Computed tomography in evaluation of patients with stage III melanoma

BACKGROUND: Metastatic disease is detected infrequently by computed tomography (CT) in early stage melanoma. The diagnostic yield of routine CT for stage III melanoma is less established, despite extensive use in clinical practice. METHODS: Charts from 347 asymptomatic patients with stage III melanoma were reviewed. Findings suggestive of metastatic melanoma identified by head or body CT, chest radiography, bone scan, or liver function studies were confirmed histologically or by progression of disease. RESULTS: Individual CT scans identified 33/788 (4.2%) instances of metastatic melanoma, with 66/788 (8.4%) false positive studies. No metastases were identified among 104 head CT scans. Chest CT had the highest yield in patients with cervical adenopathy (7/35, 20%), and the lowest yield with groin adenopathy (1/50, 2%). Pelvic CT diagnosed metastases in 7/94 (7.4%) patients with groin adenopathy, but no patients with palpable axillary (n = 76) or cervical (n = 21) nodes. Metastatic melanoma was diagnosed in 11/136 (8.1%) patients having complete body CT imaging (chest, abdomen, and pelvis), including six patients (4.4%) identified by CT alone. CONCLUSIONS: Routine CT in patients with clinical stage III melanoma infrequently identifies metastatic disease. Head CT in the asymptomatic patient, chest CT in patients with groin adenopathy, and pelvic CT in the presence of axillary or cervical adenopathy are not indicated. Selective use of chest CT in patients with cervical adenopathy or pelvic CT in the presence of groin disease may be useful.     

Nodular sarcoidosis of the liver and spleen: analysis of 32 cases

PURPOSE: To describe the computed tomographic (CT) appearance of nodular hepatosplenic sarcoidosis and its association with stage with chest radiography and clinical status. MATERIALS AND METHODS: Thirty-two patients (21 women, 11 men; aged 25-68 years) with nodular hepatosplenic sarcoidosis were evaluated. CT findings were described along with chest radiographic stage, clinical status, and level of angiotensin-converting enzyme (ACE). RESULTS: Nodules were small, multiple, and of low attenuation. Organomegaly was common. Abdominal adenopathy was present in 76% of the patients. Chest radiographs were normal in 25%; 61% had stage 1 or 2 radiographs. Abdominal or systemic symptoms were present in 66%. ACE level was elevated in 10 (91%) of 11 patients tested. No change in chest radiographic stage was noted in 74% of patients with follow-up radiographs. CONCLUSION: Nodular hepatosplenic sarcoidosis is associated with organomegaly, adenopathy, and symptoms. Nodules were not associated with advanced lung disease and did not herald a change in chest radiographic stage. An elevated ACE level may be helpful in diagnosis.     

Electrocardiographic exercises and diagnosis

An analysis was made of the incidence of various intrathoracic abnormalities noted on plain chest radiographs and tomograms in a consecutive series of 300 patients with untreated Hodgkin's disease and nonHodgkin's lymphoma. Those with Hodgkin's disease have a higher incidence of intrathoracic disease at presentation than those with non-Hodgkin's lymphoma (67% vs. 43%). Bulky superior mediastinal lymphadenopathy is the hallmark of Hodgkin's disease. Lung involvement was more common in Hodgkin's disease (11.6% vs. 3.7%) and was always accompanied by mediastinal and/or hilar lymphadenopathy.     

Computed radiography of the chest in patients with paraesophageal varices: diagnostic accuracy and characteristic findings

