Jeffrey A. Miller

Asbestos plaques in a typical Veteran's hospital population.

Previous authors have described several pleural abnormalities on chest radiology as being pathognomonic for asbestos exposure. We sought to determine the percentage of admissions and outpatients at a typical Veterans Affairs hospital with these findings, and researched medical records to verify the frequency at which patients having positive radiographs were suspected either by clinical/occupational history or radiologically to have had prior significant exposure to asbestos. Radiographs of 1,212 consecutive patients were evaluated by a certified B reader, and the medical records as well as previous radiology reports of all positive patients were reviewed. Twenty-eight (2.3%t) of the radiographs had pleural abnormalities consistent with asbestos exposure, with the patients, all male, ranging in age from 50 to 98 years (mean 75.6). Radiology reports described pleural plaques in only 12 of the 21 (57%) cases with prior exams available; in only seven (33%) was an asbestos etiology considered by the interpreting radiologist. The plaques were misdiagnosed in four instances as being indicative of other, unrelated pathology. A history of known dust exposure was expressed by only five patients (18%). Eleven described working in occupations now known to have a high incidence of exposure, but neither patient nor examining physician expressed consideration of dust inhalation. In conclusion, we have found that a significant percentage of patients in certain subpopulations show radiographic evidence of asbestos exposure that may be a harbinger of related pathology. Unfortunately, because of a low index of suspicion, thorough environmental histories are often deferred, many radiographic changes are either not recognized or are misdiagnosed, and these patients are not followed with the stringent protocols they deserve.

Granular cell tumor of the breast: Definitive diagnosis by sonographically guided percutaneous biopsy

Granular cell tumor is a rare, benign breast neoplasm that may mimic malignancy both clinically and radiologically. We present 2 cases in which granular cell tumor was initially diagnosed by sonographically guided percutaneous biopsies. Sonographic guidance confirmed needle placement during multiple passes and thereby decreased the likelihood of sampling error. A diagnosis of granular cell tumor prior to definitive resection enables optimal therapeutic planning and allows radical surgery to be avoided.

Comparison of x-ray films and low-dose computed tomographic scans: demonstration of asbestos-related changes in 2760 nuclear weapons workers screened for lung cancer.

Objective: Increased availability and technical improvements of computed tomographic (CT) scanning encourages its use for detecting asbestos-related disease. We compared low-dose scans and x-ray films in 2760 workers potentially exposed to asbestos, to assess their ability to detect interstitial lung disease (ILD) and pleural thickening (PT). Methods: A total of 2760 nuclear workers received radiography and CT scanning (2006 to 2009). X-ray films were read by a B reader for ILD and PT and CT scans by a thoracic radiologist, using a protocol for nodules, ILD, and PT. Results: Of the 2760 workers, 271 showed circumscribed PT on CT scans, and 73 on x-ray films, 54 (74%) of which were confirmed on CT scans; 76 showed ILD on CT scans, and 15 on x-ray film, 10 (67%) of which were confirmed on CT scans. Conclusions: Radiographic readings of PT and ILD were generally confirmed on CT scans. Computed tomographic scans detected three to five times more cases; the majority were minor.

Pancreaticopleural fistula : an unusual cause of persistent unilateral pleural effusion

There are a myriad of causes of a large persistent pleural effusion. Pancreaticopleural fistula is a rare entity seldomly included in the above differential. As it usually presents with thoracic rather than abdominal symptoms, a combination of imaging modalities, including chest radiography (CXR), computerized tomography (CT) and endoscopic retrograde cholangiopancreatography (ERCP) is essential in obtaining the diagnosis.

Transient Mediastinal Enlargement: An Unusual Computed Tomographic Manifestation of Pulmonary Venous Hypertension and Congestive Heart Failure

We describe a case of diffuse superior and middle mediastinal enlargement of soft tissue attenuation noted on helical computed tomography (CT) of a patient with clinical and radiographic findings of congestive heart failure (CHF). Upon treatment and improvement of his pulmonary venous hypertension, a repeat CT scan revealed resolution of the mediastinal abnormalities. We, therefore, advocate a search for primary CT signs of CHF in patients with findings of widespread mediastinal distension. If present, repeat CT scanning after resolution of the cardiac condition should be performed before further intervention for the mediastinal abnormality is attempted.

