[Mimics of lung cancer]

Lung cancer is a histologically, immunologically and therefore morphologically and functionally very heterogeneous group of neoplasms with the highest cancer mortality worldwide. Therefore, the range of diseases mimicking lung cancer is also very broad and includes congenital, infectious and inflammatory changes as well as other benign space-occupying lesions and other primary and secondary pulmonary neoplasms. The difficulty in radiology lies in the ability to diagnose lung cancer with a high degree of certainty. This must take the limits of the specific diagnosis, knowledge of the classical pitfalls and rare entities that can imitate lung cancer into consideration. Narrowing the differential diagnosis requires close interdisciplinary cooperation and consideration of the patient's clinical and medical history. An accurate analysis of the computed tomography (CT) pattern and distribution of the lesions as well as consideration of additional changes and involvement of other organ systems can be the key to the diagnosis. The use of fluorodeoxyglucose positron-emission tomography CT (FDG-PET-CT) is helpful only in a few mimics of lung cancer. The article describes clinical and radiological findings of mimics of lung cancer also pointing out the limitations of CT and PET-CT for the diagnosis.

[Management of subsolid pulmonary nodules]

The finding of subsolid pulmonary nodules poses a frequent problem in the daily routine of the radiologist. The biological behavior of such subsolid lesions differs significantly from solid nodules. The risk of malignancy is significantly higher in subsolid nodules as compared to solid or purely ground glass opacities or nodules. The recommendations regarding the diagnostic management of subsolid nodules have been adapted according to the tendency of growth and the risk of malignancy. A benign etiology is also seen quite often in subsolid lesions and in this case they will show a reduction of size or disappear completely by the follow-up examination. Therefore, in many cases a short-term follow-up examination is primarily recommended. As the findings will often show no changes for a long period of time, further annual follow-up examinations over a longer, not yet specified period of time are recommended. Subsolid lesions that grow in size and/or show an increase in density or develop a solid part within a ground glass lesion should remain as suspected malignancies until proven otherwise.

[Sonography of the liver following CT staging of patients with lung cancer: a retrospective analysis]

PURPOSE

Liver lesions are frequently detected in the CT staging of lung cancer patients and may require further investigation. The aim of our study was to assess the value of an ultrasound (US) examination of the liver in addition to routine CT staging.

MATERIALS AND METHODS

In this retrospective study we included 174 consecutive patients with lung cancer who underwent US of the liver in addition to contrast-enhanced CT of the thorax and upper abdomen. The reports of the examinations were evaluated for the presence of liver lesions. Based on CT and US standard criteria, liver lesions were grouped into unequivocal cysts, hemangiomas, metastases and undefined lesions.

RESULTS

With CT, liver lesions were detected in 56 / 174 patients (32 %). These included 24 cysts in 11 patients, 2 hemangiomas in 2 patients and 18 patients with liver metastases. In 31 patients, 66 small (< 1.5 cm) hypodense lesions were detected, which could not be further defined by CT. Using US, 21 of these 66 liver lesions were confirmed as benign (cysts, hemangiomas), and two lesions were diagnosed as metastases. In 2 patients US revealed metastases that were not visible on the CT scans.

CONCLUSION

The study demonstrates that a complementary US of the liver in patients with lung cancer may reveal information relevant for treatment. Therefore, liver US may play an important role in the staging of lung cancer. When equivocal small liver lesions are detected with CT, a complementary US examination may help to diagnose these lesions or detect metastases not visible on the single-phase staging CT of the liver.

Radiologische Diagnostik der Lungentuberkulose

The radiologic knowledge of tuberculosis-associated lung disease is an essential tool in the clinical diagnosis of tuberculosis. Chest radiography is the primary imaging method, but the importance of CT is still increasing, as CT is more sensitive in the detection of cavitation, of hilar and mediastinal lymphadenopathie, of endobronchial spread and of complications in the course of the disease. In addition, CT has been proven as a valuable technique in the assessment of tuberculosis activity, especially in patients where M. tuberculosis has not been detected in the sputum or in patients with multidrug-resistant tuberculosis. Depending on the immune status of the patient, the morphologic spectrum of tuberculosis is quite variable. Early diagnosis of tuberculosis is essential to prevent further spread of the disease.

