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Bronchoscopy, computed tomography (CT) and surgical staging procedures are complimentary methods of investigating patients with lung cancer. CT has been shown to be of value prior to bronchoscopy in the investigation of haemoptysis and malignancy, with excellent correlation between the detection of disease within the large airways on CT and direct visualisation at bronchoscopy. The utility of CT has been further increased by the development of multislice scanners with the generation of volumetric data enabling multiplanar image acquisition. Additionally the advent of CT co-registered with positron emission tomography will play an important role in guiding the choice of surgical staging procedures The increasing use of multidisciplinary medical care requires radiologists to have a greater understanding of the abilities and limitations of both bronchoscopy and surgical staging procedures in evaluating disease demonstrated on imaging.

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STUDY OBJECTIVES: To assess whether MRI detectable evidence of silent cerebrovascular disease is more prevalent in patients with obstructive sleep apnea (OSA) when compared to carefully matched control subjects. DESIGN AND SETTING: Case-control study of patients with OSA attending a specialist sleep clinic and matched control subjects drawn from the normal community. PARTICIPANTS: Forty-five sleep clinic patients with moderate to severe OSA and excessive daytime sleepiness, matched to 45 control subjects without excessive sleepiness or evidence of OSA on a sleep study. Matched variables included age, body mass index (BMI), alcohol and cigarette consumption, treated hypertension, and ischaemic heart disease. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: All subjects underwent 24-hour ambulatory blood pressure recordings (before treatment in OSA patients) and sagittal T1, axial T2, and coronal dual echo cerebral MRI imaging to detect clinically silent abnormalities related to hypertensive cerebrovascular disease; areas of high signal foci in deep white matter (DWM), lacunae, and periventricular hyperintensity. Lacunae/high signal foci in DWM and/or periventricular hyperintensity were present in 15 (33%) OSA subjects and 16 (35%) controls, despite significant increases in mean daytime diastolic blood pressure (4.6mmHg, p<0.05), and both nighttime diastolic (7.2mmHg, p<0.001) and systolic blood pressures (9.2mmHg, p<0.05) in OSA subjects. These data exclude more than a 17% excess prevalence of MRI detected minor cerebrovascular disease in the OSA patients, with 95% confidence. CONCLUSIONS: Sub-clinical cerebrovascular disease is prevalent in both clinic patients with OSA and their matched control subjects. Despite the increased arterial blood pressures, there is, however, no apparent excess of MRI-evident subclinical cerebrovascular disease in patients with OSA compared to appropriately matched control subjects.

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AIM: To assess the role of contrast-enhanced computed tomography (CT) prospectively in patients with suspected malignant pleural effusions. MATERIALS AND METHODS: Forty consecutive patients referred for the investigation of a suspected malignant pleural effusion had contrast-enhanced thoracic CT, thoracoscopy, thoraco-centesis and pleural biopsy, either percutaneously or at thoracoscopy. Final diagnoses were based on histopathological or cytological analysis (n = 30), autopsy findings (n = 3) or clinical follow-up (n = 7). The pleural surfaces were classified at contrast-enhanced CT as normal or abnormal and, if abnormal, as benign or malignant in appearance using previously established CT criteria for malignant pleural thickening by two observers unaware of the pathological diagnosis. RESULTS: Pleural effusions were malignant in 32 patients and benign in eight patients. Pleural surfaces assessed at CT showed features of malignancy in 27 out of 32 patients with a malignant effusion (sensitivity 84%, specificity 100%). Overall, CT appearances indicated the presence of malignancy in 28 of 32 (87%) patients. All eight patients with benign pleural disease were correctly diagnosed by CT. CONCLUSION: Contrast-enhanced CT is of value in patients with suspected malignant pleural effusions. The previously established criteria for malignant pleural thickening of nodularity, irregularity and pleural thickness >1 cm are reliable in the presence of a pleural effusion.

