Intrathoracic Manifestations Research Articles

Book reviews

Dr Norman Blank is Active Emeritus Professor of Diagnostic Radiology and Nuclear Medicine at Stanford University School of Medicine, California. His name is well known to radiologists interested in chest medicine for his papers with Dr Castellino and others on pleural reflections adjacent to the mediastinum, mediastinal lymphadenopathy, intra-thoracic manifestations of lymphomas and leukaemias, etc., some inflammatory lung conditions, particularly in patients with altered immunity. The preface states that the book is intended for medical students and residents in radiology or chest medicine “to master the principles of chest film interpretation and to develop their ability to extract information from imaging studies”. He tries to show how to analyse radiographic data, whether findings are normal or abnormal, to integrate radiological with clinical findings, and with one's knowledge of disease processes to formulate a differential diagnosis.

Intrathoracic manifestations of disseminated prostatic adenocarcinoma

Four cases of disseminated adenocarcinoma of the prostate illustrating the clinical spectrum of intrathoracic involvement in this disease are presented. In two cases the presenting features of prostatic cancer were with lymphangitis carcinomatosa and an isolated pleural effusion, whereas two other cases developed intrathoracic metastases in the setting of previously known locally advanced prostatic cancer. In one this took the form of hilar and mediastinal lymphadenopathy and in the other that of pulmonary nodules. An immuno-cytochemical marker for prostatic specific antigen, a highly sensitive and specific tool for identifying prostatic epithelium, identified the prostate as the primary site of malignancy in the first two cases. Symptomatic and radiological responses were noted in all four cases after bilateral orchidectomy. Pulmonary metastases are common in the advanced stages of prostatic cancer but may also be present at the initial presentation with the disease even when the primary tumour is not clinically apparent. We recommend that (i) immuno-cytochemical stains for prostatic specific antigen are applied to all lung, pleural and mediastinal biopsy specimens showing adenocarcinoma in male patients, and (ii) all males with intrathoracic adenocarcinoma have prostatic aspiration cytology performed if the prostatic specific antigen stain is positive.

Mediastinal adenopathy and endobronchial involvement in metastatic renal cell carcinoma

Mediastinal adenopathy and endobronchial metastases are sometimes the only radiological manifestation of metastatic disease from extrathoracic neoplasms. We report on four patients in whom hilar and paratracheal adenopathy (n = 3) and endobronchial involvement (n = 1) were the only intrathoracic manifestations of metastatic renal cell carcinoma. Three of the patients had nephrectomies 9 months to 4 years before the appearance of intrathoracic disease; another patient presented with medastinal disease as the initial manifestation of renal cell carcinoma. If a patient with a history of renal cell carcinoma develops pulmonary hilar adenopathy, metastatic disease should be suspected and appropriate diagnostic measures should be taken.

Atypical intrathoracic manifestations of Burkitt's lymphoma.

Analysis of the plain chest radiographs of 11 children with Burkitt's lymphoma showed that mediastinal adenopathy was the commonest abnormality present. One child showed a pulmonary infiltrative pattern which had previously been undescribed in this disease. Nigerian children with this lymphoma present more commonly with mediastinal glandular enlargement whereas pleural effusion is more frequently encountered in Caucasians.

Diffuse interstitial lung disease in rheumatoid arthritis. Views on immunological and HLA findings.

Immunological parameters including HLA typing were studied in 32 patients with rheumatoid arthritis (RA) associated diffuse interstitial lung disease (DILD) and in 32 age- and sex-matched RA control patients. The male RA patient group with DILD also included patients with other intrathoracic manifestations and had a higher prevalence of HLA-B8 and Dw3 than did healthy controls, thus agreeing with our earlier results that RA patients with this antigen combination are prone to multiple intrathoracic complications. Patients with DILD had higher titres of rheumatoid factor (RF) and lower complement (C4) levels than matched RA controls. The RF titre was in inverse correlation with C3 and C4 levels, suggesting that RF immune complexes may also promote rheumatoid lung disease via activation of the classical pathway of complement.

Rheumatoid arthritis with pleural effusion includes a subgroup with autoimmune features and HLA-B8, Dw3 association.

