Chest Roentgenographic Findings Research Articles

Bronchial foreign body misdiagnosed as pulmonary tuberculosis

Retained and neglected foreign bodies in the respiratory tract in children are a common occurrence. Undiagnosed foreign bodies can cause mechanical effects or chemical reactions and may present as chronic pulmonary infection, bronchiectasis, asthma, and lung collapse or lung abscess. Delay in diagnosis, appears to result from a failure to give serious consideration to the diagnosis, normal chest roentgenographic findings, and negative bronchoscopic findings. A case of left bronchial foreign body aspiration is herein reported to illustrate the causes and complications of the delayed diagnosis. It is hoped that this will help sensitize the medical practitioner of the need for a high index of suspicion in children presenting with symptoms suggestive of foreign body aspiration. This study will also serve as advocacy for the provision of adequate bronchoscopic equipments for paediatric practice in our health facilities.

Utilization Of Ventilation / Perfusion Lung Scan In A Cancer Hospital

Utilization Of Ventilation / Perfusion Lung Scan In A Cancer Hospital

Endotracheal-endobronchial metastases: report of 14 cases

Introduction: Endotracheal-Endobronchial Metastases (EEM) secondary to extrapulmonary neoplasm are rare. Since 1989 we have encountered 14 patients with EEM. Materials and Methods: EEM were defined as documented extra pulmonary neoplasm metastatic to subsegmental or more proximal central bronchi in a bronchoscopically visible range. The developmental modes were described on the basis of classifying categories of Kiryu. Results: The primary tumors included breast cancer (4 cases including 3 women,1 man), colorectal carcinoma 1, renal cell carcinoma 1, embryonal cell carcinoma of testis 1,uterine cervix carcinoma 2,melanoma 1,osteogenic sarcoma 2,papillary thyroid carcinoma 1and prostatic sarcoma 1. The chest roentgenographic findings were: collapse 5, parenchyma mass 5, multiple nodule 2 and hilar enlargement 2. Median interval from diagnosis of primary tumor was 39.5 months. Endobronchial lesions were detected by bronchoscopy and their metastatic nature was confirmed histopathologically in all patients. Six patients were treated with external radiotherapy, while 6 patients had chemotherapy and 2 patients underwent surgical resection of metastasis. Conclusions: The cases we have reported are similar to those found in the literature, regarding their clinical and roentgenographic presentation. Local treatment is effective for palliating symptoms. All patients with extra pulmonary malignant tumor who are suspected to have pulmonary metastasis should undergo bronchoscopy to diagnose end bronchial metastasis and to differentiate it from primary lung cancer.

Tuberculous Peritonitis Associated with Ovarian Teratoma Presenting as Peritoneal Carcinomatosis

Peritoneal tuberculosis (TB) is a fatal disease if not promptly diagnosed. We present a case of unexplained ascites with miliary peritoneal TB and a review of the literature. A 56-year-old woman was admitted to our hospital because of severe abdominal fullness for 20 days. Computed tomography scans of the abdomen showed massive ascites and a huge intrapelvic mass mimicking an ovarian dermoid cyst. Laboratory examinations revealed an elevated serum cancer antigen 125 level of 1,132.9 IU/mL and normal chest roentgenographic findings. About 5 L of ascitic fluid and many superficial whitish miliary deposits on the intra-abdominal and pelvic surfaces were found during exploratory laparotomy. A right ovarian cystic mass measuring 15 × 14 × 10 cm in size was noted and removed. Pathologic studies of the cyst revealed a mature cystic teratoma, and all the specimens from the peritoneum and the ovarian surface had chronic granulomatous inflammation with central caseous necrosis compatible with TB. She received postoperative anti-TB chemotherapy and was doing well 5 months after surgery. Tuberculous peritonitis is not easy to diagnose. We suggest that tuberculous peritonitis associated with ovarian teratoma should be included in the differential diagnosis of peritoneal carcinomatosis.