[The limping child. Differential radiologic diagnosis of acute gait disorder in childhood and adolescence]

Limping is a common and often challenging problem in children and adolescents. A limp is defined as asymetric deviation from a normal gait pattern. A systematic approach is necessary to determine the cause of the limp, so the radiologist should combine a thorough history, clinical information and pertinent radiologic testing. The possible differential diagnosis is extensive and includes many pathologies of the lower extremity and spine like trauma, infection, neoplasia, furthermore inflammatory, developmental and congenital disorders. In cases with knee or tight pain, an underlying hip condition should be considered. The childs age can narrow the possible differential diagnoses, because certain entities are age-related. Despite this wide bandwidth of entities, potential catastrophic causes like septic arthritis and malignant disease should be excluded first. Plain radiographs are often diagnostic. The choice of further imaging modalities like ultrasonography, magnetic resonance imaging, computed tomography and bone scan should be guided by the history and clinical findings.

[Current development sin the area of digital thoracic radiography]

All three currently commercially available systems for digital radiography of the chest such as the selenium drum, storage phosphor plates and the flat panel direct detector systems provide an excellent image quality that is at least equivalent or superior to that of conventional film. Reasons for that are the continuously improved detective or dose efficiency of the detector systems and an improved image processing. The new direct detector systems have the largest potential for dose reduction while storage phosphor and selenium radiographs are usually obtained with a dose comparable to that of a 400 speed system. Improved image processing algorithms allow for the production of digital images that are adapted to the conventional image characteristics within the lung regions combined with an increased transparency of the high absorption areas such as the retrocardial and retrodiaphragmatic regions.

Videofluoroscopy of swallowing in symptomatic patients who have undergone long-term intubation

OBJECTIVE

The aim of this study was to evaluate whether specific patterns of swallowing dysfunction occur in symptomatic patients after long-term intubation.

SUBJECTS AND METHODS

Twenty-one patients (16 men, five women; mean age, 66 years) who presented with clinical signs of aspiration after long-term intubation (mean duration, 24.6 days) underwent videofluoroscopy. They were analyzed for functional abnormalities of the tongue, soft palate, epiglottis, hyoid and larynx, pharynx, and the upper esophageal sphincter. We assessed the presence or absence of aspiration, the type of aspiration (pre-, intra-, and postdeglutitive), and a spectrum of other swallowing abnormalities.

RESULTS

There were 18 patients (86%) with radiologically proven aspiration. In another patient only laryngeal penetration occurred. There were 11 combinations of pre-, intra-, and postdeglutitive aspiration. Predeglutitive aspiration was predominant and present in 52% of our patients. We found functional abnormalities of the tongue in 48%, of the soft palate in 10%, of the epiglottis in 48%, of the pharynx in 71%, and of the upper esophageal sphincter in 24%.

CONCLUSION

Patients who are symptomatic after undergoing long-term intubation do not develop a specific type or pattern of swallowing dysfunction or aspiration, but show a large variety of aspiration types and associated swallowing disorders. Nevertheless, videofluoroscopy has the ability to reveal complex deglutition disorders and to aid precise planning of individualized functional swallowing therapy.

Improved outcome prediction in unconscious cardiac arrest survivors with sensory evoked potentials compared with clinical assessment

OBJECTIVE

To compare the prognostic ability of sensory evoked potentials in cardiac arrest survivors with the outcome predicted by a panel of experienced emergency physicians based on detailed prehospital, clinical, and laboratory data.

DESIGN

Inception cohort study.

SETTING

Medical intensive care unit and department of emergency medicine at a university hospital.

PATIENTS

A total of 162 unconscious, mechanically ventilated patients who survived > or =24 hrs after resuscitation from cardiac arrest.

INTERVENTIONS

Recording of sensory evoked potentials and outcome prediction after review of detailed clinical and laboratory data by emergency physicians within 24 hrs after cardiac arrest.

