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Purpose: To determine whether contrast material-enhanced helical computed tomography (CT) of the thorax and upper abdomen changes the tumor stage and management compared with nonenhanced helical CT in patients with newly diagnosed lung cancer., Materials and Methods: During 15 months, any patient in whom lung cancer was strongly suspected or newly diagnosed and who was scheduled for thoracic CT was considered eligible for the study. All patients underwent nonenhanced thoracic helical CT from the lung apices through the adrenal glands and then contrast-enhanced thoracic helical CT from the lung apices through the entire liver. Each study was read independently, and the thoracic radiologic stage was determined. Tissue sampling was performed and the final pathologic stage assigned., Results: Ninety-six patients had a final pathologic diagnosis of lung cancer. There was agreement in stage between the nonenhanced and contrast-enhanced examinations in 92 of the 96 patients. In three patients, the tumor stage at nonehanced CT increased at contrast-enhanced CT, from IA to IIA (n = 1), IIB to IV (n = 1), and IIIB to IV (n = 1). In one patient, the tumor stage decreased from IIIB to IIB. There was no substantial change in management of any patient., Conclusion: The results suggest that contrast-enhanced thoracic CT through the liver for staging lung cancer rarely changes the tumor stage determined with nonenhanced CT through the adrenal glands and does not substantially influence management decisions.

Objective: We describe the chest radiographic and CT findings of pulmonary cholesterol granulomas in patients with pulmonary artery hypertension., Conclusion: Histopathologic evidence of cholesterol granulomas was found in five (25%) of 20 patients with severe pulmonary hypertension. In three of these five patients, the granulomas manifested on chest radiographs and CT as small centrilobular nodules mimicking the appearance of sarcoidosis, bronchiolitis, hypersensitivity pneumonitis, or aspiration.

Thirty-two patients with a known primary malignancy and a symptomatic malignant pleural effusion underwent small-bore-catheter thoracostomy and talc pleurodesis. Twenty-three patients (72%) had a complete response; four (12%), a partial response; and five (16%), no response. Symptoms in all those who responded were clinically improved. Complications included fever in 13 patients (41%) and moderate shortness of breath, chest pain, or both in six (19%). Small-bore-catheter thoracostomy and talc pleurodesis was successful in treating malignant pleural effusions.

We report a unique case of early-phase Takayasu arteritis in which the vessels demonstrated accumulation of [18F]fluorodeoxyglucose (FDG) on PET scanning. This observation suggests the possible use of FDG-PET for the diagnosis of vasculitis. Early diagnosis of Takayasu arteritis may permit early treatment and possibly could prevent progression to the occlusive or pulseless phase of this disease.

The clinical and radiologic manifestations of aspiration are truly protean. The diagnosis is straightforward in patients with known risk factors and new radiographic findings in dependent portions of lung. However, diagnosis is difficult in patients without known risk factors or who present with less specific radiologic findings. Careful history-taking skills and knowledge of the diverse radiologic appearances of aspiration are thus required to facilitate diagnosis and expedite treatment.

Purpose: To compare the accuracy of virtual bronchoscopy (VB) with that of axial computed tomography (CT) in the assessment of bronchial anastomotic complications in lung transplant recipients., Materials and Methods: Twenty-seven bronchial anastomoses in 17 patients were evaluated with helical CT. Axial CT and VB images were evaluated for surface irregularity and the presence, length, and severity of stenosis. Findings were correlated with the results of fiberoptic bronchoscopy (FOB)., Results: There were 12 anastomotic stenoses at FOB. Pooled accuracy (among all four readers) of VB and axial CT for diagnosis of clinically relevant stenosis was 97% and 80%, respectively, at the right bronchial anastomoses and 92% and 75%, respectively, at the left bronchial anastomoses. Pooled accuracy of VB and Axial CT for stenosis length was 72% and 62%, respectively, at the right anastomoses and 81% and 69%, respectively, at the left anastomoses. These differences were not statistically significant. Both the VB and axial CT images showed surface irregularities when anastomotic infection (n = 2) or dehiscence (n = 1) was present but resulted in an overdiagnosis of mucosal abnormalities when anastomoses were normal., Conclusion: VB was slightly more accurate than axial CT for diagnosis of clinically relevant stenoses at bronchial anastomoses in lung transplant recipients. However, because VB is not 100% accurate and has no role in the diagnosis of infection or dehiscence, it probably will not replace FOB for assessment of bronchial anastomotic complications in this population.

We report a case of early phase Takayasu arteritis that predominantly involved the pulmonary arteries and had, along with expected radiographic findings, the unusual pattern of diffuse pulmonary parenchymal lesions on CT. We suggest that this finding may be an additional feature in early phase Takayasu arteritis and need not require investigation for an additional diagnosis.

Aspiration of leguminous vegetables can cause a granulomatous pneumonitis know as lentil aspiration pneumonia that manifest on radiologic studies with small, poorly defined nodular opacities. We report two cases of lentil aspiration pneumonia that manifested with nodules up to 1.0 cm in diameter on radiographs and CT, simulating metastases.