Pleural effusions associated with acute pancreatitis: Incidence and appearance based on computed tomography

Recognition of pleural effusions in acute pancreatitis is important since it carries prognostic implications. This study evaluates the incidence and characteristics of pleural effusions on computed tomography (CT) of patients with mainly an alcohol ingestion etiology of acute pancreatitis. A review of medical records and abdominal CT scans in 50 patients with clinical and laboratory evidence of acute pancreatitis was carried out. All patients were referred for abdominal CT scanning based on an initial clinical presentation consistent with acute pancreatitis and had confirmatory elevation of the corresponding serum enzyme levels. The presence, laterality, and size of any pleural effusions were recorded from the initial sections through the lung bases.Based on a review of medical records, 36 patients (72%) had an alcohol-related etiology of acute pancreatitis.Overall, 10 patients (20%) with acute pancreatitis had pleural effusions on abdominal CT imaging. Five of the effusions were bilateral, three were unilateral right sided, and two were unilateral left sided. Nine of the effusions were small (<1 cm in maximal height) or medium (1–2 cm) in size.Small and medium-sized pleural effusions are not uncommon in acute pancreatitis. The higher incidence in this study compared to that in earlier reports likely represents the increased sensitivity of cross-sectional imaging for small amounts of pleural fluid. The absence of left-sided effusion predominance in our study group is contrary to much of the earlier literature and may reflect demographic factors, such as etiology and previous history of pancreatitis, although statistical variability must also be considered.

Significance of backboard artifacts on portable trauma series chest radiographs

Purpose: To evaluate the degree to which the artifacts created by the radio-opaque components of a backboard obscure the findings on the initial trauma series chest radiograph (BBCXR). Methods: We reviewed 40 consecutive trauma victims admitted to our level I trauma center over a 3-month period who underwent a follow-up portable supine chest radiograph (PCXR) off the backboard no longer than 1 h after the initial trauma BBCXR. The original interpretation of the BBCXR was compared to the reading of the PCXR as well as to a retrospective analysis of the BBCXR performed by two radiologists blinded as to the findings on the original report. Results: The initial interpretation of the BBCXR failed to identify abnormalities reported in the follow-up PCXR of 10 individuals (25 %), most frequently bone fractures, misplaced hardware, and pleural effusions. Of these missed abnormalities, 80 % were identified retrospectively. Conversely, the initial reading of the BBCXR described a widened mediastinum in five cases, right upper lobe opacities in two, and cardiomegaly in one. Of these eight reported findings, only five (63 %) – the cardiomegaly and four of the mediastinal abnormalities – were also reported upon retrospective analysis, while the PCXR taken with the patient off the backboard confirmed widened mediastinum in only three cases. Conclusions: The initial, often hurried reading of a portable chest radiograph taken on a backboard as part of a trauma series often misses significant pathology, most of which can be detected upon more thorough examination of the original film. The backboard also tends to magnify mediastinal structures more than routine PCXR. Therefore, we advocate a more cautious analysis of the original BBCXR and routine utilization of a follow-up PCXR to confirm mediastinal abnormalities.

Thoracic computed tomography in victims of blunt trauma: changes in utilization after the introduction of helical technology

Purpose: In blunt trauma, CT of the thorax is often performed because of the limitations of plain film chest radiography in accurately depicting injuries to the thoracic aorta. The advent of helical CT has allowed the entire chest to be imaged more expeditiously. We will evaluate the extent to which this ability to rapidly obtain additional images of the thorax has increased the utilization of chest CT in blunt trauma. Methods: The radiologic records of all victims of blunt trauma who underwent total body CT (TBCT), which included abdomen, pelvis, and chest images, in the 10 months before and 10 months after our institution acquired helical CT (HCT), were retrospectively evaluated. Results: In the 10 months before we obtained HCT, 520 conventional CT of the abdomen and pelvis were completed, of which only 11 (2.1 %) included images of the full thorax. After HCT was instituted, 684 abdomen and pelvis CT were performed, of which 59 (8.6 %) were ordered with the entire chest. Of the 11 conventional TBCT, 6 (55 %) showed findings in the chest; in 2 of these cases (18 %) the abnormalities were confined exclusively to the thorax. Similarly, of the 59 helical TBCT, 31 (53 %) depicted traumatic abnormalities in the thorax, and in 23 of these cases (39 %) injuries were only within the chest. In 4 of the latter the injuries were mediastinal hematomas, 1 of which (25 %) was confirmed angiographically to represent an aortic laceration. Conclusion: The speed and ease with which additional images can be obtained by HCT has greatly increased utilization of cross-sectional imaging of the thorax after blunt trauma (approximately four-fold). Over half of these depict traumatic injuries.

