Prior Radiographs Research Articles

Do All Postoperative Vancouver B2 Fractures Require Revision Arthroplasty With Cementless Stems?

BackgroundManagement of periprosthetic fractures has been guided by the Vancouver classification, which recommends revision for fractures around a loose femoral implant (B2). New studies have challenged this approach, demonstrating acceptable outcomes with internal fixation. This study evaluates our experience with Vancouver B2 fractures, comparing internal fixation to femoral revision. We hypothesized that in select cases with cementless stems, internal fixation would provide acceptable results with reduced morbidity. MethodsA retrospective review was performed of periprosthetic hip fractures treated at our institution between 1 January 2012 and 4 November 2022. We excluded patients who did not have prior radiographs and evidence of stem subsidence, suggestive of a Vancouver B2 fracture. Thirteen patients were included in the analysis. ResultsFour patients (31%) underwent revision of the femoral component, 4 patients (31%) underwent plating, and 5 patients (38%) underwent internal fixation with cerclage cabling. The average operative duration was 158 minutes, 203 minutes, and 62 minutes for the revision, plating, and cabling cohorts, respectively (P = .009). Blood loss was 463 cc, 510 cc, and 90 cc for the revision, plating, and cabling cohorts, respectively (P = .036). Three patients in both the revision and plating cohorts each received a transfusion (75%), whereas no patients in the cabling cohort required a transfusion (P = .033). All patients demonstrated fracture healing on the postoperative radiographs. No patients required additional surgery during the follow-up period. ConclusionsWe have demonstrated that Vancouver B2 periprosthetic fractures with intact lateral cortices may be treated with internal fixation with cerclage cabling with excellent results.

Ultrasound measurements of the normal peroneal tubercle: validation of the normal anatomical measurements and evaluation of the intra- and interobserver reliability.

The aim of this study was to investigate if ultrasound could be a reliable and accurate tool to measure the size of the peroneal tubercle. This study measured the width, length, and height of the peroneal tubercle in 100 asymptomatic patients, comparing the measurements to prior radiographs of the foot (if available) and previously reported anatomical data. This study also assessed the intra- and interrater reliability of ultrasound as a measurement tool. Our findings show that ultrasound measurements of the peroneal tubercle were consistent with values reported in the literature and prior radiographs concerning width. Both intra- and inter-observer measurements were reliable. This study highlights the potential of ultrasound imaging as a promising tool to measure the peroneal tubercle, and it could contribute to a better understanding of peroneal tendon disorders.

Patient-based outcomes of slipped capital femoral epiphysis after treatment with in-situ percutaneous fixation

Abstract Introduction: Percutaneous in situ fixation with a single screw is regarded as safe and remains the gold standard of treatment for slipped capital femoral epiphysis (SCFE). However, reliance is based on subsequent remodeling of the femoral neck. Healing in a non-anatomic position may predispose the patient to femoral-acetabular impingement (FAI) and degenerative arthritis of the hip. Consequently, some surgeons advocate for surgical hip dislocation and reduction of severe SCFE. This study aimed to assess patient-based outcomes after in situ pinning. Methods: Twenty-six patients (36 hips) with SCFE treated at our institution between 2011 and 2016 were included in this retrospective study. Patients with less than two years’ follow-up and those without prior radiographs were excluded. Hips were radiologically classified into three groups: mild, moderate, and severe SCFE. Outcome measures included a modified Harris Hip Score and Visual Analogue Pain Score. Results: There were no cases of avascular necrosis in both mild and moderate slips treated with in situ pinning. Only one avascular necrosis (AVN) was reported out of eleven severe slips (9.1%). This is significantly lower than previous studies that evaluated in situ pinning in severe slips. In addition, one FAI case developed in eleven severe slips (9.1%). Conclusion: Our results suggest that in situ percutaneous pinning is safe and has a low complication rate. High patient satisfaction in pain and function suggests that remodeling is effective regardless of the severity of the slip.