Twenty-eight patients with rheumatoid pleural effusion were investigated to examine the frequency of HLA antigens as compared with 56 rheumatoid arthritis (RA) patients without this intrathoracic manifestation of RA and with 283 healthy controls. HLA-B8 was strongly associated with the presence of pleural effusion (PE) in RA patients. A high prevalence (71%) of B8/Dw3 was found among male RA patients of the PE group in whom the joint disease had begun at an age over 50 years and who also had besides pleuritis other intrathoracic manifestations of RA associated with high rheumatoid factor titres and low complement (C4) levels in sera. Actually, the HLA-B8 association was not seen in the rest of the PE group. The finding may be related to the heterogeneity of RA, a male subgroup of the disease being characterized by multiple intrathoracic manifestations and genetically associated with the large group of autoimmune disorders, such as SLE, characterized by high prevalences of HLA-B8 and D(R)3.

Intrathoracic Manifestations in Mixed Connective Tissue Disease

A high frequency of occurrence of pleuropulmonary manifestations in mixed connective tissue disease (MCTD) has been reported in the literature. A retrospective analysis of 81 adult patients with the diagnosis of MCTD who were examined at our medical center from 1973 through 1977 revealed that pleuropulmonary involvement occurred in 20 (25%). Thirteen patients (16%) had dyspnea, six (7%) had chest pain, and four (5%) had cough. Chest roentgenograms disclosed basal interstitial processes in 15 patients (19%), pleural effusion in 5 (6%), pneumonic infiltrates in 3 (4%), and pleural thickening in 2 (2%). Abnormalities of pulmonary function were noted in 9 (69%) of 13 patients tested, and esophagographic abnormalities were present in 19 (53%) of 36 patients tested. Systemic corticosteroid therapy was beneficial in two of the eight patients so treated, and nonsteroidal anti-inflammatory drugs resolved most of the clinical features in four of the seven patients so treated. Six patients died during a 5-year follow-up period.

Intrathoracic histiocytic lymphoma.

Intrathoracic manifestations of histiocytic lymphoma were reviewed in a retrospective study of 112 nonselected patients who had at least a 2 year follow-up period or had died. In 50% (56 cases), intrathoracic histiocytic lymphoma was found. In 26% (29 cases), intrathoracic manifestations were initially seen. In 11% (12 cases), the disease was completely confined to the chest. Mediastinal involvement was present in 25% (28 cases), hilar involvement in 17% (19 cases), pulmonary involvement in 20% (22 cases) (interstitial or mixed interstitial alveolar infiltrates in 13% [14 cases], nodular lesions in 8% [nine cases], localized homogeneous consolidations 5% [six cases]), and pleural involvement in 18% (20 cases), of which 4% (four cases) had localized pleural plaques. Intrathoracic manifestations of histiocytic lymphoma are similar in the early and late stage of the disease. However, sarcoidlike hilar and mediastinal involvement (3% [three cases]) and a localized mass in the lower posterior mediastinum (4% [four cases]), the anterior mediastinum (2% [two cases]) or unilaterally in a hilum (2% [two cases]) were initial presentations not encountered late in the disease. Because of the rapid progression of this entity, early recognition of its intrathoracic manifestations is mandatory for effective therapy.

Non-hodgkin's lymphoma, chronic lymphatic leukaemia and the lung

In a retrospective study of 81 patients with non-Hodgkins's lymphoma and 35 patients with chronic lymphatic leukaemia, pulmonary involvement was found in 25% of cases and pleural effusion in 19%. Twenty-four patients (20%) had intrathoracic lymphadenopathy and 12 of these had associated pleural or lung involvement. Infiltration occurred almost exclusively in diffuse lymphocytic lymphoma and chronic lymphatic leukaemia, whereas round lesions were seen only in undifferentiated lymphomas. Pleural effusion complicated most histological types of non-Hodgkin's lymphoma but was uncommon in chronic lymphatic leukaemia. Pleural biopsy was successful in diagnosing lymphoma in nine of ten patients with an effusion in whom it was performed. Both pulmonary and pleural involvement responded poorly to treatment and had an adverse effect on prognosis. In contrast, intrathoracic lymphadenopathy responded well to radiotherapy and/or chemotherapy and did not affect prognosis adversely when it occurred in the absence of other intrathoracic manifestations of lymphoma.

Isolated Mediastinal Mass in Primary Amyloidosis

A previously healthy man with lytic bone lesion of the left talus was found to have a large middle mediastinal mass on routine admission chest roentgenogram. A large amyloid tumor of the mediastinum, representing the sole intrathoracic manifestation of primary amyloidosis, was resected. This presentation of intrathoracic amyloidosis has not previously been reported.

