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Twenty-nine patients, aged 66(+/- 7) years with a peripheral pulmonary opacity (mean diameter 3.6 +/- 1.8 cm) believed to be a tumor, were randomly allocated to initial investigation by either fibreoptic bronchoscopy or percutaneous fine needle aspiration biopsy, the latter performed under fluoroscopic control. The patients proceeded to the alternative investigation in the event of the first failing to achieve a diagnosis. Malignancy was confirmed by the initial procedure in 14/15 patients randomized to fine needle aspiration biopsy but only in 1/14 patients randomized to fibreoptic bronchoscopy (P less than 0.01). Overall, these figures were 25/28 fine needle aspiration biopsy and 2/15 fibreoptic bronchoscopy (P less than 0.01). These results confirm the clinical suspicion that fine needle aspiration biopsy is far more likely than fibreoptic bronchoscopy to establish the presence of malignancy in peripheral pulmonary opacities.

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We report a case of giant pulmonary hamartoma found in a patient who had undergone lobectomy and thoracoplasty 40 years previously. This particular case may be consistent with the theory of hamartomas as acquired lesions.

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The role of fine needle aspiration biopsy has been assessed prospectively in the diagnosis of discrete lung shadows. A questionnaire was completed before each of 100 biopsies (in 97 patients) to determine the clinician's pretest diagnosis and the likelihood of malignancy. The latter estimates were combined with the previously established sensitivity (71%) and specificity (100%) of the procedure for diagnosing malignancy in the unit to allow calculation in each case of the change in certainty of malignancy as a result of the investigation. Among the 100 biopsies there were 73 true positive and 13 true negative results. There were no false positive results but there were 14 false negatives (cases where malignancy was later proved but where the biopsy did not show unequivocal evidence of malignancy). Among the 27 negative biopsy results the clinician had estimated the likelihood of malignancy as 80% or more in 13 cases. In 11 of these 13 patients the eventual diagnosis proved to be a malignant tumour; on the other hand, six of the 10 patients given a less than 50% chance of malignancy had a benign outcome. A positive biopsy result was therefore quantitively of greatest value when the prior estimate of malignancy was low. In the case of the false negative results the prior probability of malignancy was usually sufficiently high to merit further investigation. It is estimated that the procedure led to the avoidance of thoracotomy in up to 14 of 97 patients.

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We have reviewed the clinical and investigative details of 141 patients who underwent laparoscopy in order to determine how best this technique can be used. The clinical history and biochemical investigations usually only indicated some form of hepatobiliary disease, but all patients with spider telangiectasia, splenomegaly, or esophagogastric varices had diffuse parenchymal liver disease, and further investigation was only required to detect its cause. Laparoscopy succeeded in 129 patients (91%), and serious complications occurred in six (4%). The appearance of the liver did not accurately reflect the underlying pathology, indicating the need for biopsy in all cases. Laparoscopy and 99mTc-sulfur colloid liver imaging each failed to detect a few hepatic malignancies, but none were missed by both investigations combined, and similar results were obtained for parenchymal liver disease. Scanning and laparoscopy proved a highly accurate diagnostic combination.

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A 74 year old man presented with cryptogenic liver cirrhosis and ascites. On 99Tcm sulphur colloid scanning he was found to have a filling defect in the right lobe of the liver which disappeared when the liver scan was repeated with 75Se selenomethionine. This lesion, initially thought to be a hepatoma, proved eventually at post mortem to be a hyperplastic hepatic nodule.

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In 1974 a project was initiated in which patients with apparently operable breast carcinoma underwent special investigations in an attempt to identify occult metastasis in bone and liver. One hundred and seventy-two patients have been followed for two years or more and their axillary node histological findings reviewed. From analysis of these patients the following conclusions may be drawn. Careful clinical assessment, especially measurement of the primary tumour and palpation of the axillary nodes, remains a fundamental guide to the likelihood of early recurrence. Histological confirmation of node metastases is as valuable as clinical assessment, but is not superior unless other features of node histology are considered. Micrometastases do not increase the probability of early recurrence except in comparison with a group whose nodes lack both metastases and other unfavourable features. The majority of special investigations do not have additional predictive value, though a bone scan is useful in the small number (less than 10%) in whom it is positive.

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A prospective study has been carried out in 172 women to determine the sensitivity of methods to detect occult metastatic disease in the skeleton and liver. With the exception of bone scintiscans, the results of these tests bore little relationship to recurrence rates. On the other hand, knowledge of the histopathology of the lower axillary (pectoral) lymph nodes is of value in this respect.A follow-up study is also reported which confirms the importance of accurate measurements of the primary tumour clinical node status and oestrogen receptor contact of the tumour in defining prognostic groups. Elastosis (estimated in 165 tumours) did not prove to be a useful prognostic index.

