CT-pathologic correlation for the alveolar extension of pulmonary adenocarcinoma

Alveolar extension of pulmonary adenocarcinoma is characteristically demonstrated as an area of ground-glass attenuation (GGA). We correlated the CT attenuation value of GGA with the aeration rate of the pathologic specimen measured with a high-resolution image analyzer (OLYMPUS). The CT values of GGA seen in fourteen adeno-carcinomas were measured for helical (slice thickness 10mm) and thin slice CT (slice thickness 1 or 2mm). A positive correlation was found between the CT attenuation value and the aeration rate in the pathologic specimen (Spearman analysis < 1%).     

Farmer''s lung disease in Somerset

A survey of laboratory records was made to assess the value of the precipitin test and isolation methods in the diagnosis of farmer's lung disease and also to determine its prevalence in the farming population of Somerset. A link was established between the clinical diagnosis as written on the form that accompanied the specimen and the actual number of positive laboratory diagnoses made. Fifty (43%) of the clinically diagnosed patients were serologically positive for farmer's lung during a four-year period. If the clinically diagnosed but serologically negative cases of farmer's lung disease are added to this number, a prevalence of about 23 per 1000 of the farming population of Somerset is obtained.     

Exercise limitation in obstructive lung disease

OBJECTIVE: To study the relationship of resting pulmonary function to maximal exercise power output (Wmax) in obstructive lung disease (OLD). SETTING: University Hospital Pulmonary Function Laboratory. SUBJECTS: Twenty-five patients with OLD (6 with asthma and 19 with COPD). METHODS: Measurement of pulmonary lung function, resting arterial blood gases, and maximal symptom-limited exercise on a cycle ergometer. RESULTS AND CONCLUSIONS: In OLD, the only significant contributor to Wmax was the inspiratory capacity (r2 = 0.66; p < 0.001).     

HIV-related interstitial lung disease

The progressive breakdown of the cell-mediated immunity, which characterizes the natural history of HIV infection, invariably leads to the development of miscellaneous opportunistic infections or neoplasms involving a number of tissues, including the respiratory tract. In particular, given the extent and the severity of most infectious complications, it is not surprising that respiratory failure is a common finding in patients who have AIDS-related interstitial lung disease. Extensive knowledge of the sequence of events that starts with HIV infection of CD4+ cells and leads to the development of respiratory complications has been recently achieved. The present understanding of the pathogenesis of AIDS-related interstitial lung disease comes from the evaluation of cell populations retrieved from bronchoalveolar lavage fluid. In particular, the information gained from bronchoalveolar lavage studies led to the realization that HIV strains are present in the respiratory tract of HIV-seropositive subjects at all stages of infection. Furthermore, the characterization of bronchoalveolar lavage fluid cells proved to be central in evaluating the striking local immunologic reactions that can be detected in the lungs of these patients. Bronchoalveolar lavage studies have also demonstrated that local protective mechanisms may cause the shift toward accelerated progression to AIDS and the development of respiratory failure. This reviews briefly examines clinical aspects and cellular patterns of HIV infection in the respiratory tract. We will also consider data showing that HIV infection evokes an inflammatory response, initiated and sustained by cytotoxic T lymphocytes and macrophages and mediated by a number of cytokines that amplify host defenses as well as facilitate the spread of the retrovirus throughout the lower respiratory tract.     

Drug-induced interstitial lung disease

Cationic liposomes provide a means to introduce genes into cells both ex vivo and in vivo. In the past few years their use has been described in several tissues, e.g. lungs, liver, endothelium, brain. In this study we evaluated a commercially available poly-cationic liposome formulation in delivering a reporter gene into cultured myogenic cell lines from mouse and rat, and primary fetal human myoblasts. We also examined the effect of serum on liposome-mediated transfection and designed a new procedure to enhance transfection efficiency, based on the pre-condensation of plasmid DNA with polylysine. Polylysine pre-condensation was particularly effective when transfecting the cells in the presence of serum, a finding that could be significant for in vivo transfections.     

Thoracoscopic lung biopsy or open lung biopsy for interstitial lung disease

Both traditional open lung biopsy through a limited thoracotomy and VATS lung biopsy are effective methods for obtaining parenchymal samples in patients who have respiratory insufficiency and radiographic pulmonary infiltrates. For patients with slowly progressive disease processes, who require an elective biopsy, VATS biopsy is the procedure of choice because of the ability to visualize and sample multiple areas of the lung, and because of the decreased postoperative pain. On the other hand, when patients are critically ill and already on high-level ventilatory support, the VATS method offers no advantages over the standard minimal thoracotomy.     

