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BACKGROUND: Although the development of noncardiogenic pulmonary edema or pulmonary reimplantation response (PRR) after lung transplantation has been well described, the incidence has not been established and the relationship of PRR to clinical risk factors has not been analyzed. STUDY OBJECTIVES: (1) To describe the incidence of PRR in lung transplant recipients, (2) to identify the predictors of PRR, (3) to examine the correlation of suspected predictors with the severity of PRR, and (4) to evaluate the impact of PRR on morbidity and mortality of lung transplant recipients. DESIGN: Retrospective review of clinical records and radiographic studies. SETTING: Tertiary care referral center. PATIENTS: Ninety-nine consecutive patients with end-stage lung disease undergoing lung transplantation between February 1990 and October 1995. METHODS: Review of clinical records and postoperative chest radiographs of all lung transplant recipients to identify patients who experienced PRR. Chest radiographs of patients with PRR were graded for severity on a scale of 0 (none) to 5 (very severe). Demographic, pre- and perioperative factors were also evaluated along with short- and long-term survival of patients with PRR. RESULTS: Fifty-six of 99 lung transplant recipients (57%) experienced PRR. The median ischemia time of patients with and without PRR was 168 and 180 min, respectively (p = 0.62). The incidence of PRR was 51% in patients without preoperative pulmonary hypertension, 78% in mild to moderate pulmonary hypertension, and 58% in patients with severe pulmonary hypertension (p = 0.10). Incidence and severity of PRR was similar in patients receiving right, left, or double-lung transplantation. Similarly, age and sex of the recipients and underlying lung disease did not affect the incidence or severity of PRR. The incidence and severity of PRR was higher in patients undergoing cardiopulmonary bypass during lung transplantation. Patients with PRR had prolonged duration of mechanical ventilation and ICU stay. Overall, PRR did not affect the survival of the patients. However, survival of female lung transplant recipients was significantly better than male recipients (median survival, 60 vs 21 months; p = 0.02). CONCLUSIONS: Acute pulmonary edema or PRR occurs frequently (57%) after lung transplantation. In this series, PRR was not associated with a prolonged ischemia time, preoperative pulmonary hypertension, the type of lung transplant, underlying lung disease, or age or sex of recipients. However, use of cardiopulmonary bypass during surgery was associated with increased incidence and severity of PRR. Also, the development of PRR resulted in prolonged mechanical ventilation and a longer ICU stay, but did not affect survival. Female lung transplant recipients survived significantly longer than male recipients. The reason for this difference in survival is unclear.

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The purpose of this controlled study was to determine the diagnostic accuracy of computed tomography (CT) in the diagnosis of round atelectasis (RA). We reviewed two groups of chest CT scans of 22 patients (with 24 masses). Group 1 scans represent 10 patients (12 masses) known to have RA, and Group 2 scans represent 12 patients with "RA look-alike" masses. Scans in both groups were selected for review by two of the authors and later independently reviewed by the other authors, who were blind to the actual diagnosis. Scans were rated for the presence/absence of 18 features ascribed to RA in the literature and assigned a percent probability of RA by each rater. Consensus was achieved for discordant ratings, and the individual percent probabilities were averaged to create a consensus probability. ROC curve analysis of the consensus percent probability showed that diagnostic accuracy significantly exceeded chance [area under curve (AUC) = 0.95, p < 0.001]. Of all the features of RA examined, the presence of converging bronchovascular markings discriminated best between RA and "RA look-alikes" (sensitivity 83%, specificity 92%, likelihood ratio 11). Presence of adjacent pleural thickening and pleural-based location were even more sensitive features of RA (100% each), but lacked specificity (33 and 67%, respectively; likelihood ratios 3 and 1.5, respectively). We conclude that (a) although the diagnostic accuracy of CT for RA was high in this series, radiographic diagnosis is imperfect and that (b) the presence of converging bronchovascular markings was the best discriminator between the two groups, but that no single CT feature permitted perfect discrimination.

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Two adult patients with patent ductus arteriosus (PDA), resulting in Eisenmenger's syndrome, were evaluated by computed tomography and Magnetic Resonance imaging of the chest, which clearly demonstrated the patent arterial duct as well as the morphologic features of long-standing pulmonary arterial hypertension. Massively dilatated, calcified pulmonary arteries were seen, and the arterial duct was identified as a vascular channel between the distal aortic arch and the main pulmonary artery.