Descriptive patterns of severe chronic pulmonary hypertension by chest radiography

To find chest roentgenographic (CXR) features to help differentiate two representative diseases with severe chronic pulmonary hypertension (PH). Thirty-six consecutive patients with chronic thromboembolic PH (CTEPH), 38 with primary PH (PPH), and 37 with left heart disease and PH. CXRs were reviewed about 6 features (left 2nd arc protrusion, right descending pulmonary artery diameter (rPAD), cardiothoracic ratio (CTR), right 2nd arc width, avascular area and pleural abnormality). Hemodynamic data and the degree of tricuspid regurgitation (TR) on echocardiography were compared with CXR findings. The diagnostic pattern of CTEPH was the presence of one of two findings, an avascular area or marked rPAD (>20mm) together with pleuritic change. The diagnostic pattern of PPH was one of the two features; without pleuritic abnormality, marked left 2nd arc protrusion (>10mm) or moderate left 2nd arc protrusion (5-10mm) with marked rPAD (<20mm). The sensitivity for the diagnosis of CTEPH among the three diseases was 78% and specificity was 92%. The sensitivity for the diagnosis of PPH was 45% and specificity was 88%. CTR and right 2nd arc width were related to the degree of TR in CTEPH and PPH. Characteristic roentgenographic findings can help differentiate two frequent diseases associated with chronic pulmonary hypertension and reflect the severity of disease.

Acute idiopathic pericarditis with transient constriction

A 28-year-old man was referred to a hospital because of acute illness, fever, malaise, and retrosternal chest pain. On the admission, he was eupnoic, the heart rate was 90 beats/min, and the blood pressure was 110/80 mm Hg. Chest roentgenographic findings were unremarkable, and electrocardiography showed near-ubiquitous ST segment (J point) elevations, diffuse PR segment depression and specular elevation in the aVR lead. On auscultation, no pericardial rub was evident. The following laboratory data were obtained: hemoglobin, 13.5 g/dl, leucocite count, 11 10/mm, erythrocyte sedimentation rate, 98 mm in 1 h. Echocardiography disclosed a large pericardial effusion (Fig. 1). The clinical features of active acute pericardial disease subsided with bed rest and nonsteroidal antiinflammatory drugs (ibuprofen 800 mg every 8 h). A specific cause was not apparent after assessment according to our internal diagnostic protocol [1]. Acute idiopathic pericarditis was diagnosed. Six days after, his conditions deteriorated: dyspnea, hypotension, and marked giugular venous distension were noted. The echocardio-

Pneumocystis carinii Pneumonia Presenting as an Isolated Pulmonary Nodule in a Non-HIV-Infected Immunosuppressed Patient

Case Report. A 68-year-old male with stage 4A Mantel cell lymphoma diagnosed six months previously was evaluated for his seventh cycle of chemotherapy (Cytoxan, doxorubicin, vincristine, and rituxan, alternating with methotrexate and Ara-C). The prior cycle of chemotherapy was complicated by a 10-day episode of neutropenia without fever. At this evaluation, the patient had no complaints, but chest roentgenography showed a left-lower-lung-field nodule that was not present on a roentgenograph two weeks previously or a CT scan 10 weeks previously. Physical examination findings were unremarkable; temperature and lung findings were normal. CT of the chest confirmed a 1.0 × 1.8–cm nodule in the lower lobe of the left lung (Figure 1). A PET scan did not demonstrate increased signals from the lungs. CT-guided aspiration of the lung lesion was performed. A biopsy specimen from the nodule was described as a “frothy, honey-combed material in macrophages,” and a silver stain confirmed the presence of Pneumocystis carinii (Figure 2). The patient was treated with a three-week course of oral trimethoprim/sulfamethoxazole (160/800 mg; two tablets three times a day) and received his scheduled chemotherapy. One month later, chest CT demonstrated resolution of the nodule.FIGURE 1.: CT of chest, showing a nodule (1 × 1.8 cm) in the lower lobe of the left lung.FIGURE 2.: A lung biopsy showed giant cells (original magnification, × 250). The same area is enlarged in the upper left corner (original magnification, × 1000; both stained with hematoxylin–eosin). Lower left corner shows Pneumocystis (silver stain; original magnification, × 1000).Discussion. Pulmonary nodules in the immunocompromised host have a wide array of causes. Malignancy is a common cause, and a relapse of Mantel cell lymphoma or a second malignancy needed to be considered in this case. Infectious agents known to cause isolated pulmonary nodules include fungi such as Aspergillus, Mucor, Cryptococcus, Sporothrix, Histoplasma, Blastomyces, and Coccidioidomyces species, as well as bacteria such as Nocardia, Rhodococcus, Legionella, or Mycobacterium. It is unusual for Pneumocystis carinii to be the causative agent of an isolated nodule, and it was recognized as the cause only after fine-needle aspiration and microscopic identification. For this immunosuppressed patient, treatment was considered warranted because of the risk for the local process to spread. This case underlines the importance of a thorough workup of a new pulmonary nodule in such a setting. Pneumocystis carinii pneumonia (PCP) typically presents with bilateral interstitial infiltrates, but many other roentgenographic presentations have been described, including normal chest roentgenographic findings [1]. Atypical presentations of PCP have been associated with inhaled pentamidine prophylaxis. The incidence of upper-lobe disease, cysts, and spontaneous pneumothorax are increased in patients receiving such prophylaxis. Pneumocystis carinii has been rarely reported to cause pulmonary nodules [2]. In a prior case study, two of 150 HIV-infected patients with PCP presented with a solitary pulmonary nodule [3]. In a separate study of isolated pulmonary nodules in HIV-infected patients, one of 10 was determined to be due to Pneumocystis [4]. In non-HIV-infected patients this presentation of PCP is rare, and so far it has been reported to occur in only one pediatric patient [5] and one adult heart transplant recipient [6]. Although isolated pulmonary nodules are a common complication in transplantation patients, large case reviews have not revealed Pneumocystis as a cause [7,8]. A review of the literature and MEDLINE uncovered no other case report of an isolated pulmonary nodule due to Pneumocystis in a patient receiving chemotherapy. We have histopathologically confirmed Pneumocystis as the cause of a solitary pulmonary nodule in such a patient.