MEASUREMENTS AND MAIN RESULTS

At 6 months, the outcome of 36 patients was classified as favorable and 126 patients were rated as poor. After review of prehospital data, emergency physicians predicted favorable vs. poor outcome with a sensitivity of 70% and a specificity of 65%. After additional assessment of data 1 hr after cardiac arrest, the sensitivity of emergency physician predictions increased to 80%, whereas the specificity decreased to 48%. Outcome prediction by emergency physicians was most accurate after obtaining detailed patient data 24 hrs after cardiac arrest (sensitivity, 81%; specificity, 58%). In 35 of 36 patients with favorable outcomes, the cortical evoked potential N70 peak was detected between 72 and 128 msec. Of 113 patients with an N70 peak latency >130 msec or an absent N70 peak, all except one had a poor outcome. By using a cutoff of 130 msec, the N70 peak latency alone had a sensitivity of 94% and a specificity of 97%. The predictive accuracy of the N70 peak latency was significantly higher than the clinical assessment 24 hrs after cardiac arrest (91% vs. 76%, p = .0003).

CONCLUSION

In unconscious cardiac arrest survivors, a recording of long-latency sensory evoked potentials is more accurate in predicting individual outcome than an emergency physician review of clinical data.

Blood clots mimicking peripheral intrabronchial tumors in patients with hemoptysis: CT and bronchoscopic findings

We report radiographic and clinical findings in two cigarette-smoking patients presenting with hemoptysis. On CT, both patients had peripheral intrabronchial masses together with parenchymal opacities. Bronchoscopy revealed the intrabronchial masses to be blood clots and the parenchymal opacities to correspond to areas of parenchymal hemorrhage. Our cases are novel in that both bronchial and parenchymal sequelae of hemorrhage were simultaneously visualized by CT. Also, our findings suggest that bronchial blood clots should be included in the differential diagnosis of peripheral intrabronchial lesions, notably in patients presenting with hemoptysis.

Comparable postoperative pulmonary atelectasis in patients given 30% or 80% oxygen during and 2 hours after colon resection

BACKGROUND

High concentrations of inspired oxygen are associated with pulmonary atelectasis but also provide recognized advantages. Consequently, the appropriate inspired oxygen concentration for general surgical use remains controversial. The authors tested the hypothesis that atelectasis and pulmonary dysfunction on the first postoperative day are comparable in patients given 30% or 80% perioperative oxygen.

METHODS

Thirty patients aged 18-65 yr were anesthetized with isoflurane and randomly assigned to 30% or 80% oxygen during and for 2 h after colon resection. Chest radiographs and pulmonary function tests (forced vital capacity and forced expiratory volume) were obtained preoperatively and on the first postoperative day. Arterial blood gas measurements were obtained intraoperatively, after 2 h of recovery, and on the first postoperative day. Computed tomography scans of the chest were also obtained on the first postoperative day.

RESULTS

Postoperative pulmonary mechanical function was significantly reduced compared with preoperative values, but there was no difference between the groups at either time. Arterial gas partial pressures and the alveolar-arterial oxygen difference were also comparable in the two groups. All preoperative chest radiographs were normal. Postoperative radiographs showed atelectasis in 36% of the patients in the 30%-oxygen group and in 44% of those in the 80%-oxygen group. Relatively small amounts of pulmonary atelectasis (expressed as a percentage of total lung volume) were observed on the computed tomography scans, and the percentages (mean +/- SD) did not differ significantly in the patients given 30% oxygen (2.5% +/- 3.2%) or 80% oxygen (3.0% +/- 1.8%). These data provided a 99% chance of detecting a 2% difference in atelectasis volume at an alpha level of 0.05.

CONCLUSIONS

Lung volumes, the incidence and severity of atelectasis, and alveolar gas exchange were comparable in patients given 30% and 80% perioperative oxygen. The authors conclude that administration of 80% oxygen in the perioperative period does not worsen lung function. Therefore, patients who may benefit from generous oxygen partial pressures should not be denied supplemental perioperative oxygen for fear of causing atelectasis.