Prediction of future curve angle using prior radiographs in previously untreated idiopathic scoliosis: natural history from age 6 to after the end of growth (SOSORT 2022 award winner)

PurposeTreatment selection for idiopathic scoliosis is informed by the risk of curve progression. Previous models predicting curve progression lacked validation, did not include the full growth/severity spectrum or included treated patients.The objective was to develop and validate models to predict future curve angles using clinical data collected only at, or both at and prior to, an initial specialist consultation in idiopathic scoliosis.MethodsThis is an analysis of 2317 patients with idiopathic scoliosis between 6 and 25 years old. Patients were previously untreated and provided at least one prior radiograph prospectively collected at first consult. Radiographs were re-measured blinded to the predicted outcome: the maximum Cobb angle on the last radiograph while untreated. Linear mixed-effect models were used to examine the effect of data from the first available visit (age, sex, maximum Cobb angle, Risser, and curve type) and from other visits while untreated (maximum Cobb angle) and time (from the first available radiograph to prediction) on the Cobb angle outcome. Interactions of the first available angle with time, of time with sex, and time with Risser were also tested.ResultsWe included 2317 patients (83% of females) with 3255 prior X-rays where 71% had 1, 21.1% had 2, and 7.5% had 3 or more. Mean age was 13.9 ± 2.2yrs and 81% had AIS. Curve types were: 50% double, 26% lumbar/thoracolumbar-lumbar, 16% thoracic, and 8% other. Cobb angle at the first available X-ray was 20 ± 10° (0–80) vs 29 ± 13° (6–122) at the outcome visit separated by 28 ± 22mths.In the model using data at and prior to the specialist consult, larger values of the following variables predicted larger future curves: first available Cobb angle, Cobb angle on other previous X-ray, and time (with Time2 and Time3) to the target prediction. Larger values on the following variables predicted a smaller future Cobb angle: Risser and age at the first available X-ray, time*Risser and time*female sex interactions. Cross-validation found a median error of 4.5o with 84% predicted within 10°.Similarly, the model using only data from the first specialist consult had a median error of 5.5o with 80% of cases within 10° and included: maximum Cobb angle at first specialist consult, Time, Time2, age, curve type, and both interactions.ConclusionsThe models can help clinicians predict how much curves would progress without treatment at future timepoints of their choice using simple variables. Predictions can inform treatment prescription or show families why no treatment is recommended. The nonlinear effects of time account for the rapid increase in curve angle at the beginning of growth and the slowed progression after maturity. These validated models predicted future Cobb angle with good accuracy in untreated idiopathic scoliosis over the full growth spectrum.

Cognitive load and processes during chest radiograph interpretation in the emergency department across the spectrum of expertise.

In the emergency department (ED), chest radiographs (CXRs) provide essential information for clinical diagnostic reasoning. Errors in interpretation by emergency physicians can lead to negative patient outcomes. To aid in teaching this important skill, an understanding of cognitive processes and cognitive load (CL) in CXR interpretation in emergency medicine (EM) personnel is warranted. This study adopted a concurrent mixed-methods research design. Participant groups included medical students (M), junior (J) and senior (S) EM residents, and attending emergency physicians (P) in the ED at an academic hospital. To elucidate cognitive processes, a real-time cognitive task analysis during CXR interpretation was performed. Interviews were audio recorded, transcribed verbatim, and analyzed thematically. The interview was followed by a questionnaire, where participants rated their CL, stress, and confidence level. Levels of CL (M vs. S and M vs. P, p=0.002; J vs. S, p=0.004; J vs. P, p=0.005) and stress (J vs. P, p=0.002) decreased, while confidence levels increased (M vs. S, p=0.006; J vs. S, p≤0.001; J vs. P, p=0.003) as experience level increased. Qualitative analysis of interviews revealed four themes: checking behavior, information reduction, pattern recognition versus systematic viewing, and recognizing scope of practice. Experts commonly utilized checking behavior (e.g., comparison to prior radiographs) and deprioritized task irrelevant data. Experts used a general overview technique as their initial approach as opposed to a systematic viewing approach, and they more readily recognized an EM physicians' scope of practice in this task. This study characterized differences in cognition that led to increased CL, stress, and lower level of confidence in EM learners during CXR interpretation and provided insight into expertise development in this important skill.

Diagnostic Yield of Routine Skull Radiographs in Infants With Deformational Plagiocephaly.