OBJECTIVE: The purpose of our study was to determine the diagnostic accuracy of computed radiography of the chest in the detection of paraesophageal varices and to describe the characteristic radiographic findings. SUBJECTS AND METHODS: From June 1995 through May 1997, in 100 consecutive patients, portal hypertension was diagnosed through both clinical and radiologic evidence. Computed radiographs of the chest and hepatic helical CT scans of these 100 patients with portal hypertension and 20 control subjects were analyzed by two chest radiologists and one abdominal radiologist, who were not aware of the results of the other study. RESULTS: On CT, paraesophageal varices were seen in 38 (38%) of 100 patients with portal hypertension. Overall, the sensitivity, specificity, and accuracy of chest computed radiography in the detection of paraesophageal varices were 53% (20/38), 90% (74/82), and 78% (94/120), respectively. In the patients with paraesophageal varices, splenomegaly (29/38, 76%), lateral displacement or obliteration of the inferior portion of the azygoesophageal interface (18/38, 47%), obliteration or nodularity of the inferior portion of the descending thoracic aorta interface (9/38, 24%), lateral displacement of the right inferior paraspinal interface (6/38, 16%), lateral displacement of the left inferior paraspinal interface (4/38, 11%), and varices in the left inferior pulmonary ligament (1/38, 3%) were seen on chest computed radiographs. Paraesophageal varices smaller than the diameter of the descending thoracic aorta (usually <2.5 cm) were not detected. CONCLUSION: Although chest computed radiography is only moderately sensitive for paraesophageal varices, the findings are characteristic when well developed, with a limited differential diagnosis. Splenomegaly, whether detected clinically or radiographically, eliminates most other diagnostic possibilities.     

Lymphoma: role of whole-body 2-deoxy-2-[F-18]fluoro-D-glucose (FDG) PET in nodal staging

PURPOSE: To compare 2-deoxy-2-[fluorine-18]fluoro-D-glucose (FDG) positron emission tomography (PET) with computed tomography (CT) in primary nodal staging of malignant lymphoma. MATERIALS AND METHODS: Sixty consecutive patients with untreated, histopathologically proved malignant lymphoma (aged 7-72 years; 33 with non-Hodgkin lymphoma, 27 with Hodgkin disease) underwent FDG PET and contrast material-enhanced CT for nodal staging. Lymph node regions identified at both CT and PET were regarded as actual locations of disease. Discordant results were verified with biopsy or clinical follow-up whenever possible. RESULTS: One hundred sixty of 740 evaluated lymph node regions were identified as diseased at both CT and PET. Of the 25 additional regions seen with PET, seven were true-positive; two, false-positive; and 16, unresolved. CT showed six additional disease manifestations; three were false-positive, and three were unresolved. Staging was changed in the four patients with the seven confirmed additional PET findings: from stage I to II in one patient and from stage II to III in three patients. Staging was changed from stage II to I in one of the three patients with false-positive CT findings. CONCLUSION: FDG PET may be more accurate for detecting nodal lymphoma than incremental CT.     

CT evaluation of the anterior mediastinum: spectrum of disease

Computed tomography (CT) is the study of choice for evaluating disease in the anterior mediastinum. Mediastinal CT is usually performed with intravenously administered contrast material, and spiral CT is the preferred technique for evaluating a mediastinal mass. CT demonstrates thymic hyperplasia and thymic cysts and can help differentiate thymoma and thymic Hodgkin lymphoma. It is also useful in staging Hodgkin lymphoma and non-Hodgkin lymphoma. In thyroid malignancy, CT can depict mediastinal extension and lymphadenopathy; it also allows detection of goiter and ectopic parathyroid glands. Germ cell tumors such as teratoma and seminoma have characteristic appearances at CT. CT can also demonstrate miscellaneous mediastinal masses, such as lymphangioma, hematoma, those due to fibrosing mediastinitis, and pericardial cysts. Adenopathy due to tuberculosis or sarcoidosis is evident at CT, as is osteomyelitis due to a postsurgical abscess. Finally, CT features can suggest the pathologic origin of metastasis in the anterior mediastinum.     

Cutaneous sarcoidosis treated with methotrexate

Sixteen patients with cutaneous sarcoidosis, 15 of whom also had involvement of other organs, were treated with methotrexate (MTX) orally once a week in an open study. The treatment period was from 1 to 72 months (mean 23 months). In 12 patients the skin lesions cleared, and in 3 of 4 patients who had sarcoid uveitis this cleared as well. The chest X-ray of 6 patients showed no corresponding improvement in pulmonary changes or in hilar adenopathy. Ten patients suffered side effects, usually nausea on the day MTX was taken. Two had transiently increased transaminase levels. Treatment was discontinued in 2 patients due to nausea. It is concluded that MTX is a useful alternative to systemically administered glucocorticoids in the treatment of disfiguring cutaneous sarcoidosis and sarcoid uveitis. The effect of MTX on hilar adenopathy and pulmonary sarcoidosis is uncertain.     