Pneumatosis [correction of Pneumocystis] cystoides intestinalis with pneumoperitoneum and pneumoretroperitoneum in a patient with extensive chronic graft-versus-host disease

Pneumatosis cystoides intestinalis is a rare finding of intramural gasfilled cysts in the bowel wall and sometimes free air in the abdomen. A few conditions are reported to cause this disease, one of them being immunosuppression. We describe a 50-year-old Caucasian male with extensive chronic graft-versus-host disease (GVHD) of the gut and skin who developed PCI with pneumoperitoneum and pneumoretroperitoneum. To our knowledge, this is the first report of PCI occurring in a patient with active chronic GVHD which resolved spontaneously.

[Liver transplantation in acute liver failure]

Acute hepatic failure is characterized by jaundice and hepatic encephalopathy within eight weeks after the onset of disease. Although acute hepatic failure is a rare occurrence, its rapid progression and high mortality (50 to 90%, depending on the etiology of disease) necessitate immediate intervention. In the absence of causal therapy, orthotopic liver transplantation is currently the only definitive and effective means of treating acute hepatic failure in Europe, acute hepatic failure accounts for 11% of all liver transplantations. At the University department of transplantation surgery in Vienna a total of 27 patients with acute hepatic failure underwent 31 liver transplantations in the last 10 years (1.1.1987 to 31.12.1996). Twenty (74%) of the 27 patients survived the acute event and were discharged from hospital in good general condition after a median postoperative stay of 25 days (range 14-81 days). Seven patients (26%) died between the first and 34th postoperative day (median 26 days) in the intensive care unit, although all potential modern options of intensive care and surgery were used. The causes of death were irreversible cerebral edema (n = 3), multiple organ failure due to bacterial sepsis (n = 3) and uncontrollable haemolysis (n = 1). With a 3-year graft survival rate of 70% the 3-year patient survival rate was 74%. A retrospective analysis of our patients revealed that the postoperative graft function and the incidence of re-transplantation were significant prognostic factors (p < 0.05) for survival following orthotopic liver transplantation for acute hepatic failure. In the absence of further prognostically relevant preoperative indices and in consideration of the potentially fulminant progression of disease, we strongly recommend that any patient, in whom acute hepatic failure is suspected, is immediately transferred to a specialized center with experience both in the conservative treatment of acute hepatic failure and emergency liver transplantation.

[Prognostic factors in acute liver failure]

Acute liver failure is defined as acute severe, potentially reversible hepatic failure complicated by cerebral dysfunction. The high mortality rate of between 50% and 90% justifies early transfer to a specialised centre with the possibility of orthotopic liver transplantation to ensure adequate intensive care monitoring and treatment, 57 patients with acute liver failure (34 female, 23 male, aged 6 to 87 years, median 33 years) treated at our intensive care unit during the past 10 years were analysed retrospectively. Various factors and laboratory data were analysed in respect to their prognostic value. Depending on the aetiology, the survival rate in acute liver failure under conservative treatment ranges from 79% (amanita intoxication) to 10% (cryptogenic genesis). The most important predictive parameter is the extent of cerebral dysfunction. The extent of cerebral dysfunction is a determining factor of the survival rate under conservative treatment; it ranges from 94% (patients with hepatic encephalopathy grade I) to 11% (patients with hepatic encephalopathy grade IV). The occurrence of complications such as infections, cerebral oedema, respiratory failure or renal failure is also associated with an unfavourable outcome. Additionally, various laboratory parameters have a predictive ability. The mortality rate of our patients with acute liver failure has decreased from 56% to 32% since early intensive care monitoring and treatment and the possibility of acute orthotopic liver transplantation were established.

Differential diagnosis of atypically located single or double hot spots in whole bone scanning

Our study assessed the predictive value of atypically located hot spots in routine 99mTc-DPD (3,3 diphosphono-1, 2-propane dicarboxylic acid tetrasodium salt) bone scanning for osseous tumor spread in patients with a history of malignant tumor.

