Full-lung Tomography Research Articles

Primary Lymphoma of Bone: Long Term Results in Patients Treated with Vincristine - Adriamycin - Cyclophosphamide and Local Radiation

Primary lymphoma of bone (PLB) is an unusual but well-recognized extranodal presentation of non-Hodgkin's lymphoma. In most series treatment with radiotherapy alone results in a cure rate of approximately 40%. Between January 1972 and December 1982, 26 patients with biopsy proven PLB were treated at the Rizzoli Institute with radiotherapy (4000-5,500 rad) and chemotherapy (vincristine, cyclophosphamide and adriamycin). The minimal clinical staging included complete blood cell counts and serum chemistries, bone radiography, full lung tomography, isotope bone scan, bone marrow biopsy and bipedal lymphoangiograms. At a median follow-up of 13 years (8.5-18.5) there were only three relapses (2 cases of meningeal involvement and 1 recurrence in another bone). No local recurrences nor second tumor in the irradiated field were observed. We conclude that the addition of chemotherapy to radiotherapy results in an excellent cure rate for patients with PLB.

Diagnostic imaging in metastatic lung disease

Chest radiographs, full lung tomography and computed tomography of the chest provide increasing sensitivity for evaluation of pulmonary metastases. Pulmonary nodules of 5-10 mm diameter are detectable with increasing frequency by use of high kilovoltage chest radiographs. Full lung linear tomography provides an overall accuracy of 72-97% in diagnosis of pulmonary nodules. Chest CT delineates pulmonary nodules as small as 3 mm within 10 mm slice sections. However, as sensitivity increases, specificity diminishes in identifying metastatic nodules. Sensitivity in CT is also reduced by false negative findings due to unequal respiratory cycles. Comparative radiologic-pathologic evaluation of nodule detection proved CT to be the most sensitive screening method for pulmonary metastases. Timing of follow-up studies for pulmonary nodule detection in cancer patients can be determined by tumor growth kinetics; 3-6 month intervals proved to be useful.

Intra-abdominal extrahepatic disease in patients with colorectal hepatic metastases.

The resection of hepatic metastases in patients with extrahepatic disease is of no proven benefit. Preoperative identification of extrahepatic disease may prevent unnecessary laparotomy. Preoperative evaluation including physical examination, computed tomography of the abdomen, full lung tomography or chest-computed tomography, and radionuclide bone scanning identified extrahepatic metastases, most commonly in the lung, in 25 of 132 patients with purported isolated liver metastases. Of 107 patients with negative staging evaluations, intra-abdominal extrahepatic metastases were found in 26 percent (28 of 107) at laparotomy, most commonly in portal and celiac lymph nodes. The presence of extrahepatic disease correlated with greater than 25 percent hepatic replacement by tumor, presence of symptoms, and Dukes' C primary lesions; however, none was predictive. We were unable to develop a model to preoperatively predict the presence of intra-abdominal extrahepatic disease. The authors recommend a preoperative evaluation including physical examination, and computed tomographic scans of the abdomen and chest. A bone scan is required only in patients with symptoms referable to bone. Despite a negative preoperative evaluation, however, a considerable proportion of patients with colorectal hepatic metastases will have extrahepatic disease at the time of abdominal exploration.

Resection of recurrent pulmonary metastases in patients with soft-tissue sarcomas.

Survival benefit and prognostic factors useful for patient selection have not been previously analyzed for patients with recurrent pulmonary metastases from soft-tissue sarcomas. Twenty-nine patients in our study had two or more resections of pulmonary metastases from 1976 to 1983. There were no operative deaths and three complications for 40 operations (7.5%). Factors predictive of increased survival following the second resection of pulmonary metastases were resectability and a disease-free interval of greater than six months from the first thoracotomy to the second recurrence in the lung. The tumor doubling time of the first recurrence and the presence of three or fewer nodules on full-lung tomography before the first thoracotomy, which were predictors of survival following initial resection, also predicted survival following subsequent resections. Overall median survival following the second resection was 14.5 months (22% overall three-year survival). The postresection actuarial survival curves for patients undergoing 1, 2, or 3 or more resections were not significantly different. Our findings demonstrate that patients undergoing repeated resections of pulmonary metastases from soft-tissue sarcomas can achieve prolonged survival.