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Most patients referred for lung biopsy have a focal lesion that is likely to be a carcinoma, and fine needle aspiration is usually sufficient to confirm the diagnosis. When non-carcinomatous disease is suspected, tissue architecture is important and potential diagnostic techniques include percutaneous cutting needle biopsy (CNB). We retrospectively reviewed 37 CNBs performed for clinically suspected non-carcinomatous disease; recording the biopsy result, final diagnosis, radiological nature of the pulmonary abnormality, distance from the pleura of the lesion biopsied and biopsy complications. 9 patients had a single pulmonary nodule/mass; 13 had multiple nodules/masses; 8 had a lobar consolidation/mass; and 7 had multifocal consolidation. The lesion abutted the pleura in 31 cases, lying within 1 cm in the other 6 cases. The minor complication rate was 14%, with no major complications. Specific malignant diagnoses were made in 9 patients, and specific benign in 23, in all of whom clinicoradiological follow-up was concordant. CNB did not yield a specific diagnosis in five patients, including two lymphomas and one case of unsuspected tuberculosis in which the sample was not cultured. The overall accuracy of CNB was 32/37 (86%). CNB is a safe and accurate means of achieving a tissue diagnosis for patients with peripheral pulmonary parenchymal disease thought not to represent carcinoma.

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OBJECTIVE: To determine the accuracy of ultrasound in the detection of pneumothorax. METHODS: Prospective blinded study comparing ultrasound, CT and radiographic findings in 29 patients following 41 CT-guided lung biopsies. Ultrasound examination of the chest was limited to the biopsy needle entry site. RESULTS: Thirteen patients developed a post-biopsy pneumothorax demonstrated by CT. Seven of these were detected by ultrasound and six were visible on erect chest radiographs. Six of the 13 pneumothoraces were not detected by ultrasound, but five of these were loculated away from the biopsy needle entry site and were therefore in areas not examined during the limited ultrasound examination. There were no false-positive diagnoses of pneumothorax using ultrasound. The positive predictive value for ultrasound was 100% and the negative predictive value was 82%. CONCLUSION: In this patient group, ultrasound was more sensitive than erect chest radiography in the detection of pneumothorax. Both have a specificity of 100%. This study suggests that ultrasound may prove valuable in pneumothorax detection when rapid conventional radiography is not possible or practical, and in circumstances where ultrasound is readily available, such as during ultrasound-guided interventional procedures.

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AIM: To determine the frequency of isolated, asymptomatic metastases of the peripheral skeleton in patients with breast and prostate cancer. METHODS: A retrospective review was performed of staging skeletal scintigrams. Patients with hot spots in the peripheral skeleton in the absence of convincing evidence of metastatic disease in the axial skeleton were followed-up to determine the nature of the peripheral lesion(s) based on other imaging modalities, serial imaging or biopsy, and to determine if the lesion(s) had been symptomatic at the time of the scintigram. SUBJECTS: 200 patients with histologically proven carcinomas of the breast or prostate. RESULTS: Four patients (2%) had isolated metastatic involvement of the peripheral skeleton, and would, therefore, have been wrongly staged by a magnetic resonance 'marrow screen' of the axial skeleton. However, in three of these patients the lesions were painful, prompting diagnostic plain radiographs independent of the scintigraphic findings. Twelve patients (6%) had isolated scintigraphic abnormalities of the peripheral skeleton suggestive of metastatic disease but which on further investigation were shown to be benign lesions. CONCLUSION: A limited magnetic resonance (MR) 'marrow screen' confined to the axial skeleton would not result in any significant loss of accuracy in staging patients with breast and prostate carcinoma compared with skeletal scintigraphy. Given the proven increased sensitivity of MR over skeletal scintigraphy in the detection of bone metastases, and the additional information MR provides, it is likely to provide a more accurate basis for management.

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OBJECTIVE: Pleural effusions are a frequent complication of malignancy and cause considerable morbidity from dyspnea. The drainage and control of malignant effusions relieve symptoms and maintain quality of life but these are difficult in patients with multiloculated effusions in whom drainage usually fails. This observational series reports the use of intrapleural streptokinase (IPSK) in the management of malignant multiloculated pleural effusions resistant to standard chest tube drainage. METHODS: Ten consecutive patients with malignant multiloculated pleural effusions, aged 39 to 89 years, were given 250,000-IU doses of IPSK twice daily after failure to drain the effusions with a standard chest tube because of multiloculation and multiseptation, as demonstrated by CT or ultrasound scanning. Outcome was assessed by radiographic improvement and symptom control. RESULTS: All 10 patients responded to between 500,000 and 1,500,000 IU of streptokinase. There was an increase in pleural fluid drained (mean volume+/-SD; pre-IPSK, 843+/-690 mL; post-IPSK, 2,368+/-1,051 mL; p < 0.001, paired t test), and radiographic improvement was seen in all 10 patients. All subjects tolerated the instillation of streptokinase well. One subject required opiate analgesia for transient chest pain, and there were no hemorrhagic or allergic complications. One patient died of unrelated septicemia. CONCLUSIONS: This series suggests that IPSK may be useful in the drainage of malignant multiloculated pleural effusions in patients who fail to drain adequately with a standard chest tube. Malignant pleural effusions should not be considered a contraindication to IPSK.