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Ehlers-Danlos syndrome (EDS) is an inherited disorder of connective tissue with multiple thoracic manifestations. We present an unusual thoracic manifestation of EDS consisting of parenchymal cysts and fibrous and fibroosseous nodules. These manifestations may be related to an abnormal attempt at repair of parenchymal or vascular tears.

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Barium swallow and endoscopy are complementary procedures in the detection of early esophageal carcinoma. CT is useful in the detection of distant metastases, and mediastinal invasion of key structures such as airway, aorta, and pericardium, but does not reliably differentiate T2 from T3 lesions or define subtle upper abdominal adenopathy. The disparity in reported results from different series published over the last 12 years can be accredited to two causes. First is the lack of uniformity in the way the studies were performed. Most authors agree that slice thickness should be 1 cm and contiguous. Lehr et al used 2-cm slices through the upper abdomen with additional slices through areas of special interest. Similarly, Markland defines his technique as "1-cm intervals from the thoracic inlet to the carina and below this at 1.5 cm intervals to the level of the adrenal glands." Such parameters are hardly optimized for the detection of 8-mm lymph nodes. The other cause of the disparity is interobserver variation in study interpretation. Goei et al staged 35 cases of esophageal cancer using CT. The CT interpretations of each of three readers were subsequently correlated with surgical and pathologic findings of 17 patients. CT pathologic correlation of the three observers showed sensitivities ranging from 50% to 57%, specificities ranging from 50% to 60%, and accuracies ranging from 46% to 71%. CT is useful as a surveillance tool in the postoperative patient. MR imaging does not have a defined role in the workup of esophageal tumors at this time.

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BACKGROUND: Tumors metastatic to the pleura are a leading cause of pleural effusions. The computed tomographic (CT) appearance of malignant pleural effusions varies from uniformly low attenuation without pleural abnormalities to thickened, irregular, contrast-enhanced pleura with or without discrete masses. There may be associated changes in the subcostal tissues. OBJECTIVE: To determine the prevalence of abnormalities observed with CT scanning in patients with malignant pleural effusion. METHODS: We analyzed the CT appearance of the pleura in 86 patients with documented malignant pleural effusions. Patients with primary malignancy of the pleura (mesothelioma) were excluded. RESULTS: In 98% of the malignant effusions the fluid was homogeneous. Focal tumor masses were identified within the effusion in 10%. CT evidence of fluid loculation was seen in 40%. Pleural thickening, either smooth or irregular, was identified in 62%. CONCLUSIONS: The transaxial anatomic display afforded by CT scanning facilitates demonstration of several features that should arouse the suspicion of the radiologist and the clinician to the possibility of malignancy involving the pleura.

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We describe surgical relocation of the mesoazygos without its visceral pleura, from an intrapulmonary location to a normal right superior mediastinal position. The pictorial sequence presented confirms the postulated theory of azygos disimpaction and excludes the theory of symphysis of the azygos fissure.

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With the increasing number and improved survival of lung transplant recipients, radiologists should be aware of the imaging features of lung transplants and the associated complications. Reimplantation response, a noncardiogenic pulmonary edema seen 48 hours after transplantation that subsequently resolves, varies in appearance from a mild perihilar haze to a dense consolidation in the perihilar areas and lung bases. A late complication of omentopexy (used to prevent bronchial dehiscence) is herniation of abdominal contents through the diaphragmatic incision into the thorax. Extrabronchial air collections are a radiologic manifestation of anastomotic dehiscence. Stricture formation that compromises the bronchial lumina is usually visible with plain radiography, but computed tomography can aid in the evaluation. Acute rejection is evident radiographically as new or increasing pleural effusions, septal lines, subpleural edema, peribronchial cuffing, and air-space disease, without increase in cardiac size. Radiographic features of chronic rejection include both increased and diminished lung volumes, central and peripheral bronchiectasis, localized air-space disease, partial lobar atelectasis, thin linear irregular areas of increased opacity, pleural thickening, and diminished peripheral lung markings. Infection is frequently seen, especially gram-negative pneumonias, with fewer occurrences of cytomegalovirus infection, candidiasis, and invasive aspergillosis.