Purpose: Our goal was to determine the spectrum of 2-[18F]fluoro-2-deoxy-D-glucose (FDG) PET findings in patients with round atelectasis (RA)., Method: All patients from 1992 to 1997 with radiologic features of RA and FDG-PET scans were evaluated. There were nine men ranging in age from 52 to 75 years (mean 65 years). All had chest radiographs and CT scans that were correlated with FDG-PET. FDG-PET was considered positive if lesion activity was greater than mediastinal activity and negative if lesion activity was the same as or less than mediastinal activity., Results: Nine patients had 10 lesions, ranging in size from 1.2 to 5.0 cm (mean 3.1 cm). Lesion locations were right lower lobe (n = 5), left lower lobe (n = 4), and lingula (n = 1). All lesions were homogeneous and of soft tissue attenuation on CT. None contained air bronchograms or calcification. All had in-curving vessels and bronchi (comet tail sign), adjacent pleural thickening, and volume loss on CT. All lesions were negative on FDG-PET. Four lesions were percutaneously biopsied and showed chronic inflammation consistent with RA. Two lesions were unchanged on 2 and 3 year follow-up CT and were presumed to be RA as were four other lesions with characteristic CT features and negative FDG-PET., Conclusion: Our experience suggest that RA in not metabolically active on FDG-PET imaging. Thus, FDG-PET scans can play a role in differentiating RA from malignancy when there are few or atypical features of RA on chest radiographs and CT.

Background: Malignant pleural effusions are a common problem for patients with metastatic disease. Most patients are treated with tube thoracostomy and sclerotherapy, although there remains no standard approach. The purpose of this study was to compare the efficacy of bleomycin with doxycycline sclerotherapy for the treatment of malignant pleural effusions using small-bore catheters., Methods: All patients with a symptomatic malignant pleural effusion referred for chest tube drainage and sclerotherapy over a 2-year period were considered eligible. Using image guidance, a 14F self-retaining catheter was inserted into the pleural space and connected to continuous wall suction. When drainage fell below 200 mL/d, patients were randomized to 60 U of bleomycin or 500 mg of doxycycline sclerotherapy. Response at 30 days was determined., Results: One hundred six patients were enrolled in the study. Fifteen men (29%) and 37 women (71%) with a mean age of 57 years received bleomycin sclerotherapy. Twenty-one of the 29 patients (72%) alive and evaluable at 30 days had successful sclerotherapy. Twenty-three men (43%) and 31 women (57%) with a mean age of 61 years received doxycycline sclerotherapy. Twenty-three of the 29 patients (79%) alive and evaluable at 30 days had successful sclerotherapy. There was no significant difference in response rates between doxycycline and bleomycin (p=0.760)., Conclusions: These data continue to support a role for small-bore chest drainage and sclerotherapy, although there was no significant difference in 30-day response rates between doxycycline and bleomycin.

Objective: We conducted a preliminary investigation of virtual bronchoscopy as a guide for transbronchial needle aspiration of hilar or mediastinal lymph nodes to assess the usefulness of this technique., Conclusion: Virtual bronchoscopic images derived from routine helical CT scans were useful for directing transbronchial needle aspiration in a clinical setting. In addition, virtual bronchoscopy may have been responsible for improving the yield of transbronchial needle aspirations done by our bronchoscopists when 22-gauge needles were used.

Objective: The purpose of this study was to determine the spectrum of positron emission tomography (PET) with 18F-fluorodeoxyglucose (FDG) findings in patients who have primary pulmonary carcinoid tumors., Conclusion: On FDG PET imaging, pulmonary carcinoid tumors usually have lower FDG uptake than expected for malignant tumors. Biopsy or close radiologic follow-up is therefore recommended for solitary pulmonary nodules that are clinically suspected of being carcinoid tumors and that do not show increased metabolic activity on FDG PET images.

Pneumothorax is a frequent complication of interventional pulmonary procedures. Percutaneous catheter placement enables safe and effective drainage of pneumothoraces with rapid restoration of vital capacity, oxygenation, and lung reexpansion.

The D-glucose analogue 2-(fluorine-18) fluoro-2-deoxy-D-glucose (FDG) is the most commonly used radionuclide in positron emission tomography (PET) of the thorax. Increased glucose metabolism by malignant cells allows physiologic differentiation between benign and malignant abnormalities. FDG PET is consequently useful in characterizing indeterminate pulmonary nodules and in staging and assessing the response to treatment of lung cancer. FDG PET is accurate in classification of indeterminate pulmonary nodules as benign. Nodules with low FDG uptake are followed up radiographically; nodules with increased FDG uptake should be evaluated with biopsy or resected. In the staging of lung cancer, FDG PET is useful in evaluating local disease and pleural and chest wall involvement. The accuracy of FDG PET in demonstrating intrathoracic metastatic nodal disease is greater than that of computed tomography or magnetic resonance imaging. Whole-body PET is useful in detection of extrathoracic metastases. Conventional imaging often does not allow differentiation of tumor from posttreatment scarring. Increased FDG uptake at the sites of residual radiographic abnormalities is indicative of persistent or recurrent tumor.

