable tumor or teratoma from residual fibrosis and necrosis, cross-sectional imaging remains essential in the presurgical evaluation of potential metastatic disease. FDG PET and CT-guided needle biopsy may be useful in select, high-risk patients.

Pediatric digital chest imaging.

The Philips Computed Radiography system performs well with pediatric portable chest radiographs, handling the throughout of a busy intensive care service 24 hours a day. Images are excellent and routinely provide a conventional (unenhanced) image and an edge-enhanced image. Radiation dose is decreased by the lowered frequency of repeat examinations and the ability of the plates to respond to a much lower dose and still provide an adequate image. The high quality and uniform density of serial PCR portable radiographs greatly enhances diagnostic content of the films. Decreased resolution has not been a problem clinically. Image manipulation and electronic transfer to remote viewing stations appear to be helpful and are currently being evaluated further. The PCR system provides a marked improvement in pediatric portable chest radiology.

Esophageal fistula complicating mediastinal histoplasmosis: Response to amphotericin B

A 41-year-old man was admitted for evaluation of hemoptysis, dysphagia, and pleuritic chest pain associated with a mediastinal mass. Esophagography demonstrated a fistula between the mass and the esophagus. Results of histoplasmosis complement fixation serologic testing suggested an active infection. A methenamine silver stain of a lymph node obtained at mediastinoscopy revealed Histoplasmosis capsulatum. The patient was successfully treated with amphotericin B. This is believed to be the first reported case of an esophageal fistula as a complication of mediastinal histoplasmosis successfully treated with amphotericin B.

Painful transthoracic needle biopsy: a sign of neurogenic tumor.

Neurogenic tumors most commonly appear initially as posterior mediastinal masses. These tumors, however, may occur in other intrathoracic locations and present a diagnostic challenge. In such cases transthoracic fine-needle aspiration (FNA) often is used to make a definitive diagnosis. This procedure usually does not result in severe pain. We report two patients who experienced severe pain during transthoracic FNA of neurogenic tumors. We believe that severe pain associated with transthoracic needle biopsy of an intrathoracic mass is suggestive of a neurogenic tumor. When pain accompanies this procedure, a cytopathologist should be notified so that specific immunostaining techniques can be performed to confirm the diagnosis.

Noninfectious and nonmalignant pulmonary disease in AIDS.

Infectious and malignant disease processes are responsible for most pulmonary abnormalities seen in patients with acquired immunodeficiency syndrome (AIDS). There are, however, a number of noninfectious and nonmalignant disorders that can involve the lungs of these individuals. Nonspecific interstitial pneumonitis and lymphocytic interstitial pneumonitis may mimic opportunistic infections both clinically and radiographically. Congestive cardiomyopathy may develop and result in pulmonary edema. Other disorders such as alveolar proteinosis and desquamative interstitial pneumonitis are also reported. Bronchoalveolar lavage, a diagnostic technique frequently employed in AIDS patients, may itself produce pulmonary opacities. Knowledge of these disorders may aid in the evaluation of AIDS patients for whom an infectious etiology for pulmonary abnormalities cannot be found.

The value of opacification of the esophagus by low density barium paste in computer tomography of the thorax.

A 3% barium paste was used in the CT evaluation of 100 normal and 60 abnormal esophagi. Successful esophageal opacification occurred in 87% of both groups. In cases of extrinsic disease involving the esophagus the contrast medium administration assisted in separating the esophagus from adjacent mass lesions, as well as identifying displacement, compression, proximal dilatation, and length of involvement. In cases of esophageal carcinoma the contrast medium administration assisted in the measurement of wall thickness and length of the lesion as well as identification of the site of origin of the tumor. The contrast medium was simple to administer, well tolerated, and did not produce scan artifacts.

Diagnosis of Lung Cancer: Perspective of a Pulmonary Radiologist

The solitary pulmonary nodule (SPN), a common incidental finding on routine radiographic imaging, is defined as a focal, oval, or round area of increased density in the lung that is less than 3 cm in diameter. In fact, there are an estimated 150,000 SPNs detected annually in the United States [1], and a single pulmonary nodule is detected on up to 0.2% of all chest radiographs [2]. The majority of SPNs are due to benign diseases such as hamartomas or granulomas [3,4]. A significant number, however, are malignant (up to 40% of single pulmonary nodules) [5]. Because the care of lung cancer is dependent on diagnosis at an early stage, it is important to evaluate nodules as expeditiously as possible. The evaluation of an SPN involves the use of a variety of modalities, because up to 25% to 39% of malignant nodules are inaccurately classified as benign after radiologic assessment of size, margin, contour, and internal characteristics [6]. In this article, the authors address the assessment of SPN radiographically for benign or malignant characteristics.

Surgical management of pulmonary carcinoma secondary to recurrent respiratory papillomatosis.

Recurrent respiratory papillomatosis is a rare, but acknowledged, risk factor for pulmonary squamous cell carcinoma. Although previous reports suggest a poor prognosis for lung cancer associated with papillomatosis, we have successfully treated 1 such patient, who presented with three synchronous pulmonary malignancies, using parenchyma-sparing resection techniques.