Resection of Recurrent Pulmonary Metastases in Patients With Soft-Tissue Sarcomas

Survival benefit and prognostic factors useful for patient selection have not been previously analyzed for patients with recurrent pulmonary metastases from soft-tissue sarcomas. Twenty-nine patients in our study had two or more resections of pulmonary metastases from 1976 to 1983. There were no operative deaths and three complications for 40 operations (7.5%). Factors predictive of increased survival following the second resection of pulmonary metastases were resectability and a disease-free interval of greater than six months from the first thoracotomy to the second recurrence in the lung. The tumor doubling time of the first recurrence and the presence of three or fewer nodules on full-lung tomography before the first thoracotomy, which were predictors of survival following initial resection, also predicted survival following subsequent resections. Overall median survival following the second resection was 14.5 months (22% overall three-year survival). The postresection actuarial survival curves for patients undergoing 1, 2, or 3 or more resections were not significantly different. Our findings demonstrate that patients undergoing repeated resections of pulmonary metastases from soft-tissue sarcomas can achieve prolonged survival.

Chest X-rays and full lung tomograms in gynecologic malignancy.

Four-hundred-seventy-one patients with gynecologic malignancy were studied. All of these had chest x-rays at the time of staging and 323 had concurrent full lung pleuridirectional tomography performed. In no instance were pulmonary parenchymal metastases identified by tomograms when the chest x-ray was negative and tomography led to more equivocal readings than did the chest x-ray. The current study indicates that there is extremely low diagnostic yield of full lung tomography in gynecologic malignancies. Full lung tomography was poor in assessing the presence of small pleural effusions. The yield of positive chest x-ray at varying follow-up times was also examined. The yield has been expressed by site of origin of the tumor as well as by stage at initial diagnosis. Some of these yields are quite high. There is a very poor prognosis when pulmonary findings become evident, regardless of the site of origin of the tumor. More than one half of the patients who develop pulmonary abnormalities will be dead within one year.

Median sternotomy for resection of pulmonary metastases

Thoracic surgeons have been reluctant to adopt the median sternotomy as a suitable approach to pulmonary operations. However, its lesser functional morbidity and the capability to assess both lungs are advantageous in selected patients. Examined herein is a concentrated experience with 53 median sternotomies in 46 patients for the resection of pulmonary metastases. Forty of the 46 patients had soft tissue or osteogenic sarcoma. Full-lung tomograms diagnosed but did not accurately reflect the extent of disease. Fifty-three percent more tumor nodules were found at median sternotomy than were seen on full-lung tomography. Eleven of 18 patients (61%) thought to have unilateral disease by full-lung tomography had bilateral metastases found at median sternotomy. Most median sternotomies involved wedge resections (mean 8.9 range one to 52). Two segmentectomies, six lobectomies, and one pneumonectomy were also performed. Repeat median sternotomy was accomplished seven times; one patient underwent four median sternotomies. Sixty-six percent of the nodules removed proved to be tumor. Complications included one reoperation for bleeding; three patients had air leaks for more than 1 week, including one bronchopleural fistula; four required respirator assistance for more than 3 days; and there were four major infections. There was no operative mortality. Because of its low morbidity, the high incidence of unsuspected bilateral disease, and the elimination of a second operative procedure, median sternotomy is the approach of choice for the surgical treatment of pulmonary metastases.

Full-lung tomograms and bone scanning in the initial work-up of patients with osteogenic sarcoma. A review of 126 cases

The value of full-lung tomograms and of bone scanning in the initial work-up of patients with osteogenic sarcoma is evaluated in 126 consecutive cases observed at the Bone Tumor Center of the Istituto Ortopedico Rizzoli from July 1976 to December 1980. Full-lung tomograms and bone scanning showed unsuspected metastases in 3 patients and 2 patients respectively. False abnormal results were observed in 4 cases by tomography and in 3 cases by bone scan. The authors conclude that in osteosarcoma, the yields of full-lung tomography and of bone scanning are small in detecting unsuspected lung and bone metastases at the time of presentation. It therefore appears improbable that the improvements recently observed in this tumor with adjuvant chemotherapy are the result of unintentional case selection bias due to these examinations not having been performed in the historical group.

The efficacy of full-lung tomography in the detection of early metastatic disease from melanoma.