Objective: The purpose of this study was to assess the usefulness of positron emission tomography (PET) with 18F-fluorodeoxyglucose (FDG) when differentiating benign from metastatic adrenal masses in patients with bronchogenic carcinoma., Subjects and Methods: For our prospective study, any patient presenting to our institution with pathologically proven bronchogenic carcinoma and an adrenal mass was eligible. Thirty-three adrenal masses (mean size, 3 cm; range, 1-9 cm) in 27 patients were revealed by CT. PET was performed in all 27 patients and interpreted as positive when FDG uptake in the adrenal mass was greater than background activity or negative when FDG uptake in the adrenal mass was equal to or less than background activity. In addition, semiquantitative analysis was performed by computing a standardized uptake ratio. All studies were reviewed independently by three radiologists and then correlated with biopsy and CT findings. Specificity and sensitivity for determining metastatic disease to the adrenal gland were calculated., Results: FDG uptake was positive (abnormally increased) in 25 adrenal masses. Twenty-three (92%) of the 25 masses were metastatic disease. The mean standardized uptake ratio of these was 6.28 (range, 3.22-14.41). The remaining two masses (8%) that had positive FDG uptake showed no tumor at percutaneous biopsy. The standardized uptake ratio values for these two masses were 3.0 and 3.7. FDG uptake was negative (normal) in eight adrenal masses. All these lesions were benign as proven by biopsy (n = 2) and CT attenuation values of less than 10 H (n = 6). The mean standardized uptake ratio value for these eight lesions classified as benign was 1.77 (range, 0.93-3.70). The sensitivity for detecting metastatic disease was 100%, and the specificity was 80%., Conclusion: PET with FDG is an accurate, noninvasive way to differentiate benign from metastatic adrenal masses in patients with bronchogenic carcinoma.

Purpose: To determine the computed tomographic (CT) appearance of telescoping bronchial anastomoses., Materials and Methods: CT scans obtained in 36 adult patients with 54 telescoping anastomoses (30 right bronchus, 24 left bronchus) were retrospectively reviewed. Seventeen scans were obtained with 10-mm collimation, one with 5-mm collimation, and 18 with 3-mm collimation. Multiplanar volume reconstruction images were retrospectively generated in 19 patients. CT findings were correlated with fiberoptic bronchoscopic findings and clinical records., Results: Smooth, spherical air collections caused by diverticula of redundant mucosa were seen at the inferior or medial aspect of 22 anastomoses (41%). Endoluminal flaps and linear air collections caused by separation of the invaginated bronchus from the recipient bronchus were seen in 16 anastomoses (30%). Flaps and linear air collections were seen only at the anterior, superior, or inferior aspects of the anastomosis. Flaps and diverticula were more common at right anastomoses than at left anastomoses. No patient with an endoluminal flap or diverticulum at CT had dehiscence at bronchoscopy. Irregular air collections or posterior wall defects were suggestive of dehiscence at four anastomoses (7%). Dehiscence was confirmed bronchoscopically at two of these four anastomoses., Conclusion: Endoluminal flaps and linear or spherical air collections can be a normal feature of the telescoping anastomosis and should not necessarily be interpreted as dehiscence.

Objective: The objective of this study was to evaluate the incidence and significance of pneumothorax after small-bore chest tube placement for symptomatic malignant pleural effusions., Subjects and Methods: Over a 2-year period, 90 patients with a known primary malignant tumor and symptomatic pleural effusion were referred to the radiology service at Duke University Medical Center. All patients underwent placement of a small-bore chest tube with fluid drainage in preparation for intrapleural sclerotherapy. Two of these patients were excluded because of coexisting empyema (n=1) and thoracentesis (n=1). The remaining 88 patients (30 men and 58 women; 26-86 years old [mean, 60 years old], who had 90 chest tubes placed, formed our study group. The incidence, duration, and clinical significance of their pneumothoraces and the amount of pleural effusion drained were recorded., Results: Among the 88 patients with 90 chest tubes, 27 patients with 28 chest tubes (31%) were found to have pneumothorax after the procedure. For 23 patients with 24 chest tubes, pneumothorax was evident on chest radiographs taken immediately after tube insertion and fluid drainage. Four patients with four chest tubes were found to have pneumothorax on chest radiographs taken the next day. No significant difference in the amount of fluid drained during the procedure was noted for patients with or without pneumothorax (831 ml versus 853 ml). No relationship between the size of each pneumothorax and the size of each drainage catheter was seen. The duration of pneumothorax ranged from 2 hr to 18 days (average, 3.5 days). Resolution of pneumothorax was seen in 22 (79%) of 28 cases; the remaining six cases of pneumothorax (21%) were stable, and the patients showed eventual fluid reaccumulation after chest tube removal and no sclerotherapy. No patient developed tension pneumothorax, respiratory distress, or other complications., Conclusion: Pneumothorax should be recognized as a common finding after chest tube placement and immediate fluid drainage for malignant pleural effusions. We suggest that this finding is related to rapid removal of fluid from a relatively stiff, noncompliant lung. Patients whose lungs do not fully re-expand in several days will probably not benefit from sclerotherapy. Their tubes may be removed without risk of an enlarging tension pneumothorax.