Differentiating synostotic and nonsynostotic plagiocephaly can be challenging, and many providers routinely obtain screening skull radiographs when evaluating an infant with plagiocephaly. However, the diagnostic yield of radiographs has not been studied in this clinical setting. This study was a retrospective chart review. The study took place in a tertiary care center. We retrospectively reviewed the records of all patients referred to Children's Medical Center (Dallas, TX) between the years 2010 to 2012 with a diagnosis of plagiocephaly. After an initial evaluation, skull radiographs were obtained to rule out craniosynostosis. We reviewed clinical and demographic data and radiographic findings to determine the diagnostic yield of routine screening radiographs in infants presenting with plagiocephaly. There were 1219 patients in total, and 1213 of these patients received screening four-view conventional skull radiographs. Six had computed tomography without prior radiographs. Of the patients in the skull radiograph group, 24% (289 of 1213) had abnormal radiographic findings, and 7.6% of this group (22 of 289) had findings that were indicative of craniosynostosis. Of these 22 patients, 12 obtained follow-up studies, and only three patients (0.2% of skull group) had true craniosynostosis. In comparison, 50% (three of six) in the group of patients who underwent computed tomography without prior conventional screening radiographs had true craniosynostosis. Routine screening skull radiographs have a low diagnostic yield in differentiating between synostotic and nonsynostotic plagiocephaly in patients presenting to a tertiary care deformational plagiocephaly clinic. Considering the costs and radiation exposure, the benefit of the routine use of skull radiographs in patients with deformational plagiocephaly is questionable.

MRI of the Knee and Shoulder Performed Before Radiography

Available data are limited on the level of adherence to established guidelines for appropriate utilization of MR in musculoskeletal imaging. This study estimates the percentage of MRI examinations for knee and shoulder pain or tendonitis performed without prior radiography, which thus may fall outside the ACR Appropriateness Criteria for the Medicare and commercially insured populations. The percentage of MRI examinations for knee and shoulder pain or tendonitis performed without prior radiography was estimated among patients in the Medicare 5% carrier claims limited data set and among commercially insured patients in the Truven Marketscan Treatment Pathways database in 2010. Approximately 28% of all knee MRIs, and 35%-37% of all shoulder MRIs were performed without recent prior radiographs. The extrapolated expense of these potentially unwarranted MRIs in the entire fee-for-service Medicare population was between $20 and $35 million. Between 20% and 23% of patients undergoing knee MRI, and 27%-32% undergoing shoulder MRI, did not have radiographic examination at any point before the MRI in the same calendar year. MRI performed without prior radiography represents a potential gap in care and should be considered as an area for establishment of performance measures.

Ganglion Cyst in the Tarsal Tunnel

The patient was a 35-year-old man who worked as a pipe fitter. He was referred to a physical therapist by an orthopaedic surgeon for a chief complaint of progressively worsening pain in the medial aspect of the right distal Achilles tendon and heel that began insidiously 12 months earlier, which was consistent with a diagnosis of insertional Achilles tendonitis. Prior radiographs revealed mild calcification at the insertion of the Achilles tendon. Despite physical therapist intervention for 8 weeks, the patient did not improve. Subsequent magnetic resonance imaging revealed a large multiloculated ganglion cyst in the tarsal tunnel.

Diagnostic evaluation following a positive lung screening chest radiograph in the Prostate, Lung, Colorectal, Ovarian (PLCO) Cancer Screening Trial

Lung cancer is the major cause of cancer mortality. One of the aims of the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO) was to determine if annual screening chest radiographs reduce lung cancer mortality. We enrolled 154,900 individuals, aged 55–74 years; 77,445 were randomized to the intervention arm and received an annual chest radiograph for 3 or 4 years. Participants with a positive screen underwent diagnostic evaluation under guidance of their primary physician. Methods of diagnosis or exclusion of cancer, interval from screen to diagnosis, and factors predicting diagnostic testing were evaluated. One or more positive screens occurred in 17% of participants. Positive screens resulted in biopsy in 3%, with 54% positive for cancer. Biopsy likelihood was associated with a mass, smoking, age, and family history of lung cancer. Diagnostic testing stopped after a chest radiograph or computed tomography/magnetic resonance imaging in over half. After a second or subsequent positive screen, evaluation stopped after comparison to prior radiographs in over half. Of 308 screen-detected cancers, the diagnosis was established by thoracotomy/thoracoscopy in 47.7%, needle biopsy in 27.6%, bronchoscopy in 20.1% and mediastinoscopy in 2.9%. Eighty-four percent of screen-detected lung cancers were diagnosed within 6 months. Diagnostic evaluations following a positive screen were conducted in a timely fashion. Lung cancer was diagnosed by tissue biopsy or cytology in all cases. Lung cancer was excluded during evaluation of positive screening examinations by clinical or radiographic evaluation in all but 1.4% who required a tissue biopsy.