CD5+ B cells in Graves' disease: correlation with disease activity

In the present paper the distribution of peripheral blood CD5+/CD19+ (CD5+B) and CD5-/CD19+ (CD5-B) B-lymphocytes in Graves' disease (GD) patients is analyzed in order to correlate them with disease activity, interleukin-2 (IL-2) and IL-6 binding to T and B cells as well as with anti-thyrotropin (TSH) receptor antibodies and the thyroid hormone serum levels. The combination of flow cytometry and 3-color immunofluorescence revealed a remarkable increase in the absolute numbers of CD5+ B cells in hyperthyroid-untreated GD patients (218 +/- 137 x 10(6)/l vs. 66 +/- 69 x 10(6)/l in healthy subjects, p < 0.01) that gradually fell to normal values once hyperthyroidism had been controlled by methimazole. However, relative numbers of CD5+ B cells persisted at a relatively stable but increased level in GD patients in long term remission of an average of 3.1 years. This was also confirmed in a follow-up study of a group of 12 newly diagnosed patients during the first 90 days of anti-thyroid drug therapy with methimazole. No correlation was observed between either CD5+ B cells or CD5- B cells and the serum levels of pathogenic anti-TSH receptor antibodies. Increased numbers of CD5+ B cells were related to the increased free thyroxine and total triiodothyronine serum levels. In addition, a strong correlation between both the absolute levels of B cells binding to exogenous IL-2 and IL-6 and the absolute number of CD5+ B cells in hyperthyroid GD patients (LR = 0.798, p < 0.001; LR = 0.569, p < 0.01, respectively) was observed. These results suggest that CD5+ B cells in GD are partly regulated by thyroid hormone serum levels as well as by IL-2 and IL-6 binding to B cells. Nevertheless, they are not involved, at least directly, in the production of anti-TSH receptor antibodies.     

High-resolution CT of epidermoid carcinoma in peripheral lung fields: radiologic-pathologic correlation

We correlated high-resolution CT (HR-CT) images of 30 surgically resected epidermoid carcinomas in peripheral lung fields with pathologic findings. We classified peripheral epidermoid carcinomas into three types based on HR-CT findings. All tumors showed a notch along their margin. Type 1 shows scanty speculations without the convergence of surrounding lung structures. Type 2, which has two subtypes, shows a spiculated border with the convergence of peripheral lung structures. Type 2a has fine irregularities in its border, while type 2b has few fine irregularities. The convergence of peripheral lung structures seen in type 2 carcinoma is caused by the presence of scar tissue within tumors. Speculations corresponded to tumor extension or lymphocytic infiltration, sometimes along pulmonary vessels or interlobular septa, and fine irregularities seen in type 2a corresponded to summation of fibrous thickening of alveolar septa. Nine tumors showed varying-sized cavities, which were caused by the circulatory disturbance and/or central necrosis seen in tumor nests. In conclusion, HR-CT images were well correlated with pathologic findings of the resected specimens; however, some type 2a tumors may mimic adenocarcinoma on HR-CT findings.     

Lung reduction surgery in chronic obstructive lung disease

In the 1960s the promise of the Brantigan lung reduction surgery was shattered when it was shown that the improvement in airway conductance drifted back towards the preoperative value over a period of 12 to 18 months. Since then there has been a marked improvement in our understanding of emphysema, its pathology, and techniques for obtaining images of the lung. In addition, reliable automated cardiopulmonary and physiologic testing, advances in critical care medicine, and new pharmacologic agents have improved patient care. Surgical techniques now allow better control of air leaks and access to anatomic regions not previously accessible. The combination of all of the above makes lung reduction surgery worth re-examining as a palliative procedure for severely symptomatic patients. Clearly, it is not a panacea but can in some cases produce dramatic improvements in symptomatology and quality of life. This article presents the available data describing potential mechanisms of improvement and clinical outcomes following lung reduction surgery. It also outlines areas that need further work, such as patient selection and surgical techniques.     