Clinical features of non-specific interstitial pneumonia

The clinical features of 24 patients with non-specific interstitial pneumonia (NIP) were evaluated. The patients consisted of seven men and 17 women, with a median age of 60 years. In seven patients, the disease was idiopathic and eight had collagen vascular diseases. Cough, dyspnoea and fever were frequently observed. The time interval between the onset of symptoms and open lung biopsy was 3 months. Mild increases of IgG, CRP, and LDH were also frequently observed. The average per cent VC was 65·1 ± 3·2% and the average PaO 2 was 71·3 ± 2·4 Torr. Bronchoalveolar lavage was done in 20 patients, and a moderate increase in lymphocytes (27·8 ± 6·7%) with a low CD4 CD8 ratio (0·86 ± 0·22) was observed. Multiple patchy infiltration or diffuse interstitial shadows, located predominantly in the lower fields of both lungs were the characteristic chest CT findings. Lung biopsies in this group were characterized by varying proportions of chronic interstitial inflammation and fibrosis which was temporarily uniform. Patients were given steroid pulse therapy or oral steroids. The results were mild to marked improvements in chest roentgenographic findings and lung functions. Four patients (16·7%) died because of respiratory failure caused by NIP. This is the first report to describe clinical features of NIP since the original report by Katzenstein and Fiorelli.

Two strategies for managing invasive aspergillosis: a decision analysis.

We devised a diagnostic approach based on screening plasma for an Aspergillus antigen with use of a sandwich enzyme-linked immunosorbent assay (ELISA), thoracic computed tomographic scanning, and radionuclide imaging for managing patients at risk for invasive aspergillosis. We used a decision analytic model to compare this alternative strategy with the conventional strategy, which relies only on the presence of clinical symptoms, persistent fever, and chest roentgenographic findings. Use of the alternative strategy reduced the number of patients who would receive antifungal treatment empirically, but this strategy was more expensive. The specificity of the sandwich ELISA had a significant impact on cost, but the sensitivity did not. A 13% prevalence of infection resulted in equal costs for both strategies. As much as 43.3% of the patients treated empirically could be given liposomal amphotericin B (L-AmB) before the conventional strategy became the most expensive. The costs of the alternative strategy were less than those of the conventional strategy when >5.3% of all patients, irrespective of strategy, were treated with L-AmB.

Coronary artery fistulas in infants and children: A surgical review and discussion of coil embolization