Computed tomography in injuries to the respiratory system in children. The correlation with adults

INTRODUCTION: Diagnostic imaging in emergency rooms may be inadequate and delayed, which makes chest traumas in children more severe and difficult to treat. We carried out a retrospective study on adults and children who had survived major chest traumas involving the respiratory tract to assess the differences between the two age groups and the role of emergency CT. MATERIAL AND METHODS: Our series consisted of fourteen children admitted to the emergency department for various accidents. Home accidents prevailed (9/14 = 64.3%). On admission, chest radiography was performed in most cases (11/14 = 78.6%); CT was carried out in 21.4% (3/14 patients). RESULTS: Trauma involved more organs in pediatric patients (11/14 = 78.6%) and lung involvement was always associated with other types of injury, namely contusion (14/14 = 100%), pneumothorax (11/14 = 78.6%), hemothorax (10/14 = 71.4%), tear (4/14 = 28.6%). CT corrected or integrated the radiographic findings of contusion focus in 67% (8/14) and that of pneumothorax in 63.6%; both patterns cannot be demonstrated otherwise. DISCUSSION: Mixed and multiple posterior parenchymal injuries with no rib fractures prevail in young subjects because their bones and ligaments are more elastic, which may lead to trauma underestimation. Tracheobronchial ruptures and pneumomediastinum are much more severe in children than in adults. Chest plain film is often the only diagnostic tool used, despite its major technical and interpretative limitations, also because skull and abdomen are the most investigated regions. Executive limitations are stronger in childhood, increasing the margin of error and the risk of delayed treatment. CT is as cost-effective as radiography and shows even the injuries missed or poorly depicted on conventional images; CT also gives accurate information on damage severity and nature. CONCLUSIONS: Traumatic injuries are more severe in pediatric patients due to their build and to biomechanical, clinical and management factors. Spiral CT should be considered the examination of choice to be performed in the emergency department equipped also for pediatric re-animation.     

Improved retroperitoneal and gastrointestinal sonography using oral contrast agents in a porcine model

PURPOSE: To evaluate use of functional imaging with positron emission tomography (PET) versus computed tomography (CT) for detection of extranodal lymphoma spread. MATERIALS AND METHODS: Eighty-one consecutive and previously untreated patients with malignant non-Hodgkin lymphoma (n = 43) or Hodgkin disease (n = 38) were examined with 2-[fluorine-18]fluoro-2-deoxy-D-glucose (FDG) PET and contrast material-enhanced CT. Concordant findings at both CT and FDG PET were regarded as actual locations of disease; discordant results were resolved on the basis of biopsy or follow-up results when possible. RESULTS: Forty-two lesions were identified at both PET and CT, and 19 were verified with biopsy results. PET demonstrated a further 24 lesions. Verification was possible in 15 of these lesions with biopsy (n = 10), magnetic resonance imaging (n = 1), scintigraphic (n = 1), or follow-up (n = 3) results. In 14 of these 15 lesions, PET findings were confirmed (bone marrow, nine; spleen, three; other, two). Seven lesions not visualized at FDG PET were identified at CT, six of which were verified with biopsy (n = 2) or follow-up (n = 4) results. Five of these six CT findings were found to be erroneous. In 13 patients, PET findings led to changes in tumor staging. CONCLUSION: PET may provide more information about extranodal lymphoma than does incremental CT.     