Single lung transplantation in patients with systemic disease

OBJECTIVE: To report functional results and survival in patients undergoing single lung transplantation (SLT) for pulmonary involvement associated with systemic disease or prior malignancy, criteria traditionally considered contraindications to SLT. DESIGN: Case series. SETTING: The University of Texas Health Science Center at San Antonio. PATIENTS: Nine patients who have undergone SLT for end-stage lung disease: four patients with sarcoidosis; two patients with limited scleroderma; and three patients with prior malignancies (two with prior lymphoma and bleomycin-induced pulmonary fibrosis and one who received two bone marrow transplants for acute lymphocytic leukemia and subsequently developed chemotherapy-induced pulmonary fibrosis). MEASUREMENTS: Pulmonary function testing, exercise oximetry, quantitative ventilation-perfusion lung scanning. Actuarial survival. RESULTS: All patients had marked improvement in pulmonary function, exercise oximetry, and quantitative ventilation perfusion to the SLT. One patient with scleroderma died 90 days postoperatively from Pseudomonas pneumonia with a sepsis syndrome. One patient with sarcoidosis died 150 days postoperatively from disseminated aspergillosis. At autopsy, there was no evidence of recurrent fibrosis or sarcoidosis in the transplanted lungs in either of these two patients. The seven surviving patients have returned to work or school and are conducting all activities of daily living without pulmonary disability. The 1- and 2-year actuarial survival rates in these nine patients is 68.6 percent as compared with the 1- and 2-year actuarial survival rates of 66.3 percent and 55.8 percent in the remainder of our SLT group as a whole (n = 49). Despite pharmacologic immunosuppression, there is no evidence of recurrent malignancy in the 3 patients with prior malignancies. CONCLUSIONS: We conclude that carefully selected patients with end-stage lung involvement related to systemic disease or chemotherapy-induced fibrosis may benefit from SLT.     

Tracheobronchomalacia in preterm infants with chronic lung disease

Tracheobronchomalacia is a treatable cause of persisting ventilatory requirements in the preterm neonate, and warrants a high index of suspicion. Five preterm infants with persisting ventilatory requirements with evidence of tracheobronchomalacia are reported. Four were diagnosed by tracheobronchogram and one by flexible endoscopy. All were successfully managed by continuous positive airway pressure (CPAP) via a tracheostomy. One infant died of unrelated causes. The oldest child in this series at the age of 2 years requires no further ventilatory support. Tracheobronchial anomalies should be considered in all preterm infants with persisting ventilatory requirements.     

Ventilation in the patient with unilateral lung disease

Severe ULD presents a challenge in ventilator management because of the marked asymmetry in the mechanics of the two lungs. The asymmetry may result from significant decreases or increases in the compliance of the involved lung. Traditional ventilator support may fail to produce adequate gas exchange in these situations and has the potential to cause further deterioration. Fortunately, conventional techniques can be safely and effectively applied in the majority of cases without having to resort to less familiar and potentially hazardous forms of support. In those circumstances when conventional ventilation is unsuccessful in restoring adequate gas exchange, lateral positioning and ILV have proved effective at improving and maintaining gas exchange. Controlled trials to guide clinical decision making are lacking. In patients who have processes associated with decreased compliance in the involved lung, lateral positioning may be a simple method of improving gas exchange but is associated with many practical limitations. ILV in these patients is frequently successful when differential PEEP is applied with the higher pressure to the involved lung. In patients in whom the pathology results in distribution of ventilation favoring the involved lung, particularly BPF, ILV can be used to supply adequate support while minimizing flow through the fistula and allowing it to close. The application of these techniques should be undertaken with an understanding of the pathophysiology of the underlying process; the reported experience with these techniques, including indications and successfully applied methods; and the potential problems encountered with their use. Fortunately, these modalities are infrequently required, but they provide a critical means of support when conventional techniques fail.     

Clinical overview of occupational lung disease

The workplace has been a source of lung injury for centuries, yet awareness of the types of injuries has varied over time. Because of distinctive differences among the occupational lung disorders, a continual update of the clinical findings, dose response data, physiologic characteristics, and radiographic findings is needed. The radiologist plays a key role for the evaluation of miners, foundry or factory workers exposed to mineral dusts, and of workers exposed to the "biologic" dusts, infectious agents, cancer causing agents, and chemicals causing interstitial lung diseases. This overview includes a discussion of classification systems, criteria for diagnosis of occupational lung diseases, the pulmonary clinician's evaluation, and important aspects of specific disorders and concludes with a discussion of pulmonary disability determination.     

Pulmonary rehabilitation for chronic lung disease

Its is the task of each medical specialty to develop guidelines for diagnosis and therapies. Examinations done by several specialties should follow a common consensus. A randomized survey at 70 German ENT departments investigated the current position of tracheobronchoscopy and esophagoscopy at each institution. Sixty questionnaires were evaluable. Altogether 8,295 tracheobronchoscopies and 10,404 esophagoscopies were performed. Thirty-six percent of all tracheobronchoscopies and 6% of all esophagoscopies were done with a flexible system. Approximately 58% of all tracheobronchoscopies and 55% of all esophagoscopies were performed for tumor staging. Complications during tracheobronchoscopy occurred in 0.8% of cases and in 0.58% of the esophagoscopies. Using these data an interdisciplinary quality assurance concept was developed for tracheobronchoscopy and esophagoscopy. Current experience has shown that a otolaryngologists in Germany mainly perform rigid tracheobronchoscopy and esophagoscopy. Although endoscopy is mostly done in cases with varied anatomic structures, complications are very rare and comparable to flexible techniques. Greater experience with flexible systems also is to be encouraged in ENT departments.