Purpose: To determine the feasibility of ambulatory drainage and sclerotherapy in malignant pleural effusions., Materials and Methods: Nineteen consecutive patients with symptomatic malignant pleural effusions were enrolled. None of the patients previously underwent sclerotherapy. A fluoroscopically placed 10.3-F catheter was connected to a closed gravity drainage bag system. Sclerotherapy was performed with bleomycin when daily drainage was less than 100 mL. Radiographic response was graded at 30 days. All patients were examined for symptomatic response and for complications., Results: The tubes remained in place 2-11 days (mean, 5.1 days). Total pleural drainage ranged from 950 to 3,925 mL (mean, 1,647 mL); all 19 patients had improvement of symptoms. At 30 days, 10 (53%) patients had a complete response, five (26%) had a partial response, and four (21%) had progressive disease., Conclusion: Ambulatory sclerotherapy is a safe, viable alternative to conventional inpatient treatment of malignant pleural effusions.

Purpose: To describe the occurrence, cause, and significance of hemoptysis following thrombolytic therapy for acute myocardial infarction., Patients and Methods: We retrospectively reviewed 2,634 patients presenting with acute myocardial infarction who received thrombolytic therapy to determine the incidence of hemoptysis. Chart and radiographic review included the type, dose, and route of thrombolytic therapy. In addition, the onset, duration, and severity of hemoptysis were recorded and correlated with radiographic and bronchoscopic findings., Results: Eleven patients (0.4%) developed hemoptysis following administration of thrombolytic therapy for an acute myocardial infarction. The duration and severity had a wide range, although no patient had significant hemodynamic compromise. The source of hemoptysis was identified in only one patient who had a tongue laceration following cardiopulmonary resuscitation, and blood was seen within the oropharynx and trachea. No definitive cause was identified in all other patients. There was no correlation between the different types or doses of thrombolytic therapy and the duration or severity of hemoptysis. Chest radiographs were nonspecific and demonstrated resolution within 11 days following hemoptysis. CT of the thorax in one patient and bronchoscopy in two patients confirmed chest radiographic findings and in no patient was an underlying pulmonary abnormality identified., Conclusions: Pulmonary hemorrhage and hemoptysis are unusual complications of thrombolytic therapy in patients with acute myocardial infarction. Although hemoptysis may be the first indicator of an underlying pulmonary abnormality, we found no case in which a significant abnormality was unmasked. This study suggests that follow-up chest radiographs are recommended and further evaluation may be unnecessary if complete resolution is demonstrated.

The purpose of this study is to compare sensitivity and specificity of helical CT and MR imaging for detecting acute pulmonary embolism(PE). Patients who were suspected clinically of having PE were randomly assigned to undergo either helical contrast-enhanced CT or gradient-echo MR (if one modality was contraindicated, the patient was assigned to the other.) Patients were considered to have PE if they had: 1) high-probability V-Q scan and low clinical probability of PE; 2) pulmonary angiogram positive for PE. Patients were considered not to have PE if they had either:1)normal V-Q scan; 2) low probability V-Q scan and low clinical probability of PE; or 3) pulmonary angiogram negative for PE. The CT and MR images were read randomly and independently by five radiologists with varying levels of CT and MR experience. Twenty eight patients underwent CT and 25 MR. A total of 21 patients underwent pulmonary angiography (6 had PE, 15 did not have PE). Of the other 32 patients, 15 had high probability scan/high clinical probability and 17 had low probability scan/low clinical probability. For the five observers, the average sensitivity of CT was 75% and of MR 46%; the average specificity of CT was 89% and of MR 90%. Experience with vascular MR and enhanced CT influenced diagnostic accuracy. For the two vascular MR experts, average sensitivity and specificity of MR were 71% and 97%, and of CT 73% and 97%. In this pilot study, when CT and MR were interpreted with comparable expertise, they had similar accuracy for detecting pulmonary embolism.