Sarcoid myopathy: imaging findings

Sarcoidosis is a granulomatous multisystem disorder that may uncommonly involve muscle. Muscular sarcoid may be nodular, atrophic myopathic, or acute myositic. We illustrate a case of the myopathic type of muscular sarcoid that is unusual because the abdominal wall muscles, rather than the extremity muscles, were involved. Muscular involvement by sarcoid should be considered in the differential diagnosis of focal muscle disease, especially in a patient with a known history of sarcoid. The presence of typical bilateral hilar adenopathy on a chest radiograph as well as the presence of abdominal findings (hepatosplenomegaly and retroperitoneal adenopathy) may help establish the diagnosis. Otherwise, sonographically guided biopsy may be necessary for definitive diagnosis.     

Identification of the tumor antigen 90K domains recognized by monoclonal antibodies SP2 and L3 and preparation and characterization of novel anti-90K monoclonal antibodies

PURPOSE: To study the imaging findings in patients with systemic mastocytosis and to correlate the findings with the severity of disease on the basis of an established classification system. Pathologic findings, when available, were correlated with imaging findings. MATERIALS AND METHODS: Computed tomographic (CT) and ultrasound (US) scans and corresponding pathologic findings, when available, were retrospectively reviewed in 27 patients with systemic mastocytosis. RESULTS: Only five (19%) of the patients in our series had normal abdominal CT and/or US examination results. Common abdominal imaging findings associated with systemic mastocytosis were hepatosplenomegaly, retroperitoneal adenopathy, periportal adenopathy, mesenteric adenopathy, thickening of the omentum and the mesentery, and ascites. Less common findings included hepatofugal portal venous flow, Budd-Chiari syndrome, cavernous transformation of the portal vein, ovarian mass, and complications such as chloroma. The findings were more common in patients with category II and those with category III disease. CONCLUSION: Abdominal findings at CT and US are common in patients with systemic mastocytosis. Although the findings in patients with systemic mastocytosis are not specific to the disease, they are useful in directing further studies for diagnostic confirmation and in estimating the extent of systemic involvement.     

Diffuse airway narrowing from carcinoma metastatic to the bronchial submucosa: identification by chest CT

The differential diagnosis of dyspnea in patients with prior malignancy and nondiagnostic chest radiographs is broad. We report a case of breast carcinoma diffusely metastatic to the bronchial submucosa presenting as obstructive airway disease. Chest radiographs failed to suggest metastatic disease as the cause of dyspnea. CT, however, revealed the unusual finding of diffusely thickened and narrowed airways. Carcinoma confined to airway submucosa was identified using bronchial biopsy. We suggest that diffuse airway narrowing from submucosal metastasis can be demonstrated by CT and should be added to the differential diagnosis of dyspnea in cancer patients with nondiagnostic chest radiographs and evidence of airflow obstruction.     

Guidelines for the selective ordering of admission chest radiography in adult obstructive airway disease

STUDY OBJECTIVE: To validate previously developed guidelines for the selective use of chest radiography in adults admitted for exacerbation of obstructive airway disease. DESIGN: Prospective, observational cohort study using criteria developed in a previous retrospective study. PARTICIPANTS: Unselected convenience sample of 128 adults with obstructive airway disease who did not respond to standard emergency department treatment and required admission. SETTING: Municipal hospital ED and inpatient medical service. INTERVENTIONS: Patients were categorized as "complicated" or "uncomplicated" according to previously developed criteria. Management was recorded as altered if the patient's physician answered the question, "Did the chest radiography alter your management of this patient?" affirmatively. RESULTS: Of 27 patients whose management was altered by the chest radiography, 26 were classified as complicated, for a sensitivity of 96% (95% confidence interval [CI], 81, 100). One of 44 admissions classified as uncomplicated had management altered by the chest radiography (negative predictive value, 98%, 95% CI, 88, 100). This chest radiography was later reread as normal. Classification as an uncomplicated patient with obstructive airway disease was strongly associated with either a normal chest radiography or a radiographic finding that was clinically unimportant (P = .0002). CONCLUSION: Patients with acute exacerbation of obstructive airway disease who are otherwise uncomplicated do not benefit from routine admission chest radiography. The use of this simple clinical strategy would safely reduce the number of chest radiographs by about one-third in this and similar patient populations, decreasing both health care costs and exposure to ionizing radiation.     