Coronary artery fistula (CAF) is a rare congenital anomaly that can be complicated by intracardiac shunts, endocarditis, myocardial infarction, or coronary aneurysms. Recent reports have emphasized the efficacy of percutaneous transcatheter techniques. The purpose of this article is to review a 28-year surgical experience with CAF as a standard for comparison and to discuss the emergence and efficacy of transcutaneous catheter coil embolization as an alternative form of therapy. From 1968 to 1996, 17 patients (age, 6 weeks to 16.5 years; mean age, 5.5 years) were diagnosed with CAF: 8 of 12 by echocardiography and 17 of 17 by cardiac catheterization. All patients with isolated CAF (n = 13) were asymptomatic despite significant clinical, electrocardiographic, and chest roentgenographic findings in 10. Sixteen had congenital CAF and 1 had acquired CAF after tetralogy of Fallot repair with injury of the anomalous left anterior descending coronary artery. Associated anomalies included tetralogy of Fallot (2), atrial septal defect (1), and patent ductus arteriosus (1). Nine fistulas originated from the right coronary artery and eight from the left. Drainage was to the right ventricle (9), right atrium (4), pulmonary artery (3), and left atrium (1). All patients had a median sternotomy with epicardial or endocardial ligation. Cardiopulmonary bypass was used in 8; 1 of these (iatrogenic CAF) required distal internal mammary artery bypass graft. There were no operative or late deaths. Follow-up evaluation by physical examination (17), echocardiography (8), and catheterization (2) showed no evidence of recurrent or residual CAF. A retrospective review of the 16 available cine cardioangiograms showed that coil embolization was possible in, at most, 6 patients. Early surgical management of CAF is a safe and effective treatment resulting in 100% survival and 100% closure rate. Transcatheter embolization is a reasonable alternative to standard surgical closure in only a very small, select group of patients. These surgical results should be considered the standard against which transcatheter techniques are compared.

64-Year-Old Woman With Chest Pain and Presyncope

64-Year-Old Woman With Chest Pain and Presyncope

74-Year-Old Woman With Dyspnea, Fever, and Cough

74-Year-Old Woman With Dyspnea, Fever, and Cough

Clinical Features and Differential Diagnosis of Aortic Dissection: Experience With 236 Cases (1980 Through 1990)

Acute aortic dissection is the most common fatal condition that involves the aorta; nevertheless, despite major advances in noninvasive diagnosis, the correct antemortem diagnosis is made in less than half the cases. To promote continued improvement in the prompt recognition of aortic dissection, we present a review of the Mayo Clinic experience with 235 patients who had 236 substantiated aortic dissections. At the time of initial assessment, 158 patients (67%) had acute and 78 patients (33%) had chronic aortic dissection. Hypertension was the most common predisposing factor (78% of patients overall). The acute onset of severe chest pain was the most common initial complaint (74%), but 33 patients (15%) had painless aortic dissection and abnormal chest roentgenographic findings. Less common manifestations included congestive heart failure, syncope, cerebrovascular accident, shock, paraplegia, and lower extremity ischemia. The initial clinical impression was aortic dissection in 62% of patients overall. In 17 patients (28%), the correct diagnosis was not made before postmortem examination. Although the clinical features of aortic dissection have gained wider appreciation, the diagnosis still remains unsuspected in a substantial number of patients. In a patient who has a catastrophic illness and unexplained symptoms that could be of vascular origin, especially in the presence of chest pain, aortic dissection should always be included in the differential diagnosis.

Carcinoid heart disease. Clinical and echocardiographic spectrum in 74 patients.

The carcinoid syndrome is a rare cause of acquired valvular heart disease. Although the typical echocardiographic features of carcinoid heart disease are well recognized, this large series provides new information about unusual manifestations of the disease as well as the role of Doppler echocardiography. Between 1980 and 1989, 132 patients with carcinoid syndrome underwent echocardiographic study. The echocardiographic, Doppler, and clinical features of the 74 patients (56%) with echocardiographic evidence of carcinoid heart disease are described. Among these patients, 97% had shortened, thickened tricuspid leaflets. Tricuspid regurgitation was present in all 69 patients with carcinoid heart disease who underwent Doppler examination, and it was of moderate or severe degree in 62 patients (90%). Severe tricuspid regurgitation was characterized by a dagger-shaped Doppler spectral profile with an early peak pressure and rapid decline. The pressure half-time was prolonged (mean, 116 msec), which is consistent with associated tricuspid stenosis. The pulmonary valve appeared thickened, retracted, and immobile in 36 patients (49%) and was diminutive to the extent of not being visualized in an additional 29 patients (39%). Among the 47 patients who underwent Doppler evaluation of the pulmonary valve, regurgitation was present in 81%, and stenosis was present in 53%. Left-sided valvular involvement was present in five patients (7%), four of whom had patent foramen ovale or carcinoid tumor involving the lung. Previously undescribed myocardial metastases were present in three patients (4%) and were confirmed by biopsy in each case. Small pericardial effusions were present in 10 patients (14%). Patients with and without echocardiographic evidence of carcinoid heart disease did not differ with regard to sex, age, location of the primary tumor, duration of diagnosis, or duration of symptoms of carcinoid syndrome. However, the mean pretreatment level of urinary 5-hydroxyindoleacetic acid was higher in patients with carcinoid heart disease than in patients without carcinoid heart disease (270 versus 131 mg/24 hrs, p < 0.001). The symptom of dyspnea was more prevalent among patients with carcinoid heart disease than in patients without the disease (54% versus 27%, p = 0.003); as expected, heart murmurs were also noted more frequently in patients with disease (92% versus 43%, p < 0.0001). Treatment regimens and response to therapy were similar in the two groups. Survival of patients with echocardiographic evidence of carcinoid heart disease was reduced compared with those without cardiac involvement (p = 0.0003). ECG and chest roentgenographic findings in patients with carcinoid heart disease were nonspecific. The broad spectrum of carcinoid heart disease is detailed in this large series. This includes not only right-sided valvular lesions but also left-sided involvement, pericardial effusion, and myocardial metastases.