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Our study sought to determine whether tracheal dimensions were reduced in patients with Down's syndrome and whether such a narrowing, if present, was related to the presence of congenital heart disease or to body habitus (height or weight). The inner diameter of the tracheal air column was measured at 2 cm above the aortic arch in 14 adult patients with Down's syndrome, and the results compared with previously established norms. Two-way analysis of variance showed no significant difference in z-scores between sexes or between those with or without congenital heart disease. Z-scores were significantly different from zero for both coronal diameters (p = 0.0010) and sagittal diameters (p = 0.0003). The negative limits on the 95% confidence interval for coronal z-scores (-2.5 to -0.8) and sagittal z-scores (-2.6 to -1.0) indicate that our patients have tracheal diameters significantly smaller than normal. Linear regression analysis showed no significant correlation between tracheal diameters and patients' height or weight. We conclude that tracheal diameters in adult patients with Down's syndrome are reduced and that the narrowing cannot be ascribed to associated congenital heart disease or to body habitus.

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Cancer patients experience many gastrointestinal symptoms which may lead to weight loss. Assessment of gastrointestinal motility may contribute to our understanding of these symptoms and suggest rational therapeutic approaches to the anorexia-cachexia syndrome. We have evaluated a simple, inexpensive, well-tolerated test of upper gastrointestinal motility in patients with advanced cancer. One-centimetre portions of radiopaque nasogastric tubing were ingested with food. Six hours later, a flat-plate abdominal x-ray was obtained to determine the marker placement. Patients were evaluated for gastrointestinal symptoms. Those with more symptoms, particularly early satiety, had a greater incidence of reduced upper gastrointestinal motility.

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The difficulty associated with achieving precise alignment in a bedside radiographic setting has led many departments to abandon the use of a grid and forfeit the improved contrast it affords. The authors describe a method of alignment that has proved successful in overcoming the hazards of grid cut-off in a bedside setting. The method affords obtainment of reproducible high-quality bedside radiographs with a 10:1 linear grid.

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Twenty patients with non-small cell bronchogenic carcinoma were prospectively studied for intrathoracic lymphadenopathy using computed tomography (CT) and magnetic resonance imaging (MRI). The CT and MRI results were correlated with the surgical histopathology results of 103 harvested lymph nodes. Based on node dimension (utilizing a 1-cm cutoff value), neither imaging modality was accurate in predicting the histopathology of the nodes. CT had a sensitivity of 21%, specificity of 95%, and an overall accuracy of 85%; MRI had a sensitivity of 14%, specificity of 97%, and an overall accuracy of 85%. Moreover, CT and MRI detected preoperatively only 17% and 14%, respectively, of the harvested nodes. In summary, lymph node sizes measured by CT and MRI are inaccurate in predicting the benignity or malignancy of lymph nodes. Lymphadenopathy can be present even with a "negative" CT or MRI scan of the thorax.

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The successful application of computerized tomographic density analysis for evaluating the solitary pulmonary nodule has previously been described and the technique has since been simplified by using a calcium-equivalent nodule reference phantom. Because published experience with this technique remains limited, the current research reports the Cleveland Clinic experience with the CIRS model III pulmonary nodule reference phantom. Without knowledge of the final diagnosis, the nodule phantom was used as the standard for categorizing 31 nodules in 29 patients as either benign or indeterminate. Secure diagnoses were obtained in all cases. Eleven nodules were called benign and ten proved so, whereas 20 nodules were classified as indeterminate. One lesion, an adenocarcinoma, was falsely called benign using this technique. The excellent density discrimination achieved with CT makes this a superior tool for analysis of the solitary pulmonary nodule, and the nodule reference phantom has greatly simplified the technique of CT densitometry. As demonstrated by this and prior studies, calcification is not a unique feature of the benign lesion and successful clinical application of this technique requires cautious interpretation of results.

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Bronchopulmonary sequestration is a congenital anomaly in which part of the pulmonary tissue is detached from the normal lung and is supplied by anomalous systemic arteries. The sequestered, aberrant lung tissue does not have normal connections with the tracheobronchial tree or pulmonary arteries. In some patients with angiographic characteristics of this disorder, no sequestration is found at the time of surgery. We present three cases in which systemic arterialization of a portion of lung occurred without actual sequestration. Such cases of pseudosequestration can present a diagnostic challenge preoperatively and should be considered whenever angiographic findings compatible with bronchopulmonary sequestration are found.

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Standard coronal magnetic resonance (MR) imaging cannot depict long segments of the tracheobronchial tree and left pulmonary artery owing to the normal thoracic kyphosis and posteriorly angled course of these structures. By the use of electronic axial rotation (EAR), however, MR is capable of imaging any plane. We used EAR in 25 patients undergoing MR examinations of the thorax. This technique allowed superior definition of the longitudinal axis of the tracheobronchial tree and left pulmonary artery. The right pulmonary artery was satisfactorily imaged by the standard coronal plane.

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