Pulmonary alveolar proteinosis: high-resolution CT, chest radiographic, and functional correlations

STUDY OBJECTIVE: To determine whether a correlation exists between pulmonary function and both frontal chest radiographs and high-resolution chest CT findings in patients with pulmonary alveolar proteinosis (PAP). DESIGN: Retrospective review of radiographic and clinical data. SETTING: Tertiary referral hospital. PATIENTS: Seven patients with PAP were studied on 25 occasions using high-resolution chest CT (n=21), frontal chest radiographs (n=19), and pulmonary function tests (PFTs) (n=25). MEASUREMENTS AND RESULTS: Visual estimates of the extent, degree, and overall severity of parenchymal abnormalities were determined for plain radiographs and high-resolution chest CT, and were correlated with PFTs. With high-resolution CT, the extent and severity of ground-glass opacity correlated significantly with the presence of a restrictive ventilatory defect, reduced diffusing capacity, and hypoxemia. Chest radiographic findings also correlated significantly with restrictive ventilatory defect, diffusing capacity, and hypoxemia. CONCLUSION: In patients with PAP, although high-resolution CT correlates more closely with pulmonary function, plain radiographs should be sufficient for follow-up.     

Chronic pulmonary nocardiosis with eosinophilia in an immunocompetent host

A 75-year-old man who worked at a horse racing track, had an abnormal shadow on a chest radiography. He had a history of dilated cardiomyopathy and mitral regurgitation but had not had any respiratory or systemic symptoms for two years. Chest radiographs and CT scans showed slowly increasing consolidation with internal areas of low attenuation, and without cavity formation, at the left S8. The erythrocyte sedimentation rate, C-reactive protein level, WBC count, percentage of eosinophils, and IgE level were 35 mm/hr, negative, 8400, 17%, and 3628 IU/ml, respectively. Eosinophils were found in samples of sputum. His immunological status was normal. Transbronchial lung biopsy yielded necrotic tissue, along with gram-positive and irregular acid-fast branching filaments that grew in culture. The microorganism was identified as Nocardia asteroides. Occupational inhalation of soil may have caused his disease.     

Pulmonary tuberculosis in five young infants with nursery exposure: clinical, radiographic and CT findings

Clinical, radiographic (n = 5) and CT findings (n = 4) of five Korean infants ranging in age from 2 to 3 months with confirmed tuberculosis were retrospectively analysed. All of the patients were symptomatic, anergic to tuberculin, and had a positive culture of Mycobacterium tuberculosis in gastric aspirates. The probable source of infection was the hospital in which they were born. CT scans demonstrated hilar and mediastinal lymph node enlargement with central low attenuation and peripheral enhancement in all cases. CT may be useful in diagnosis by demonstrating characteristic adenopathy and disseminated disease in young infants.     

Kaposi sarcoma of the lungs in patients with acquired immunodeficiency syndrome (AIDS). Thoracic radiography and scanning

Twenty-four patients with AIDS presenting with Kaposi's sarcoma of the lung were retrospectively studied to assess the merits of thoracic radiographs and of CT for the diagnosis of this disease. Evidence for Kaposi's sarcoma of the lung was given by a characteristic fiberendoscopic appearance in 10 cases and by the histologic diagnosis in 14 cases. All patients had chest radiographs and 14 patients a concomitant thoracic CT study. Chest radiographs showed perihilar opacities in 18 patients, nodules in 8, mediastinal and/or hilar adenopathies in 2 and pleural effusion in 16. Comparison of the patients who had had thoracic radiographs and a CT scan showed better detection of adenopathies, described in 2 cases on chest radiographs and 7 on CT scans, and of nodules, detected in 5 cases on chest radiographs and 6 on CT scans. In 12 patients with perihilar opacities on thoracic radiographs, CT provided a better view of the peribronchovascular distribution of these opaque areas. In 1 patient, CT showed peribronchovascular thickening while radiographs were normal. In 1 patient, both examinations were normal. This study emphasizes the merits of thoracic radiographs and, even more, of CT for the diagnosis of Kaposi's sarcoma of the lung. Peribronchovascular thickening appears to be a characteristic sign that is well analyzed with computed tomography. Since histological evidence of Kaposi's sarcoma is rarely obtained because of the aggressive nature of biopsies in such patients, CT has an important role for the diagnosis of this condition.     