Association between Neutrophil Concentration in Bronchoalveolar Lavage Fluid and Recent Losses in Diffusing Capacity in Men Formerly Exposed to Asbestos

It has been observed widely that some individuals exposed to asbestos will experience continued losses of lung function after asbestos exposure ceases. Unfortunately, there are few data on factors that determine clinical course, limiting the clinician's ability to determine prognosis in an individual case and restricting the possibility for testing or targeting any potential intervention to alter the course among the millions at risk. In an attempt to address this question, we studied a volunteer population of 50 such men from among a stable, heterogeneous population of asbestos-exposed workers who had been continuously followed in our occupational medicine clinics for up to 12 years (mean, 6.3 years); most had some clinical or roentgenographic sign of asbestos effect, pleural or parenchymal. Each subject was reexamined clinically, functionally, and roentgenographically. Asbestos and tobacco exposure histories were carefully reviewed with the subjects and quantified based on these reports and available data regarding the various work environments from which they came. Subsequently, each underwent a bronchoalveolar lavage to assess cellularity and levels of various proteins. The levels of risk factors, clinical findings, and biologic parameters from lavage were examined for their relationship to serial changes in lung function during the period over which they had been previously followed. Results of the study demonstrate that serial changes in lung function were not closely related to level or length of prior exposure, smoking behavior, chest roentgenographic findings, or lung volumes. Progressive loss of diffusing capacity for carbon monoxide (Dco) was significantly associated with two factors: level of neutrophil concentration in lavage fluid (0.043 +/- 0.016 ml/min/mm Hg/yr drop for each 0.1 x 10(4) neutrophils per milliliter, p = 0.02) and the level of Dco itself (0.17 +/- 0.07 ml/min/mm Hg/yr drop for each 10 percent decrease in percent Dco predicted, p = 0.01). The relationship with neutrophil concentration was statistically independent of the association with Dco itself and stronger; it persisted when loss of Dco was adjusted for baseline value. Lung volume changes were not associated with any predictor variables, alone or in combination. We conclude that the presence of neutrophils in bronchoalveolar lavage fluid is associated with recent disease progression that may have implications in studies of the mechanisms of asbestos-associated disease and in clinical treatment of patients at risk.

Tuberculosis in Patients with Human Immunodeficiency Virus Infection: How Often Does It Mimic Pneumocystis carinii Pneumonia?

Adjunctive corticosteroid therapy is recommended for selected human immunodeficiency virus (HIV)-infected patients with presumed Pneumocystis carinii pneumonia. Because corticosteroids may exacerbate undiagnosed tuberculosis, we evaluated the frequency with which tuberculosis in HIV-infected patients mimics P carinii pneumonia. Over a 12-month period, we identified 105 HIV-infected patients with pleuropulmonary tuberculosis and 84 patients with P carinii pneumonia who were sufficiently hypoxemic to warrant corticosteroid therapy. Of the 105 patients with tuberculosis, acid-fast smears of clinical samples were positive in 49 cases, and chest roentgenographic findings suggested tuberculosis in an additional 44 cases. The 12 patients with negative acid-fast smears and nonspecific chest roentgenographic findings presented a potential diagnostic dilemma between tuberculosis and P carinii pneumonia. Pneumocystis carinii pneumonia should not have been a presumptive diagnosis of eight of these 12 patients because of absence of pulmonary symptoms and chest roentgenographic abnormalities (four cases), a CD4 count greater than 500/cu mm (three cases), or marked lymphadenopathy suggestive of tuberculosis (one case). Thus, only 4 percent (4/105) of HIV-infected patients with pleuropulmonary tuberculosis had clinical and chest roentgenographic features mimicking P carinii pneumonia. Two of these four patients were sufficiently hypoxemic to warrant corticosteroid therapy. Thus, if corticosteroids had been routinely used during the study period, 84 patients with P carinii pneumonia would have been treated, including two patients with undiagnosed tuberculosis. We conclude that the use of corticosteroids for presumed P carinii pneumonia carries a small but acceptable risk of inadvertent exacerbation of tuberculosis, provided clinical and chest roentgenographic features do not suggest tuberculosis.

