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Objective: To determine the necessity of percutaneous lung biopsy in patients with a single known primary malignancy and multiple pulmonary nodules., Design: Retrospective study., Setting: Tertiary care university hospital., Results: We reviewed all percutaneous lung biopsy specimens over a 6-year period. One hundred forty-six patients with a single known primary malignancy and multiple pulmonary nodules had biopsies performed up to 19 years following diagnosis of the primary neoplasm. One hundred thirty-seven biopsy specimens (93.8%) were positive for metastases. Eight patients (5.5%) had a nondiagnostic biopsy specimen; however, subsequent imaging studies and the clinical course strongly suggested diffuse metastatic disease. One patient (< 1%) with breast carcinoma developed nodules 3 years after initial diagnosis and had resolution without a definitive diagnosis or therapy., Conclusion: Patients with a single known primary malignancy and multiple pulmonary nodules who present for percutaneous needle biopsy will have pulmonary metastases in the vast majority of cases. Biopsy in these patients rarely changes the clinical course as other diagnoses are rarely established.

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.

Cardiovascular calcifications in the thorax may be clinically significant and may prove extremely valuable diagnostically. The typical appearance and location of common cardiovascular calcifications have been well described [1, 2]. We present a series of radiologic findings in patients with atypical and unusual cardiovascular calcifications in the thorax.

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.

CT is the most sensitive radiologic method for the detection of differences in radiographic density in chest lesions. Areas of high attenuation (visually as opaque as bony structures) in an abnormality on CT scans can be an important clue to the correct diagnosis. The high attenuation is most often caused by calcification, but may also be due to iodine, barium, or radiopaque foreign bodies. This essay illustrates the patterns of high attenuation associated with chest diseases on unenhanced CT scans.

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.

Objective: Lymphangiomas are rare benign tumors most often seen in childhood. When they occur in adults, radiologic diagnosis can be difficult. A retrospective study of the CT and MR appearances of thoracic lymphangiomas in adult patients was performed in order to describe the range of radiologic features of these tumors., Materials and Methods: Cases of adult lymphangioma at three institutions were identified in the records of 19 patients, predominantly female, 18-67 years old., Results: The most common CT appearance was a smoothly marginated cystic mass. Unusual features included calcification, spiculated margins, and homogeneous soft-tissue attenuation. The majority of cases were located in the anterior or superior mediastinum. Unusual locations included the pericardium, pulmonary hilum, and pulmonary parenchyma. Signal characteristics on MR images varied., Conclusion: The radiographic appearance of lymphangiomas in the chest in adult patients is varied. The diagnosis cannot be suggested on the basis of radiologic studies alone.

The article describes eight patients with enlarged internal mammary lymph nodes visualized on the frontal plain chest radiograph. Enlarged internal mammary lymph nodes cast shadows that initially may be mistaken for a mediastinal or pleural abnormality. Although the lateral film alone may suggest these nodes, the findings on the frontal film help lateralize the abnormality.

Physiologic changes during pregnancy affect nearly every organ system. In the thorax, the diaphragm elevates as much as 4 cm because of displacement of the abdominal organs by the gravid uterus, resulting in lower lung volumes. Maternal blood volume and cardiac output increase approximately 45% by mid-pregnancy. Cardiac output can increase as much as 80% during vaginal delivery and up to 50% with cesarean section. These changes result in pulmonary vascular engorgement, progressive left ventricular dilatation, and mild hypertrophy (Fig. 1). Pregnant patients are also prone to a number of pulmonary insults, including infection, aspiration, and neoplastic disease. These abnormalities have several radiographic patterns: cardiogenic and noncardiogenic pulmonary edema, focal pulmonary abnormalities, and extraalveolar air. Radiologists must recognize not only the normal chest radiographic appearance in these patients but also the thoracic complications associated with pregnancy.

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.

Objective: Our objective was to determine if CT or MR imaging findings could be used to accurately predict resectability in patients with biopsy-proved malignant pleural mesotheliomas., Subjects and Methods: CT and MR findings in 41 consecutive patients with malignant mesotheliomas who were referred to the thoracic surgery clinic for extrapleural pneumonectomy were studied by thoracic radiologists before surgery. Review of radiologic studies focused on local invasion of three separate regions: the diaphragm, chest wall, and mediastinum. Results of all imaging examinations were carefully correlated with intraoperative, gross, and microscopic pathologic findings., Results: After radiologic and clinical evaluation, 34 patients (83%) had thoracotomy; 24 of these had tumors that were resectable. The sensitivity was high (> 90%) for both CT and MR in each region. Specificity, however, was low, probably because of the small number of patients with unresectable tumors., Conclusion: CT and MR provided similar information on resectability in most cases. Sensitivity was high for both procedures. Because CT is more widely available and used, we suggest it as the initial study when determining resectability. In difficult cases, important complementary anatomic information can be derived from MR images obtained before surgical intervention.

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.