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Pneumothorax is reported to be a more common complication of lung biopsy performed under computed tomography (CT) than under fluoroscopic guidance. This may simply reflect the greater sensitivity of CT over chest radiographs (CXRs) in the detection of small pneumothoraces. This study aimed to determine the incidence of pneumothorax detected by CXR and by CT after CT-guided biopsy of non-pleurally based pulmonary masses, and to compare these incidences with previous reports in the literature of pneumothorax incidence post fluoroscopic biopsy. 88 consecutive CT-guided lung biopsies of masses not abutting the pleural surface were included. Immediate post-biopsy CT images, and 1 and 4 h CXRs were assessed independently by two observers for the presence and size of pneumothorax. 72 biopsies were fine needle aspirations (FNAs) performed with 22 G spinal needles only, seven were cutting needle biopsies (CNBs) performed with 18 G cutting needles only, and nine were both. 37 patients (42%) developed a pneumothorax. 35 were detected on CT (40%) and 22 on CXR (25%). None required tube drainage. Of the patients in whom CT demonstrated a pneumothorax, the average depth of this was significantly greater for those in whom CXR also detected a pneumothorax compared with those in whom CXR was negative (7.3 mm versus 3.4 mm, p < 0.05). The incidence of pneumothorax detected on CXR post CT-guided biopsy is similar to the reported incidence post fluoroscopic biopsy.

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The advent of spiral CT has encouraged investigation into the diagnosis of venous thromboembolic disease. It has also exposed the limitations of prior methods of investigation and raised questions as to the significance of small pulmonary emboli. This article discusses this new technique, the clinical detection of venous thromboembolic disease and possible current and future strategies in diagnosis.

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The use is reported of percutaneous transrenal embolization for renal artery injury during percutaneous nephrostomy. If a nephrostomy catheter is seen to transfix the renal pelvis, the possibility of injury to a large renal artery must be considered. The misplaced nephrostomy catheter should be withdrawn over a guidewire. Percutaneous renal artery embolization may enable rapid arrest of life threatening haemorrhage.

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Two patients are described who developed pneumothoraces more than 24 hours after computed tomography (CT) guided percutaneous fine needle aspiration lung biopsies. The pneumothoraces required treatment in both cases. Such delayed pneumothorax after lung biopsy is extremely unusual. Patients should be warned of the possible occurrence of this complication and instructed to seek medical help if they develop chest pain or breathlessness.

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BACKGROUND: Standard treatment for pleural infection includes catheter drainage and antibiotics. Tube drainage often fails if the fluid is loculated by fibrinous adhesions when surgical drainage is needed. Streptokinase may aid the process of pleural drainage, but there have been no controlled trials to assess its efficacy. METHODS: Twenty four patients with infected community acquired parapneumonic effusions were studied. All had either frankly purulent/culture or Gram stain positive pleural fluid (13 cases; 54%) or fluid which fulfilled the biochemical criteria for pleural infection. Fluid was drained with a 14F catheter. The antibiotics used were cefuroxime and metronidazole or were guided by culture. Subjects were randomly assigned to receive intrapleural streptokinase, 250,000 i.u. daily, or control saline flushes for three days. The primary end points related to the efficacy of pleural drainage--namely, the volume of pleural fluid drained and the chest radiographic response to treatment. Other end points were the number of pleural procedures needed and blood indices of inflammation. RESULTS: The streptokinase group drained more pleural fluid both during the days of streptokinase/control treatment (mean (SD) 391 (200) ml versus 124 (44) ml; difference 267 ml, 95% confidence interval (CI) 144 to 390; p < .001) and overall (2564 (1663) ml, 95% CI 465 to 2545; p < 0.01). They showed greater improvement on the chest radiograph at discharge, measured as the fall in the maximum dimension of the pleural collection (6.0 (2.7) cm versus 3.4 (2.7) cm; difference 2.9 cm, 95% CI 0.3 to 4.4; p < 0.05) and the overall reduction in pleural fluid collection size (p < 0.05, two-tailed Fisher's exact test). Systemic fibrinolysis and bleeding complications did not occur. Surgery was required by three control patients but none in the streptokinase group. CONCLUSIONS: Intrapleural streptokinase probably aids the treatment of pleural infections by improving pleural drainage without causing systemic fibrinolysis or local haemorrhage.