Congress Summary

At the case discussion meeting, 34 Japanese cases of idiopathic bronchiolitis obliterans organizing pneumonia (BOOP) were confirmed. The clinical features, chest roentgenographic findings, and clinical courses of these cases were similar to those reported in Europe and the United States. Three agreements drawn at the Congress are summarized below.

Introduction

Many physicians have encountered a patient with fever, sputum, and respiratory difficulties, whose patchy infiltrate shadow detected by chest roentgenography suggests pneumonia. However, the patient does not respond to antibiotic treatment, and bronchoalveolar lavage (BAL) performed under the suspicion of eosinophilic pneumonia reveals no increase of eosinophils in the BAL fluid. The physician finds that in such a case, corticosteroid treatment is effective. Furthermore, many physicians concerned about interstitial lung diseases encounter a patient with clinical symptoms and chest roentgenographic findings suggesting idiopathic pulmonary fibrosis, but their symptoms and abnormal shadows eventually disappear.

Bronchoalveolar Lavage in Immunocompromised Patients: Clinical and Functional Consequences

Fiberoptic bronchoscopy and bronchoalveolar lavage are major tools in the diagnosis of acute pneumonia in immunocompromised patients. We conducted a prospective study to assess the morbidity associated with this procedure in 14 patients with AIDS and 16 patients with drug-induced immunosuppression. No patient had a PaO2 lower than 70 mm Hg with additional oxygen. Clinical data, chest roentgenogram, pulmonary function test, forced vital capacity, forced expiratory volume in one second, and arterial blood gases were recorded before and after bronchoscopy. Arterial oxygen saturation was monitored during the procedure, and initial, lowest, and final saturation values were noted. The patients were separated into three groups on the basis of chest roentgenographic findings. No procedure-induced pneumonia or need for tracheal intubation occurred. Minor clinical symptoms induced by the lavage in seven patients resolved spontaneously. By contrast, mean SaO2 decreased markedly during the procedure from 94 +/- 3 to 87 +/- 5 percent (p less than 0.0001) and returned to only 89 +/- 5 percent at the end of the procedure. Lowest SaO2 during the procedure and final SaO2 correlated poorly with initial SaO2 but correlated well with initial FVC and FEV1 (p less than 0.01). The PFT values were lower following bronchoscopy. O2 desaturation was more pronounced in patients with severe roentgenographic abnormalities. No significant differences were found between the three groups of patients, or between the AIDS and DII patients in terms of changes in PFT values. We conclude that in immunocompromised patients, bronchoscopy with BAL induces severe arterial oxygen desaturation which is correlated with initial PFT and chest roentgenographic findings, and most of these abnormalities are transient and do not lead to major complications.

Bronchoscopic and Roentgenographic Correlates of a Positive Transbronchial Needle Aspiration in the Staging of Lung Cancer

A study was conducted to determine the bronchoscopic and chest roentgenographic findings associated with a positive TBNA. One hundred fifty-seven of 465 patients who were diagnosed for the first time as having carcinoma of the lung had a positive aspirate. Bronchoscopic findings associated with a positive TBNA of N2 nodes were carinal widening and endobronchial disease, especially of the right upper lobe. Mediastinal adenopathy noted on chest roentgenograms and subcarinal nodes on CAT scans were associated with a positive aspirate as well. In 34 of 465 patients, TBNA was the only means of establishing the diagnosis of pulmonary malignancy. A useful, simple and safe procedure, TBNA can be used to stage the mediastinum in patients with lung cancer and is most likely to be positive with endobronchial and nodal disease. It can also facilitate therapeutic decision-making in patients whose surgical candidacy is marginal.