Cartilaginous disorders of the chest

Cartilaginous disorders of the thorax can arise in the parenchyma, airways, chest wall, and axial skeleton. At radiography, pulmonary hamartoma is characterized by "popcorn" calcification or fat density, either of which is diagnostic. Bronchiectasis is best demonstrated at high-resolution computed tomography (CT) and has a "tramline" or "signet ring" appearance. Tracheopathia osteochondroplastica appears at CT as multiple sessile submucosal nodules with or without calcification along the cartilaginous portion of the trachea. In relapsing polychondritis, the trachea and mainstem bronchi have diffuse or focal thickening with luminal narrowing at radiography. Costochondritis of the chest wall has become more prevalent with increased intravenous drug abuse and may be demonstrated at CT as soft-tissue swelling along with underlying cartilaginous fragmentation and bone destruction. Enchondromas are expansile and may display a calcified cartilaginous matrix at radiography. In osteochondroma, the thickness of the cartilaginous cap determines the likelihood of malignant degeneration. At radiography, chondroblastomas have a round contour, sharp margins, and cortical scalloping, whereas chondrosarcomas are large masses with indistinct margins, cortical breakthrough, and soft-tissue extension. By identifying either a process affecting a cartilage-containing structure or a cartilaginous matrix within a lesion, the chest radiologist may be able to narrow the list of differential diagnostic possibilities substantially.     

Imaging and lung disease: uses and interpretation

Diagnostic imaging has undergone a profound revolution since the first computed tomography (CT) unit was conceived in 1971; CT is now an integral part of daily practice in thoracic radiology, and has reached a relative technological maturity. Magnetic Resonance Imaging (MRI) has been introduced more recently. Technical difficulties still exist and are related to cardiac and respiratory motion. The storage-phosphor-based computed radiography system provides several advantages, including compensation for variations in exposure, but is still under evaluation especially in bedside radiography. Nevertheless careful plain film analysis still remains an important examination, and should be done before special procedures are taken to answer specific questions. Routine chest radiography is still the most frequent method of imaging employed today. Radiographic studies can suggest airway pathology such as atelectasis, endobronchial neoplasia or bronchiectasis, but CT provides a unique strategy for the localization and characterization of bronchial and pulmonary parenchymal disease. The most important role of CT is to determine, localize and characterize patterns within the pulmonary parenchyma, and correctly identify bronchiectasis even when bronchography is equivocal. In lung cancer, imaging has an important role in accurate staging with regard to the correct selection of patients and evaluation of prognosis. CT is one of the major tests used for staging. The staging system now adopted worldwide is based upon AJCC and ATS classification, and has two major components: anatomic extent of the disease (TNM) and cell types. The role of MRI with regard to lung cancer is not precisely determined. MRI can play a complementary role in the staging of lung cancer in cases of superior sulcus tumour; pericardial involvement, tumoral extension in subcarinal region and invasion of the superior vena cava. The radiologic detection of the solitary nodule is a difficult charge for the radiologist; CT provides the precise localization of the nodule and is reliable for analysing radiologic features such as calcification, cavitation, and spiculated borders. The problem remains of the discovery of an incidental benign pulmonary nodule in the patient with an extrathoracic malignancy, and often necessitates percutaneous biopsy under CT guidance. The evaluation of diffuse lung disease lies on pattern recognition. Chest radiography is the initial tool for diagnosis, high resolution CT (HRCT) can provide routine visualization of structures of less than 500 mu. HRCT can be useful in formulating a differential diagnosis with recognition of pattern and distribution of the disease.(ABSTRACT TRUNCATED AT 400 WORDS)