Prevalence and significance of thoracic pathology first detected on the lung base images of abdominal computed tomographic scans

The purpose of this study was to examine the prevalence and significance of pathology present on the lung base images of abdominal computed tomographic (ACT) scans, but not apparent on the chest radiographs, in two distinct patient populations. The reports of 853 consecutive ACT scans performed in patients at an urban Veterans Affairs hospital (DVAMC) (mean age = 69 years) and 1152 consecutive inpatient and emergency department ACT scans performed at an inner city level I trauma center (UMDNJ) (mean age = 39 years) were reviewed retrospectively. The original images of all ACT scans for which lung base abnormalities were reported were re-interpreted by two radiologists and compared with findings on chest radiographs taken within 48 hours. The degree of correlation between the two studies was analyzed, and the clinical impact of all findings incidentally imaged on ACT but not apparent on the chest radiograph were assessed.At UMDNJ, 51 ACT reports (4.4%) and at DVAMC, 95 reports (11.1%) described lung base pathology. The most common findings at both institutions were pleural effusions, with 23 and 42 depicted at UMDNJ and DVAMC, respectively. At UMDNJ, the remaining abnormalities included 7 pneumothoraces, 5 infiltrates, 1 bleeding artery, and 1 case of multiple nodules, whereas at DVAMC, the next most frequent lower thoracic pathology findings were asbestos pleural plaques (11 patients), multiple nodules (10 patients), and solitary masses (9 patients). Lung base pathology not visible on chest radiography was present in 25 of 37 cases at UMDNJ (68%) and 38 of 89 cases at DVAMC (43%), of which a total of 19 were relevant to further patient management (30%). Three of the five such clinically relevant discrepancies at UMDNJ were pneumothoraces, and 12 of 14 at DVAMC were malignancies. Overall, 0.4% of ACT scans at UMDNJ and 1.7% at DVAMC revealed previously undetected lesions relevant to patient care (P=0.012). In certain subpopulations, especially elderly patients with known carcinomas and victims of trauma, the lung base images of ACT often present findings that may alter clinical management.

The utility of urgent abdominal computed tomography in the elderly patient

The purpose of this study was to assess the utility of urgent abdominal computed tomography (CT) performed in a nontrauma setting on a predominantly elderly population. We retrospectively reviewed abdominal CT images of 170 patients (average age, 64 years); CT was performed on a “stat” basis to evaluate suspected acute abdominal pathology at a typical urban Veterans’ Affairs hospital. Imaging results were correlated with subsequent clinical intervention.Abdominal CT was most commonly ordered to assess abdominal pain (119 cases, 71%), suspected abdominal abscess (11 cases, 6.5%), suspected leaking abdominal aortic aneurysm (11 cases, 6.5%), and suspected acute pancreatitis (8 cases, 5%). Clinically relevant findings were recorded in 96 abdominal CT cases (56%), only 23 (13.5%) of which depicted acute pathology. This included nine patients with abscesses, four with diverticulitis, two with nonspecific enteric inflammation, and two with cholecystitis. Only 16 patients (9%) required urgent therapy. The most common clinically relevant findings not requiring prompt intervention were cholelithiasis (11 cases), chronic pancreatitis (9 cases), and liver metastases (6 cases). Of 13 patients with abdominal aortic aneurysm diagnosed on abdominal CT, 11 presented with abdominal pain, but none showed signs of rupture. Although, in a predominantly elderly population, urgent abdominal CT often reveals significant chronic disease, it seldom depicts pathology requiring prompt therapy. Therefore, a more focused use of this examination is warranted.