Verification of three different MMP-13 isoforms expression in human osteoarthritic cartilage

Verification of three different MMP-13 isoforms expression in human osteoarthritic cartilage

Ex vivo and in vivo magnetic resonance imaging of cartilage canals in swine at predilection sites of osteochondrosis

Ex vivo and in vivo magnetic resonance imaging of cartilage canals in swine at predilection sites of osteochondrosis

Insufficiency Fracture of the Pubic Rami

The patient was an 87-year-old woman referred to a physical therapist for right buttock and lateral calf pain of insidious onset that had been present for the past 3 weeks. She also complained of a 5-day history of right anterior hip/groin pain. Due to concern for a recent fracture of the right hip or pelvis, based on prior radiographs and the patient's medical history, radiographs were ordered that demonstrated new superior and inferior right pubic rami fractures. An orthopaedic surgeon was immediately consulted who diagnosed the patient with insufficiency fractures of the right pubic rami. The patient was instructed on toe touch weight bearing with a walker for the right lower extremity, and the orthopaedic surgeon recommended treatment by the physical therapist, as well as a reevaluation of the current management strategies for the patient's osteoporosis. J Orthop Sports Phys Ther 2010;40(10):666. doi:10.2519/jospt.2010.0416

Chest Radiographs Are Valuable in Demonstrating Clinically Significant Pacemaker Complications That Require Reoperation

Purpose To evaluate the utility of chest radiography in demonstrating clinically significant pacemaker complications that required reoperation. Methods In this retrospective case-controlled series, we identified 14 consecutive adults who required pacemaker reoperation and who had chest radiographs available for review (6 men, 8 women; mean age, 71 years [range, 43–95 years]). Ten patients had pacemakers implanted at our institution, and 4 were referred for reoperation. Forty-two controls, 3 for each patient, had postoperative chest radiographs and normal device function (25 men, 17 women; mean age 76 years [range, 37–96 years]). All postoperative chest radiographs, including 1-year follow-ups, were blindly reviewed by at least 2 of 4 radiologists for lead perforation and position of right atrial and right ventricular leads. Follow-up radiographs were assessed for lead perforation, lead displacement, and lead fracture. Data were analysed by using the Fisher exact test. Results Of the patients, 1.7% (10/581) required reoperation for pacemaker dysfunction (noncapture, oversensing, abnormal atrial and ventricular thresholds, failing impedance), extracardiac stimulation, and lead perforation and/or displacement. There were no lead fractures. Chest radiographs demonstrated pacemaker complications in 57% of patients (8/14) at a median of 2 days (<1–32 days) after implantation and in 5% of the controls (2/42) ( P < .0001). None of the abnormalities were noted on the official reports. Among subgroups, chest radiographs were abnormal for the following indications: pacemaker dysfunction in 4 of 7 patients versus 0 of 21 controls ( P = .0017), extracardiac stimulation in 1 of 3 patients vs 0 of 9 controls ( P = .25), and lead perforation and/or displacement in 3 of 4 patients vs 2 of 12 controls ( P = .06). Conclusions Chest radiographs are useful after pacemaker placement and demonstrate the majority of complications that require reoperation. Familiarity with the expected normal position of the leads, appearances of pacemaker complications, and comparison with prior radiographs is crucial in rendering a correct diagnosis that guides patient management.

