Glen A. Lillington

Management of solitary pulmonary nodules

The solitary pulmonary nodule (SPN), a single intrapulmonary spherical lesion that is fairly well circumscribed, is a common clinical problem. About half of SPNs seen in clinical practice are malignant, usually bronchogenic carcinomas. Some nodules are primary tumors of other kinds or metastatic. Virtually all benign SPNs are tuberculous or fungal granulomas. The standard management of the SPN of unknown cause is prompt surgical removal unless benignity is established by prior chest roentgenograms showing that the nodule has been stable (i.e., showing no growth) for 2 years or by the presence of a benign pattern of calcification. Less universally accepted criteria for benignity include (1) transthoracic needle aspiration biopsy (TNAB) showing a specific benign process, and (2) patients age under 30 to 35 years. Bronchoscopy has a low diagnostic yield, particularly for benign nodules. SPNs usually grow at constant rates, expressed as the doubling time (DT). A nodule with a DT between 20 and 400 days is usually malignant. Benign nodules usually have a DT greater than 400 days. The prospective determination of DT by serial chest roentgenograms (the wait and watch strategy) is widely criticized but has clinical utility in special circumstances, particularly if the likelihood of malignancy is low and/or the anticipated surgical mortality is high. The presence and pattern of calcification are best shown by high-resolution thin-section computed tomography (CT). Diffuse, laminated, central or popcorn patterns of calcification indicate benignity. An eccentric calcium deposit or a stippled pattern does not rule out malignancy. CT densitometry will often show occult calcification in nodules that show no direct visual evidence of calcium deposition. The characteristics of the edge of the nodule correlate with the likelihood of malignancy. Nodules with irregular or spiculated margins are almost always malignant. The probability that the nodule is malignant (pCA) is related to the age of the patient, the diameter of the nodule, the amount of tobacco smoke inhalation, the overall prevalence of malignancy in SPNs, the nature of the edge of the lesion, and the presence or absence of occult calcification. It is possible by Bayesian techniques to combine these factors to calculate a more precise and comprehensive prediction of pCA in any given nodule. The 5-year survival after nodule resection depends on the size of the nodule at the time of surgery; it may be as high as 80% with nodules that are 1 cm in diameter. Lymph node involvement is uncommon with small tumors, and many authorities question the need for CT staging in such cases.(ABSTRACT TRUNCATED AT 400 WORDS)

Alcohol and the Respiratory Tract

Possible mechanisms by which alcohol may adversely affect the respiratory system are considered. Alcohol ingestion impairs glottic reflexes, and alcoholics are predisposed to pneumonias and lung abscesses from aspiration of oropharyngeal bacteria. Alcohol intoxication also increases the frequency of sleep apnea and may result in respiratory failure from oversedation.

Pulmonary risk factors in surgery.

The altered pattern of ventilation and the diminution in lung vol-mes after general anesthesia and surgery predispose the postoperative patient to develop serious pulmonary complications. Many additional risk factors are readily identifiable and often reversible. Careful attention to these allows the institution of therapy which can greatly diminish the incidence of serious postoperative pulmonary complications. In patients for whom thoracic surgery is contemplated, the identification and quantification of risk factor helps identify those individuals in whom surgical risk is prohibitively great, or who will not likely tolerate lung resections of major or minor extent.

Low dose methotrexate pneumonitis in rheumatoid arthritis.

The antimetabolite drug methotrexate has recently been used in the treatment of rheumatoid arthritis refractory to conventional antirheumatic drugs.1-3 The doses of methotrexate used in such cases are much lower than those used in the treatment of malignancy or skin disorders. Instances of diffuse interstitial pneumonitis apparently related to the use of methotrexate in such low doses are uncommon.45 We report a case in which diffuse pneumonitis developed after low weekly and low accumulative doses of methorexate and which showed spontaneous resolution after the drug had been discontinued.

Serodiagnosis of Wegener's granulomatosis: pathobiologic and clinical implications.

Wegeners granulomatosis (WG) is a rather specific disease process, characterized by necrotizing granulomatous lesions of the upper and lower rexad spiratory tract, necrotizing and crescentic glomerulonephritis, and small-vessel vasculitis. The disease is relatively uncommon and manifests with considerable variability in tempo and extent of organ involvement, from limited forms with minor renal abnormalities to fulminating alveoxad lar hemorrhage and necrotizing glomerulonephritis. The differential diagnosis includes other vasculitides and granulomatoses, such as classic polyarteritis nodosa, microscopic and hypersensitivity vasculitides, Goodpastures syndrome, the allergic vasculitis of Churg and Strauss, necrotizxad ing sarcoid, and lymphomatoid granulomatosis. For the diagnosis of WG, histologic examination of affected tissue is usually necessary. Pathologically, the pulmonary lesions of WG consist of nodular infiltrates of abscesslike colxad lections of polymorphonuclear cells (PMN) surxad rounded by varied numbers of lymphocytes, plasma cells, and palisading histiocytes, fibroblasts, and giant cells that overlie a destructive vasculitis. Other features include microabscesses within and around vessels, intravascular lysis of PMN in conjunction with endothelial necrosis, and a PMN capillaritis of microvessels. The renal lesions of focal glomerulitis are less specific. The recent demonstrations that PMN anticytoplasmic antibodies (ACPA) are present in many cases of WG, as highlighted by Specks and colxad leagues in this issue of the Proceedings (pages 28 to 36), provide possible insights into the pathogenesis of WG and a potentially useful diagxad nostic test. In this editorial, we consider some df the pathobiologic and clinical implications of measurements of these antibodies.