METHODS

Of 1286 scans in consecutive patients with a history of malignant tumor, but with no current evidence of osseous tumor spread, 172 displayed one or two hot spots in the following locations: transverse process of a single vertebra, manubriosternal junction, unilateral process of L5/S1, unilateral shoulder, costal cartilage, single rib, and unilateral sternoclavicular joint. The final diagnosis could be established by a control bone scan after at least 6 mo, biopsy and/or postmortem, respectively, in 135 patients.

RESULTS

Of the atypical hot spots, 11.1% were the first indication for osseous tumor spread. This diagnosis was most probable for single hot spots in the rib (25%) and shoulder (21%). Conversely, hot spots in the sternoclavicular joint never indicated malignancy.

CONCLUSION

The likelihood of atypically located isolated hot spots indicating osseous tumor spread is higher than expected during routine investigations in patients with a history of malignant tumor but no current evidence for malignant disease. Only hot spots in the sternoclavicular joint did not indicate metastatic disease in our study.

Detection of subclinical brain dysfunction by sensory evoked potentials in patients with severe diabetic ketoacidosis

OBJECTIVE

Subclinical brain dysfunction is a potentially deleterious complication of diabetic ketoacidosis but is rarely recognized. Thus, we investigated the diagnostic value of sensory evoked potentials for detecting subclinical brain dysfunction in patients with diabetic ketoacidosis.

DESIGN

Prospective trial.

SETTING

Intensive care unit in a university hospital.

PATIENTS

5 neurologically asymptomatic patients (Glasgow Coma Scale score 15, slight drowsiness; aged 20 to 66 years) with an established diagnosis of severe diabetic ketoacidosis were studied.

MEASUREMENTS AND RESULTS

Short- and long-latency sensory evoked potentials were recorded within 2 h of initiation of therapy for ketoacidosis and 7 days after normalization of ketoacidosis, respectively. Two hours after starting therapy, sensory evoked potential peak latencies were prolonged in all five patients compared to age-matched healthy subjects [cervical N 13 to cortical N 20 interpeak latency of short-latency evoked potentials (mean) 5.8 vs 5.3 ms, p < 0.05; N 35 peak latency 40 vs 34 ms, p < 0.05; N 70 peak latency of long-latency evoked potentials 102 vs 76 ms, p < 0.01]. In all five patients, cervical N 13 to cortical N 20 interpeak latency and N 35 and N 70 peak latency reverted to normal 7 days after recovery from diabetic ketoacidosis.

CONCLUSIONS

Our study indicates that the recording of sensory evoked potentials is a sensitive method of detecting subclinical brain dysfunction in patients with severe diabetic ketoacidosis. Since sensory evoked potentials were significantly prolonged in all five patients, this strongly suggests that subclinical brain dysfunction occurs more frequently than is generally recognized.

Cyclosporine may affect improvement of cognitive brain function after successful cardiac transplantation

BACKGROUND

The effects of cardiac transplantation on cognitive brain function are uncertain.

METHODS AND RESULTS

We measured cognitive brain function and quality of life in out-of-hospital cardiac transplant candidates (n = 55; ejection fraction, 19.9%; age, 54.8 years [means]). After transplantation, the patients were serially reevaluated at 4 months (n = 25) and at 12 months (n = 19). Brain function was measured objectively by cognitive P300 evoked potentials. Additionally, standard psychometric tests (Trail Making Test A, Mini-Mental State Examination, and Profile of Mood State test) were performed. Cognitive P300 evoked potentials were impaired in cardiac transplant candidates (359 ms, recorded at vertex) compared with 55 age- and sex-matched healthy subjects (345 ms, P < .01). Trail Making Test A was also abnormal (45 versus 31 seconds in 55 healthy subjects, P < .01). After transplantation, P300 measures were normalized at 4 months (345 ms, P < .05 versus before transplantation) but declined again at 12 months (352 ms, P = NS versus before transplantation). Stepwise multiple regression analysis revealed that cumulative cyclosporine dosage was the only predictor of individual cognitive brain function 4 months (753 mg/kg body wt, P < .05) and 12 months (2006 mg/kg body wt, P < .01) after transplantation, respectively.