Purpose: To assess the role of positron emission tomographic (PET) imaging with 18-fluoro-2-deoxyglucose (18FDG) in detecting thoracic lymph node metastases in patients with bronchogenic carcinoma., Materials and Methods: Over a 2-year period, any patient presenting to our institution with newly diagnosed bronchogenic carcinoma who was to have thoracic nodes sampled was considered eligible. All PET studies were performed prior to nodal sampling and areas of increased uptake were mapped according to the American Thoracic Society classification. Studies were correlated with CT and pathology. Sensitivity and specificity for predicting nodal metastases was calculated., Results: Forty-two patients had 62 nodal stations (40 hilar/lobar, 22 mediastinal) sampled. The sensitivity and specificity for hilar/lobar lymph node station metastases using PET imaging was 73% and 76%, respectively. With CT, the sensitivity and specificity were 27% and 86%. The sensitivity and specificity using PET imaging for mediastinal node station metastases was 92% and 100%, respectively, while with CT the figures were 58% and 80%. The sensitivity and specificity for combined thoracic nodal station metastases using PET imaging was 83% and 82%, respectively, while with CT it was 43% and 85%. There was a strong statistical relationship between positive PET imaging and lymph node abnormalities., Conclusions: 18FDG-PET imaging is accurate in detecting thoracic lymph node metastases in patients with bronchogenic carcinoma. Normal results of PET studies virtually preclude the need for mediastinal nodal sampling prior to surgery, whereas abnormal results of studies most likely represent mediastinal metastases. Treatment can be based on the extent of disease suggested by PET imaging.

We compared the conspicuity of acute pulmonary emboli with contrast-enhanced spiral computed tomography (CT) and two- and three-dimensional time-of-flight magnetic resonance (MR) techniques. Seven dogs who received experimental pulmonary emboli and one control were imaged with spiral CT and with 2-D (FMPVAS and FASTCARD) and 3-D time-of-flight MR. Blinded, independent, prospective evaluations of the CT and MR images by two MR radiologists and two chest radiologists were then compared to the location of the emboli as determined by subsequent pathologic evaluation of the excised lungs. Embolus/blood contrast-to-noise ratios (CNRs) were calculated on both MR and CT images for pulmonary emboli that could be identified. Fifty emboli ranging from 1.0 to 5.5 mm (mean, 2.7, +/- 0.14 SEM) in diameter and from 3.0 to 60 mm (mean, 28.1 +/- 1.9 SEM) in length were found in the seven embolized dogs on pathologic examination. Three of the four radiologists identified more thrombi on CT images than they did on their best MR pulse sequence (FASTCARD) and with greater confidence. The fourth radiologist identified an equal percentage of clot on CT and FASTCARD images with confidence slightly greater on FASTCARD MR than on spiral CT. Mean CNR for the best MR technique was 43.4 (+/- 3.9 SEM) and for CT was 20.7 (+/- 1.3 SEM). In general, pulmonary emboli were detected more accurately on contrast-enhanced spiral CT than on MR. This occurred although the embolus/blood CNR was higher on MR than on CT. Better pulmonary embolus conspicuity on CT images was attributed to better spatial resolution and fewer artifacts on CT than on MR. One MR radiologist performed equally well with both spiral CT and FASTCARD techniques, suggesting that experience may be a factor in performance.

In the mid-1980s, the incidence of tuberculosis (TB) in the United States increased. Recently, TB became an index diagnosis for AIDS. Chest radiographs in patients with AIDS and TB may be atypical; various features are addressed in this article. Radiologists should be aware of the possibility of TB because this disease is not only communicable to health care workers and other patients but more recently has become difficult to treat because of multidrug-resistant Mycobacterium tuberculosis.

Objective: This study evaluates small-bore catheter thoracostomy combined with doxycycline sclerotherapy for palliative treatment of presumed malignant pleural effusions., Subjects and Methods: Forty-seven consecutive patients referred from the medical oncology department to the thoracic radiology section with known primary malignant tumors and symptomatic pleural effusions over a 2-year period were treated with small-bore pleural catheter drainage followed by doxycycline sclerotherapy. Of the 47 patients, 20 (43%) died less than 30 days after sclerotherapy, one (2%) died without radiographic follow-up, and five (11%) were lost to follow-up. Twenty-one patients formed the study group. Response to treatment was defined based on findings on follow-up chest radiographs obtained 30 days after sclerotherapy as complete (no reaccumulation of pleural effusion), partial (accumulation above postpleurodesis level but below that at presentation), or as a failure (reaccumulation to the amount seen at presentation)., Results: Seventeen (81%) evaluable patients showed complete response to sclerotherapy, three (14%) showed a partial response, and one (5%) showed no response. All complete and partial responders were clinically improved with resolution of their shortness of breath. Therefore, 95% of evaluable patients had clinically and radiographically successful treatment. Six patients underwent sclerotherapy when their tube output was greater than 100 ml/24 hr. Five of the six had completely successful pleurodesis, and one failed to respond. Two (10%) of the 21 patients had greater than 150 ml drainage in the 24 hr after initial doxycycline administration and were therefore given a second dose of intrapleural doxycycline. Both of these patients subsequently had less than 150 ml drainage in an additional 24-hr observation period and went on to complete response. Complications included three patients (14%) with mild discomfort at the chest tube site during drainage, one patient (5%) with pain during instillation of doxycycline, and one patient (5%) with transient fever (38.3 degrees C body temperature) one day after sclerotherapy., Conclusion: Small-bore catheter thoracostomy followed by doxycycline sclerotherapy successfully resolves symptomatic pleural effusion in patients with known primary malignant tumors.