THORACIC MANIFESTATIONS OF LIVER DISEASE

The close proximity of the liver to the right lung may be the basis for thoracic changes that occur in the presence of lung disease, or such changes may occur as part of the natural course of the disease. Whatever the etiology, the selective use of plain film radiography, fluoroscopy, radionuclide scanning, gallium scanning, and computed tomography will facilitate diagnosis and management.

Comparison of Biopsy Procedures in Intrathoracic Sarcoidosis

A series of 78 patients, mainly young males, with intrathoracic manifestations of sarcoidosis, found on routine chest X-ray, were examined according to a prescheduled program including different biopsy procedures. In 76% the intrathoracic changes were isolated hilar adenopathy, in 9% isolated pulmonary lesions and in 15% hilar adenopathy plus pulmonary lesions. Lymph nodes containing granulomas were found by mediastinoscopy in 41 of 44 patients and by scalene fat pad biopsy in 20 of 34 patients. In 27 of 76 patients granulomas were found by liver biopsy. Complications to the biopsies were more frequent with mediastinoscopy than with the other two biopsy procedures, but no serious complications occurred. Biopsy through mediastinoscopy is thus preferable in patients of this kind. The necessity of doing biopsies to support the diagnosis of sarcoidosis is discussed on the basis of the literature and our own studies. In younger patients with asymptomatic, bilateral hilar adenopathy without pulmonary lesions it seems justifiable to omit biopsy, whereas biopsy is mandatory in patients with unilateral hilar lymph adenopathy and patients with pulmonary lesions. In all cases the course of the disease should be followed for a rather long period.

Intrathoracic Manifestations of Degos' Disease (Malignant Atrophic Papulosis)

Degos' disease (malignant atrophic papulosis) is a rare multisystemic disease with characteristic cutaneous lesions, abdominal symptoms and often rapidly fatal course. Our review of the reported intrathoracic involvement in the more than 60 reported cases of Degos' disease suggests that pleuritis and pericarditis are manifestations of the underlying pathophysiologic process. Seventeen of these reported cases were said to have intrathoracic lesions, which were, in most cases, incidental findings at autopsy. We present an illustrative report of a case in which chronic pleuritis and pericarditis were the major causes of morbidity in a 32-year-old woman with Degos' disease.

Sarcoidosis

In a 10-year review of the records of 146 young male patients suspected of sarcoidosis on the basis of radiographic intrathoracic changes, the chest X-ray findings have been analysed in relation to the results of different biopsies. Most of the patients were military men, and almost all were apparently affected by the disease. Sixty-six per cent had bilateral hilar lymphadenopathy (BHL) only, 12% had isolated pulmonary lesions and 22% had both BHL and pulmonary lesions. In all patients at least one biopsy was performed, in most cases a scalene fat pad biopsy and/or a liver biopsy. Epitheloid cell granulomas were demonstrated in 86 biopsies from 64 of the 146 patients. Granulomas were obtained more frequently by scalene fat pad biopsies than by liver biopsies in the same group of patients. During the first 4--5 years of the 10-year period the scalene fat pad biopsies were done in local anesthesia in different general surgical departments without special experience of this biopsy procedure. In the last 5--6 years the scalene fat pad biopsies were done in general anaesthesia in a head and neck surgical department specially trained in this biopsy technique. Granulomas were obtained more frequently in the latter than in the former group. The highest frequency of granulomas was found among patients with both BHL and pulmonary lesions. Of the 71 patients in whom liver biopsy was performed, 43% had granulomas in the liver. A few patients had signs--although only slight--of liver affection. The results of the different biopsies are discussed in relation to the clinical picture. It is concluded that scalene fat pad biopsy in some cases can still be of some diagnostic aid in patients with radiographic intrathoracic changes suspected of sarcoidosis, although this type of biopsy has to a great extent been replaced by biopsy through mediastinoscopy. Furthermore it is concluded that comparison of different biopsies in one and the same patient could elucidate a possible relationship between the radiographic intrathoracic manifestations and the occurrence of granulomas in different intra- and extra-thoracic tissues. In this study there were only few and insignificant complications of the biopsies.

Cardiophrenic adenopathy in Hodgkin disease.

Hodgkin disease can involve diaphragmatic lymph nodes adjacent to the heart. When nodes at the cardiac apex are involved, the roentgenographic appearance simulates that of the normal pericardial fat pad. Though, to our knowledge, no cases have been reported in which this was the only intrathoracic manifestation of Hodgkin disease at the time the patient was first seen and the condition was diagnosed, it may be the only manifestation of relapse, as was true in the case presented.