CONCLUSIONS

Objective cognitive P300 auditory evoked potential measurements indicate that cognitive brain function is significantly impaired in patients suffering from stable end-stage heart failure. Successful cardiac transplantation is effective to fully normalize impaired brain function. Subsequent relative long-term decline of cognitive brain function after successful cardiac transplantation is strongly suggested to be related to cumulative cyclosporine neurotoxicity.

Detection of nontraumatic comatose patients with no benefit of intensive care treatment by recording of sensory evoked potentials

OBJECTIVES

To determine the predictive ability of sensory evoked potential recordings in nontraumatic comatose patients. To evaluate the hypothesis that patients with bilateral absent cortical responses ultimately die despite long-term intensive care treatment.

DESIGN

Prospective cohort study.

SETTING

Medical intensive care unit (ICU) of a university hospital.

PATIENTS

Four hundred forty-one adult nontraumatic comatose patients (unarousable unresponsiveness to external stimulation, Glasgow Coma Score < or = 7) from various causes. Six hundred seventy-six sensory evoked potential measurements were performed within 7 days after onset of coma.

MAIN OUTCOME MEASURES

Death or survival to hospital discharge.

RESULTS

Eighty-six patients (20%) had a bilateral loss of the cortical evoked potential N20 peak. Despite long-term intensive care treatment, all died without awakening from coma (mortality rate, 100%; 95% confidence interval, 96-100). The mean stay at the ICU after evoked potential measurement until death was 8.1 days (697 patient days). The overall cost of ICU management for these 86 patients accounted for approximately $1,324,300. In the remaining 355 comatose patients with preserved cortical N20 peak, 148 (42%) survived and 207 (58%) died. In this latter group of patients, cervicomedullary N13 to cortical N20 conduction time was prolonged in nonsurvivors (mean +/- SD, 6.7 +/- 1.3 milliseconds) compared with that in survivors (mean +/- SD, 6.4 +/- 1.2 milliseconds, P < .05) and healthy controls (mean +/- SD, 5.5 +/- 0.4 milliseconds, P < .05). Although this difference is statistically significant, a preserved N20 peak is not useful to discriminate whether the individual patient will survive (N13-N20 conduction time of > 7 milliseconds had a positive predictive value of correct prediction of death of 0.67).

CONCLUSIONS

Recording of sensory evoked potentials identifies a subgroup of adult nontraumatic comatose patients with a mortality rate of 100% in our sample. In these patients, advanced intensive care treatment should be withdrawn to provide limited ICU resources for patients with higher probability of favorable outcome. We emphasize that these results are not applicable to comatose patients following closed head trauma and particularly not to children.

Beneficial effect of renal transplantation on cognitive brain function

Cognitive brain dysfunction is a common complication of end-stage renal disease. To investigate the cerebral effect of renal transplantation, we studied P300 event-related potentials--an objective marker of cognitive brain function--trailmaking test and Mini-mental state in 15 chronic hemodialysis patients and 45 matched healthy subjects. Before transplantation, patients showed prolonged P300 latency (364 vs. 337 ms, P < 0.01), smaller amplitude (15.2 vs. 19.1 microV) and scored lower (P < 0.05) in trailmaking test and Mini-mental state as compared to healthy subjects. Following renal transplantation (14 months), P300 latency decreased (337 ms, P < 0.01 vs. before) and amplitude increased (17.4 microV, P < 0.05 vs. before), indicating improved cognitive brain function. The trailmaking test and Mini-mental state tended to improve. Following transplantation, P300 findings, trailmaking test and Mini-mental state were not different from healthy subjects. Additional studies following erythropoietin treatment in 6 of the 15 hemodialysis patients revealed decreased (improved) P300 latency (351 vs. 379 ms before, P < 0.05) with further decrease following transplantation (341 ms, P = 0.06). Our findings indicate that cognitive brain dysfunction in hemodialysis patients may be fully reversed by successful renal transplantation.