Positron emission tomography (PET) is just beginning to emerge as a clinically useful tool in the thorax. Imaging with FDG is used primarily to differentiate benign from malignant abnormalities, including solitary pulmonary nodules, staging bronchogenic carcinoma, and differentiating recurrent tumor from fibrosis following treatment. This article discusses the fundamental properties of PET images, techniques, and current clinical indications in the thorax.

Purpose: To assess positron emission tomography (PET) with 2-[fluorine-18]-2-deoxy-D-glucose (FDG) in the differentiation of recurrent bronchogenic carcinoma from fibrosis after therapy., Materials and Methods: Any patient treated for bronchogenic carcinoma who had a residual chest radiographic abnormality was eligible. Forty-three patients (mean age, 63.5 years) participated. Chest radiographs and thoracic computed tomographic scans helped localize the abnormality prior to PET. Semiquantitative analysis was performed on FDG PET images with calculated standardized uptake ratios (SURs). Sensitivity, specificity, and confidence intervals for recurrent disease were determined., Results: Thirty-five patients had recurrent or persistent tumor (median SUR, 7.6; range, 1.9-18.7). Eight patients had fibrosis but no evidence of disease (SUR, 1.6; range, 0.6-2.4). The sensitivity for detecting recurrent tumor (SUR > 2.5) was 97.1%, and specificity was 100%. The SUR for recurrent tumor was statistically significantly higher than for fibrosis (P = .0001)., Conclusion: FDG PET accurately helps differentiate recurrent bronchogenic carcinoma from fibrosis.

A large number of patients with coexisting tuberculosis and HIV infection has been reported. The chest radiographic findings are well described and primarily consist of bilateral, medium-to-coarse reticulonodular opacities often associated with hilar and mediastinal adenopathy. The evolution of chest radiographic abnormalities following treatment for tuberculosis in patients with HIV infection has not been previously studied. Initial and follow-up chest films of 33 patients with tuberculosis and HIV infection were evaluated. All 25 patients whose only pulmonary infection was tuberculosis exhibited radiographic improvement after appropriate treatment. In 8 patients, the chest radiograph worsened while on tuberculosis therapy. In each of these individuals, a newly acquired nontuberculous pulmonary disease was diagnosed as the cause of radiographic deterioration. We conclude that chest radiographs in patients with tuberculosis and HIV-infection will improve with appropriate tuberculosis therapy. Worsening of the chest radiograph does not suggest a poor therapeutic response, but instead indicates the presence of another pulmonary disease.

We retrospectively evaluated the computed tomography (CT) findings in 20 patients with pulmonary drug toxicity that followed high-dose chemotherapy and autologous bone marrow transplantation (ABMT). Eighty-five patients with Stage II or III breast cancer that involved > or = 10 axillary lymph nodes were enrolled in a treatment protocol that included four cycles of standard-dose therapy (CAF) followed by one cycle of high-dose treatment (CPA/cDDP/BCNU). After chemotherapy, ABMT was performed. Twenty-six patients (31%) developed pulmonary drug toxicity. Serial thoracic CT studies were available in 20 of these 26 patients. All 20 patients exhibited clinical symptoms (i.e., dyspnea, nonproductive cough, and fever) and abnormal pulmonary function following transplantation. Thirteen patients had pathologically proven drug toxicity, and seven patients had clinical features and treatment responses highly suggestive of this diagnosis. Multiple sputum and blood cultures were negative in all patients. CT scans of 13 patients (65%) demonstrated scattered, predominantly peripheral ground-glass or consolidated opacities that occasionally looked nodular or masslike. Two patients (10%) had CT scans suggestive of pulmonary edema and in five patients (25%), the CT examinations revealed no significant abnormalities. Pleural effusions and adenopathy were uncommon. Pulmonary drug toxicity after high-dose chemotherapy and ABMT should be suspected in the appropriate clinical and radiographic setting, and therapy may be initiated on the basis of these observations.

The authors assessed the role of positron emission tomography (PET) with fluorine-18 fluorodeoxyglucose (FDG) in differentiation of benign from malignant focal pulmonary abnormalities seen on chest radiographs. Fifty-one patients underwent FDG PET scanning. Focal abnormalities at radiography included solitary pulmonary nodules (n = 38), pulmonary masses (n = 5), and poorly marginated infiltrates or opacities (n = 8). Proof of diagnosis was obtained by means of transbronchial biopsy (n = 21), open lung biopsy (n = 14), percutaneous needle biopsy (n = 14), or cytologic evaluation of sputum (n = 1). A nodule in one patient had been radiographically stable for at least 8 years. Quantitative analysis was performed by calculation of a standardized uptake ratio (SUR). Thirty-three malignant lesions had a mean SUR (+/- 1 standard deviation) of 6.5 +/- 2.9. Eighteen benign lesions had a mean SUR of 1.7 +/- 1.2. For a benign lesion with SUR of 2.5 or less, specificity of FDG PET was 100%, while sensitivity was 89%. These results suggest that FDG PET is accurate in differentiation of benign from malignant focal pulmonary abnormalities.