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A young woman who developed a cerebral venous thrombosis shortly after commencement of an oral contraceptive preparation was subsequently found to have paroxysmal nocturnal haemoglobinuria. The aetiology of thrombotic complications in this condition is discussed, with particular reference to the additional risk factor of the contraceptive pill in this case.

PIP: A case of a young women with paroxysmal nocturnal hemoglobin (PNH) who developed thrombosis of the cerebral veins after beginning a regimen of oral contraceptives is presented. She was 24 years old and presented with a 3-week history of frontal headache, neck stiffness, paraesthesiae of both arms, and weakness of the left leg. She had begun use of Microgynon 2 months before presentation, but had discontinued use when symptoms began. Hematological studies showed a shortened partial thromboplastin time, high fibrinogen and factor VIII levels, and prlonged euglobulin clot lysis time. Though this patient had a history of coagulation difficulties, it was not until after taking the estrogen-containing contraceptive preparation that PNH developed. The mechanism of thrombosis may be related to the liberation of thromboplastic material from hemolysed erythrocytes and to interaction between complement-sensitive platelets and complement components in plasma. It is suggested that the estrogen augmented the previously existing thrombotic condition in this patient, and that administration of estrogen-containing preparations should not occur in women with thrombotic disorders.

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99Tcm-labelled HIDA administered intravenously is promptly taken up by the liver and excreted into the bile duct and gallbladder. In this study the use of this agent in hepatoscintigraphy was evaluated. Thirty patients with a variety of hepatobiliary pathology were studied. After an overnight fast 2 mCi of 99Tcm HIDA were given intravenously and the patient was scanned continuously for 1 h. A rapid outline of the liver and biliary tract was usually obtained and the T 1/2 of the tracer in the blood stream was 20 min. In total obstructive jaundice, isotope was excreted through the renal tract without visualization of the liver. Hepatoscintigraphy was compared with conventional radiographs and ultrasonography in 19 patients presenting an emergencies with suspected hepatobiliary disease and was found to be comparable to the latter modes of investigation. In the jaundiced patients hepatoscintigraphy was inferior to percutaneous transhepatic cholangiography and to ultrasonography. No adverse side effects have followed the use of the radiopharmaceutical.

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Iodine-131 labelled Biligram has been evaluated as a radiopharmaceutical for dynamic scintiscanning of the liver and biliary tract. In 10 normal subjects there was good visualisation of the liver and gallbladder. In 18 patients 131I Biligram was found to be unsatifactory for differentiating parenchymal liver disease from biliary tract obstruction owing to inability to demonstrate the gallbladder when liver function was more than mildly deranged. Quantitative analyses of blood clearance and hepatic activity curves for 131I Biligram were not clinically helpful. Urinary excretion of 131I Biligram increased with the degree of hepatic dysfunction.

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Percutaneous transhepatic cholangiography using the Chiba needle has been performed on 102 patients. There was an overall success rate of 86 out of 102 cases (84%). Dilated bile ducts were successfully demonstrated in 61 out of 65 patients (94%) and non-dilated ducts in 25 out of 37 patients (70%). Gallbladder filling was achieved in 40 out of 70 cases (67%). The hepatic lymphatics were filled in 32 cases but dilated lymphatics were mainly seen in patients with biliary cirrhosis, inflammatory liver disease or lymphoma. It is suggested that an excessive radiation dose may be given to the radiologist's fingers unless the fluoroscopy diaphrams are kept well coned down. Complications requiring active medical intervention occurred in three cases and emergency surgery in one case.

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Serial chest radiology and echocardiography were performed in seven patients undergoing chronic haemodialysis who developed pericarditis. Echocardiography was helpful in making an early diagnosis of a pericardial effusion in the absence of specific clinical or radiological signs of an effusion. It also enabled changes in the thickness of a pericardial effusion to be detected, which was of value when clinical features suggestive of cardiac tamponade occurred during dialysis, and showed that the effusion could increase in size despite the use of regional heparinisation for dialysis. Resolution of a pericardial effusion could be defined accurately using echocardiography, whereas this was not possible clinically or radiologically. It is concluded that serial echocardiography is a good method of monitoring a pericardial effusion in dialysis patients.

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Strontium 87m bone scanning was used in the assessment of 162 patients with breast cancer. Seventy-two patients had abnormal bone scans and in 63 (87 percent) these findings were subsequently confirmed. More metastases were detected by scanning and radiology than by radiology alone. There was a false positive rate of 7 percent. Of the 90 negative scans 23 showed evidence of metastasis either radiologically or at autopsy. This represented a false negative rate of 26 percent. The reasons for the false results are discussed particularly in relation to the problems of imaging the dorsal spine.

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