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We report a patient who presented with small intestinal ischaemia due to metastatic mesenteric disease from an oesophageal carcinoma. Enteroclysis suggested the diagnosis of small intestinal ischaemia, which was found at laparotomy to be due to compression of mesenteric veins by a nodal mass at the root of the small intestinal mesentery. Although this phenomenon has been described particularly in patients with carcinoid tumours, we believe that mesenteric venous ischaemia resulting from spread to the mesentery from an extra-abdominal primary neoplasm is extremely rare.

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Pseudomonas aeruginosa is increasingly reported as a respiratory pathogen in patients with advanced human immunodeficiency virus (HIV) disease. We retrospectively reviewed the chest radiographic appearances of 29 HIV-infected adults with bronchopulmonary infection in whom Pseudomonas aeruginosa was the sole respiratory pathogen isolated. The commonest radiographic abnormality was a diffuse reticular (11 patients) or reticulonodular (9 patients) infiltrate in the pulmonary interstitium. Alveolar opacification was seen in seven patients. Cavitation was rare (2 patients), as was ground-glass opacification (2 patients). Five patients had pleural effusions. No patient had mediastinal or hilar lymphadenopathy. Normal chest radiographs were seen in eight patients. Although the radiographic appearances of Pseudomonas bronchopulmonary infection in HIV-infected patients are non-specific, an interstitial infiltrate is a common finding. Pseudomonas aeruginosa should be considered along with the commoner pathogen Pneumocystis carinii in the differential diagnosis of an interstitial infiltrate in this group of patients.

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Although there have been many studies of the plain radiographic appearances of intrathoracic Kaposi's sarcoma in patients with the acquired immunodeficiency syndrome, the computed tomography (CT) findings are less well established. We performed a retrospective review of the thoracic CT findings of 15 patients with tracheobronchial Kaposi's sarcoma diagnosed at bronchoscopy in whom concurrent respiratory infection had been excluded. The commonest CT finding was the presence of ill-defined nodules, seen in all patients. In eight patients more than 20 nodules were seen. Small areas of ground-glass attenuation surrounded one or more nodules in 11 patients. Bilateral perihilar infiltrates were seen in 14 patients, extending into the pulmonary parenchyma along bronchovascular bundles. Interlobular septal thickening was seen in 13 patients and fissural nodularity in 15 patients. To our knowledge this latter finding has not been described before. Discrete areas of ground-glass attenuation were seen in six patients. Small bilateral pleural effusions occurred in six patients; four patients had a pericardial effusion. Shotty mediastinal lymphadenopathy occurred in six patients, and mediastinal nodes greater than 1 cm were present in four patients. None of the patients had CT evidence of chest wall or bone involvement. Although none of these findings are specific, the combination of poorly defined nodules, fissural nodularity and a bronchovascular distribution of perihilar opacities on CT is highly suggestive of pulmonary Kaposi's sarcoma.

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AIM: To document the phenomenon and distribution of air-trapping on computed tomography in patients with sub-acute extrinsic allergic alveolitis (EAA). PATIENTS AND METHODS: A retrospective analysis of high resolution CT scans was performed on 20 patients with proven EAA. All patients had inspiratory scans and 12 patients had expiratory scans. These were assessed for the presence and distribution of: air-trapping, ground-glass opacification and nodularity. RESULTS: Areas of decreased attenuation consistent with small airways disease was demonstrated in 15/20 patients on inspiratory scans, and confirmed to be areas of air-trapping in 11/12 patients on expiratory scans. Additional areas of air-trapping were identified in 5/11 patients on expiratory scans. 18/20 patients had found-glass opacification and 14/20 patients demonstrated a nodular patter. CONCLUSION: Air-trapping is a common finding in sub-acute extrinsic allergic alveolitis on CT and its detection is enhanced by performing expiratory scans.

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