The authors describe a variable compensation (VC) technique in which an x-ray equalizer and a computed radiography system are used. The VC technique allows retrospective alteration of equalized chest appearance with maintenance of improved signal-to-noise ratio in dense regions. Two imaging plates are used: one upstream of the patient to record the incident beam profile and one down-stream to record the equalized image. Subtraction of a weighted version of the upstream image from the down-stream image permits alteration of the appearance of the VC image, from the extremes of stimulated-unequalized to highly equalized. VC image appearance was optimized with a real-time workstation. The quality of VC images obtained in 33 patients was evaluated by three chest radiologists. Mediastinal appearance was better on VC equalized images than on conventional screen-film images. The stimulation of the appearance of a conventional radiograph with VC proved useful in interpretation of lung appearances on equalized radiographs.

Cryptococcus neoformans is a ubiquitous soil fungus that rarely causes pneumonia in normal hosts but is a common cause of opportunistic infection. Pulmonary disease is initiated by inhalation of the organism, and a spectrum of radiographic manifestations can be seen. The most common finding is a poorly marginated nodule or mass. Lobar or segmental parenchymal opacities and, less commonly, a diffuse scattered nodular or reticulonodular pattern have also been observed. Associated adenopathy, pleural effusions, and cavitation are uncommon; when present, these are more common in immunocompromised patients. Establishing the diagnosis can be difficult, but pulmonary cryptococcosis should be considered in the differential diagnosis of patients in the proper clinical setting and with compatible radiographic findings.

The chest radiographs obtained in nine patients with acquired immunodeficiency syndrome (AIDS) and pulmonary toxoplasmosis were reviewed. In three patients, a bilateral, diffuse, fine to medium reticulonodular pattern indistinguishable from that seen in Pneumocystis carinii pneumonia (PCP) was observed. In six patients, however, a bilateral, predominantly coarse, nodular pattern was observed. This type of abnormality is unusual with PCP, and its presence may help in distinguishing between pulmonary infections caused by Toxoplasma gondii and P carinii. Other opportunistic pneumonias occurring in patients with AIDS, including tuberculosis, histoplasmosis, and coccidioidomycosis, might show similar coarse, nodular opacities on chest radiographs and thus may not be differentiated from pulmonary toxoplasmosis. No hilar or mediastinal adenopathy was observed. Two patients had pleural fluid. Radiologists familiar with the chest radiographic appearance of T gondii pneumonia could be first to suggest this unusual complication of AIDS.

Pneumocystis carinii pneumonia (PCP) is the most common index diagnosis in patients with acquired immunodeficiency syndrome (AIDS). Eighty percent of AIDS patients will eventually develop PCP. Common presenting symptoms are shortness of breath, cough, weight loss, and fever. The chest radiograph typically reveals a diffuse, bilateral, symmetric, fine-to-medium reticulonodular pattern of opacities. Upper lobe disease has been reported recently in patients who have undergone prophylactic therapy with aerosolized pentamidine. Pneumatoceles, or thin-walled air-containing cysts, have been noted in 10% of patients with PCP. Lymphadenopathy and pleural effusion are extremely rare. Therapy with various agents is generally successful, resulting in clinical and radiographic improvement within 7 to 10 days. Recurrence of PCP is common.

An aggressive form of Kaposi's sarcoma has been reported in patients with acquired immunodeficiency syndrome. Although pulmonary symptoms may constitute the initial complaint, Kaposi's sarcoma is generally detected because of cutaneous lesions. The chest radiograph reveals a distinctive, poorly marginated, nodular pattern in the lungs. Coarse, linear densities are also observed, and pleural effusion is seen in many patients. Bilateral distribution is most common. Pulmonary hemorrhage occurs and rarely may result in dense air-space consolidation seen on the chest radiograph.

An increase in tuberculosis cases in the United States has been partially linked to the large number of patients with acquired immunodeficiency syndrome. Symptoms are indistinguishable from those of other opportunistic infections and include cough, low-grade fever, and weight loss. In patients with early human immunodeficiency virus (HIV) infection, radiographic findings resemble those seen in patients with reactivation tuberculosis. In patients with advanced HIV infection, chest radiographs typically reveal bilateral, symmetric, coarse, nodular densities. An upper lobe distribution is not prevalent. Lymphadenopathy is reported in many patients. Antituberculous therapy leads to clinical and radiographic improvement. Radiographic deterioration during therapy should suggest the presence of another opportunistic infection. Mycobacterium avium complex (MAC) infection of the lung cannot be distinguished from tuberculosis clinically or radiographically. Therapy, however, is less likely to be successful in patients with MAC infection.