Intra-thoracic Hodgkin's disease. Part 1. Less common intra-thoracic manifestations of Hodgkin's disease.

The less common intra-thoracic manifestations of Hodgkin's disease are ill-defined areas of opacity up to several centimetres due to intrapulmonary deposits of Hodgkin tissue; well-defined circular shadows either single or multiple, and circular shadows with central cavitation with a thin or thick cavity wall. Narrowing of lobar bronchi is of special importance in defining the lower limit of the field in radiotherapy.

Hodgkin's disease: Less Common Intrathoracic Manifestations

Hodgkin's disease: Less Common Intrathoracic Manifestations

Experience with intrathoracic injury following automobile accidents

The charts of over 400 patients admitted to the Ohio State University Hospital following automobile accidents have been reviewed. Eliminated from the study were those patients with primarily neurologic, orthopedic or intraabdominal injuries, and those patients with damage to the ribs and chest wall without intrathoracic manifestations. Of the seventy-six patients remaining, the types of injury and the basis for the mortality are discussed. The management of the specific injuries is presented.

Pulmonary hilar enlargement associated with Weber-Christian disease; report of a case.

A REVIEW of the medical literature reveals that approximately 55 cases of nodular nonsuppurative panniculitis (Weber-Christian disease) have been reported to date. None of these reports presented any radiological findings of note. In the case to be discussed here, however, certain intrathoracic roentgenographic manifestations are exhibited which have not been described in any of the cases reported elsewhere. For this reason, it is felt that it is worth while to record a full description of this additional case of nodular nonsuppurative panniculitis. Relapsing febrile nodular nonsuppurative panniculitis is characterized 1 by recurrent episodes of fever, the temperature ranging as high as 104 F., associated with the appearance of single to multiple crops of subcutaneous nodules, varying from the size of a pea to several inches in diameter, usually occurring on the thighs and arms and frequently on the abdomen, back, and legs. The nodules, tender or

Intrathoracic Manifestations of the Lymphomatoid Diseases

In the lymphomatoid diseases—Hodgkin's disease, lymphosarcoma, the chronic leukemias, and mycosis fungoides—success in palliation depends upon treatment of the deeply situated lesions as well as those which are superficial. For many years, the deep, obscure pathological processes have been reported as common findings at autopsy. Many of the lesions observed at necropsy are not readily demonstrated clinically. The frequency with which such sites as the gastro-intestinal tract, the skeletal system, the genito-urinary tract, and respiratory tract are affected by the lymphomatoid diseases is not well recognized. Although the internal processes are described or mentioned in many reports, there is still a tendency to restrict treatment largely to palpable or visible evidence of disease. In the literature of the past twenty years, sporadic references may be found to the high incidence of pulmonary and pleural involvement in the diseases under discussion. In these reports, greater emphasis has been given to the occurrence of these lesions in Hodgkin's disease. Similar pathological processes, however, are almost as frequently encountered in lymphosarcoma and lymphatic leukemia. The purpose of this presentation is to call attention to the frequency of intrathoracic manifestations of the lymphomatoid diseases, particularly of lesions other than the ordinary mediastinal or hilar adenopathies. The survey comprises all cases with proved pathological diagnoses seen in the Memorial Hospital from 1917 to 1940, excluding current cases. Two sets of figures are recorded: one for roentgen findings, the other for autopsy findings. There are no autopsy studies for mycosis fungoides. Table I shows the cases studied and the grouping of cases reviewed. Totals discussed represent the grand total of 1191 cases minus (a) all those that were lost to follow-up, (b) those without roentgenographic examination of the chest, and (c) those in which biopsies were not fully confirmed; 794 cases were acceptable for roentgenographic study and 160 cases for an analysis of necropsy findings. The autopsy material shows the incidence of intrathoracic lesions to be much higher than was indicated by roentgenography. This discrepancy might be reduced by more frequent roentgen examination of the chest. The similarity of roentgen findings in these diseases would indicate that the gross pathological changes are similar. The frequency of a mediastinal mass or discrete nodes at the roots of the lungs is well recognized. This type of intrathoracic process is analogous to enlargement of superficial nodes. The radiographic features lend themselves to analysis in the following subgroups, as differentiated by Wessler and Greene (60): (1) mediastinal tumor; (2) infiltration into the parenchyma; (3) isolated nodules in the parenchyma; (4) discrete nodes at the roots of the lungs. We add two further subgroups: pleural thickening and pleural effusion.