In a prospective study, 62 patients with proved melanoma and negative chest radiographs underwent full-lung tomography. Of 109 examinations performed, 12 patients had positive findings on tomography; nine were false-positive and three were true-positive. Of the true-positive examinations, two patients already had widespread metastatic disease and one had an advanced local lesion. Clinical staging and therapy were changed in only one patient as a result of information provided by full-lung tomography. It appears from these results that full-lung tomography is of limited use in detection of metastases from melanoma in the presence of a negative chest radiograph.

Detection of metastatic disease from carcinoma of the breast: limited value of full lung tomography.

Until now no large prospective study has been made to evaluate the efficacy of full lung tomography in detection of pulmonary metastases from carcinoma of the breast in the presence of a negative chest radiograph. In the current study, 144 patients with proven breast carcinoma and a negative chest radiograph underwent full lung tomography. Nodules were demonstrated in three patients and, in two of them, presumably reflected metastatic disease. Both patients had advanced extrapulmonary metastatic disease at the time of full lung tomography and in neither case did a change in therapy result. One presumed false-positive observation was also made. Because of the low propensity for carcinoma of the breast to metastasize to the lungs, full chest tomography does not appear warranted as a screening procedure in these patients.

The thorax as the initial site for systemic relapse in malignant melanoma: a prospective survey of 324 patients.

Thirteen of 324 patients with malignant melanoma followed during a 24 month period experienced dissemination. The thorax was the initial site for relapse in 12, all of whom were asymptomatic. Ten gave no evidence of extrathoracic disease. Retrospective analysis of previous x-rays originally interpreted as negative revealed metastases in 33%. Life table analysis demonstrated a significantly longer survival for the subset with isolated intrathoracic metastases treated surgically than for their counterparts with metastases no longer amenable to surgery and treated by other modalities. We conclude that the thorax is the site of predilection for initial systemic relapse in malignant melanoma, that detection of early, surgically resectable metastases correlates with longer patient survival, and that routine chest roentgenography is inadequate in reliably uncovering such early disease. These data suggest the potential value of more vigorous radiographic surveillance (with either computed tomography or conventional full lung tomography) in patients at high risk for relapse.

Lung Tomography in Cancer Patients

In a retrospective study of the cases of 415 patients with various malignant neoplasms, full-lung tomography and conventional chest roentgenography were compared for accuracy in the detection of pulmonary metastases. Sufficient information was available on 410 patients to permit confirmation as to whether pulmonary metastases were present at the time of screening chest roentgenographic and tomographic examinations. On screening by routine chest roentgenography, metastases were detected in 36 patients, 66.7% of the total with confirmed metastatic disease. Screening by full-lung tomography identified metastases in 51 (94.4%). Fifteen patients with normal chest roentgenograms had metastatic lesions on tomograms. Metastases were detected in 8.8% by chest roentgenograms and in 12.4% by tomograms in a population of cancer patients with a 13.2% incidence of pathologically confirmed metastatic lesions.

Routine full-lung tomography in the initial staging and treatment planning of patients with Hodgkin's disease and non-Hodgkin's lymphoma.

The yield of additional information from anteroposterior full-lung tomograms that changed stage or treatment, in comparison to that obtained from routine chest radiographs, was prospectively evaluated in 243 previously untreated patients with Hodgkin's disease and non-Hodgkin's lymphoma. Although new information was found in 21.4% of all patients, in only 1.2% did these additional data change patient staging. In 3.3% of the other patients the tomograms provided information that affected radiotherapy treatment planning as practiced in our institution.

Pediatric Hodgkin's disease. I. Radiographic evaluation.

The pretreatment roentgenographic evaluation of 105 consecutive patients less than 16 years of age with Hodgkin's disease was reviewed. The patients were divided into groups aged 1-10 years (37%) and 11-15 years (63%). All patients had chest roentgenograms, of which 36% were abnormal in the younger group and 77% abnormal in the older group. Full-lung tomography was helpful only when the chest film was abnormal or equivocal. Foot lymphography was performed in 103 patients with 20% positive for Hodgkin's disease. Lymphographic-histologic correlation was 98% in the 62 patients undergoing laparotomy. Routine skeletal surveys, as well as examinations of the urinary tract and gastrointestinal tract, were not rewarding.