AIDS-related lymphomas (ARLs) are almost always of a non-Hodgkin's type. Typically, intraabdominal or subcutaneous lymph node groups are affected. Unusual presentations are not uncommon, however. Intrathoracic involvement occurs in 10% to 30% of AIDS patients. ARLs are extremely aggressive and generally present at advanced stages of disease. The chest radiograph demonstrates linear densities, lymphadenopathy, and pleural effusions. An unusual feature of ARLs is the presence of rapidly growing, well-defined lung nodules. Radiographic response to therapy may be extremely rapid, but the prognosis for patients with ARLs is poor.

Children with acquired immunodeficiency syndrome (AIDS) may present with recurrent pneumonias or chronic debilitating illness. The chest radiographs of these patients demonstrate homogeneous densities representing staphylococcal or other pyogenic infections. Pneumocystis carinii pneumonia produces a diffuse, symmetric, fine-to-medium, reticulonodular pattern. Lymphocytic interstitial pneumonitis, a disease that is now an index diagnosis of AIDS in children under 13, may appear as a chronic, diffuse, small nodular infiltrate. An increasing number of pediatric AIDS patients will be observed in the future because of the large number of human immunodeficiency virus-infected women who are of childbearing age.

This paper is a selective review of the past year's literature on the infections and neoplasms that develop in patients with the acquired immunodeficiency syndrome. In general, the recent literature supports information previously reported and includes further suggestions about the pathogenesis of findings seen on chest radiographs.

Background and Methods: Infection with the human immunodeficiency virus (HIV) increases the risk of tuberculosis and may interfere with the effectiveness of antituberculosis chemotherapy. To examine the outcomes in patients with both diagnoses, we conducted a retrospective study of all 132 patients listed in both the acquired immunodeficiency syndrome (AIDS) and tuberculosis case registries in San Francisco from 1981 through 1988., Results: At the time of the diagnosis of tuberculosis, 78 patients (59 percent) did not yet have a diagnosis of AIDS, 18 patients (14 percent) were given a concomitant diagnosis of AIDS (as determined by the presence of an AIDS-defining disease other than tuberculosis), and the remaining 36 patients (27 percent) already had AIDS. The manifestations of tuberculosis were entirely pulmonary in 50 patients (38 percent), entirely extrapulmonary in 40 patients (30 percent), and both pulmonary and extrapulmonary in 42 patients (32 percent). The treatment regimens were as follows: isoniazid and rifampin supplemented by ethambutol for the first two months, 52 patients; isoniazid and rifampin supplemented by pyrazinamide and ethambutol for the first two months, 39 patients; isoniazid and rifampin, 13 patients; isoniazid and rifampin supplemented by pyrazinamide for the first two months, 4 patients; and other drug regimens, 17 patients. The intended duration of treatment for patients whose regimen included pyrazinamide was six months, and for patients who did not receive pyrazinamide, nine months. Seven patients received no treatment because tuberculosis was first diagnosed after death. Sputum samples became clear of acid-fast organisms after a median of 10 weeks of therapy. Abnormalities on all chest radiographs taken after three months of treatment were stable or improved except for those of patients who had new nontuberculous infections. The only treatment failure occurred in a man infected with multiple drug-resistant organisms who did not comply with therapy. Adverse drug reactions occurred in 23 patients (18 percent). For all 125 treated patients, median survival was 16 months from the diagnosis of tuberculosis. Tuberculosis was a major contributor to death in 5 of the 7 untreated patients and 8 of the 125 treated patients. Three of 58 patients who completed therapy had a relapse (5 percent); compliance was poor in all 3., Conclusions: Tuberculosis causes substantial mortality in patients with advanced HIV infection. In patients who comply with the regimen, conventional therapy results in rapid sterilization of sputum, radiographic improvement, and low rates of relapse.

The increased incidence of malignant lymphomas in patients with congenital or acquired immunodeficiency states is now well recognized. In recent years, acquired immunodeficiency syndrome (AIDS) related non-Hodgkin's lymphoma has accounted for a growing proportion of these aggressive neoplasms. This article reviews the radiographic features of lymphoma in AIDS and non-AIDS immunocompromised patients.

An association between tuberculosis and HIV infection is becoming increasingly evident. HIV seropositivity has been seen in nearly 30% of some populations with tuberculosis. In other populations nearly 25% of patients with AIDS had tuberculosis. Clinically these patients present with nonspecific findings including weight loss, night sweats, and fever. The symptoms are generally gradual in onset and last for several weeks. Early in the course of HIV infection a PPD skin test may be positive and the radiographic findings may be similar to those seen in individuals with normal immunity. Thus, upper lobe heterogeneous and cavitary opacities may be seen on the chest radiograph. In late HIV infection, however, the PPD skin test is generally negative and the radiograph demonstrates lymphadenopathy and diffuse heterogeneous parenchymal opacities. Tuberculosis should be suspected in HIV-infected patients when diffuse interstitial lung disease is demonstrated in conjunction with hilar or mediastinal lymph node enlargement. In contrast, lymphadenopathy is not expected in the most common opportunistic lung disease, Pneumocystis carinii pneumonia. Standard antituberculous drug therapy is extremely effective in treating tuberculosis in this setting.