Magnetic resonance-guided growth plate bone bridge resection at 0.23 tesla: report of a novel technique

Growth plate or physeal cartilage trauma may result in delayed or immediate failure of growth due to bone bridge formation at the insult site. With computed tomography (CT) and magnetic resonance imaging (MRI), the role of imaging has expanded from diagnosis to treatment planning and therapy guidance. To describe a technique for MR-guided growth plate bone bridge resection and to evaluate feasibility of the procedure. Three consecutive patients with growth plate bone bridges were treated surgically under MR guidance. All bridges were detected with prior MRI and radiographs. All patients were referred to procedure due to growth plate bridge associated growth anomaly and pertaining clinical symptoms. The effect of the treatment was evaluated after 48 months with a clinical follow-up. All bridges were successfully detected, marked, and removed under MRI guidance. All patients had relief from their symptoms. Two patients had lasting results from the operation with no further operative treatment needed or scheduled at 48 months from primary treatment. There was one clinical failure, with the patient requiring repeated osteotomies. We have successfully implemented a novel therapy for growth plate bridge resection.

Imaging Characteristics of Locally Recurrent Tumors of Bone

The purpose of this article is the identification of recurrent tumor of bone utilizing radiography, CT, and MRI. Radiography is frequently used to identify recurrence of treated bone tumors through findings such as osteolysis, cortical reactions, and characteristic matrix mineralization. CT can help evaluate the character of osseous and calcific abnormalities. Comparison with prior radiographs can be crucial for differentiation between postoperative alterations of bone and subtle signs of recurrence. MRI can identify soft-tissue masses and is useful for imaging patients with metallic hardware when it is optimized to decrease artifacts.

Evaluation of usefulness of color digital summation radiography for solitary pulmonary nodules on chest radiographs

The aim of this study was to evaluate the usefulness of novel color digital summation radiography (CDSR) for detecting solitary pulmonary nodules on chest radiographs by observers with different levels of experience. A total of 30 healthy controls and 30 patients with newly detected solitary pulmonary nodules were evaluated. Six radiologists and five residents evaluated three image sets: set A, current and prior radiographs only; set B, set A with temporal subtraction images; and set C, set A with CDSR. The observers were asked to rate each image set using a continuous rating scale. In addition, the reading time required for each set was recorded. The radiologists showed no significant differences in the mean A(z) value between set A, set B, and set C. However, the residents showed significant differences between set A and set B and between set A and set C. In addition, for set B and set C, the mean reading time per case of all readers was significantly shorter than that for set A. The detection capability of observers with little experience is comparable to that of experienced observers when reading radiographs with temporal subtraction images or with CDSR. The usefulness of CDSR is comparable to that of temporal subtraction.

An adult cystic fibrosis patient presenting with persistent dyspnea: case report

BackgroundPersistent dyspnea is a common finding in the cystic fibrosis patient that typically leads to further work up of an alternative pulmonary etiology. Adult cystic fibrosis patients; however, are growing in numbers and they are living into the ages in which coronary artery disease becomes prevalent. Coronary disease should be included in the consideration of diagnostic possibilities.Case presentationA 52-year-old white male with cystic fibrosis was evaluated for exertional dyspnea associated with vague chest discomfort. Diagnostic testing revealed normal white blood cell, hemoglobin and platelet count, basic metabolic panel, fasting lipid profile, HbA1c, with chest radiograph confirming chronic cystic findings unchanged from prior radiographs and an electrocardiogram that revealed sinus rhythm with left anterior fascicular block. Stress thallium testing demonstrated a reversible anteroseptal perfusion defect with a 55% left ventricular ejection fraction. Heart catheterization found a 99% occlusion of the left anterior descending artery extending into the two diagonal branches, with 100% obstruction of the left anterior descending artery at the trifurcation and 70% lesion affecting the first posterior lateral branch of the circumflex artery.ConclusionThis case report represents the first description in the medical literature of a cystic fibrosis patient diagnosed with symptomatic coronary artery disease. Applying a standard clinical practice guide proved useful toward evaluating a differential diagnosis for a cystic fibrosis patient presenting with dyspnea and chest discomfort.

The elusive Hampton’s hump

A 66-year-old man presented to the Emergency Department with a 1-day history of weakness and left-sided chest pain. He had a complex medical history including insulin-dependent diabetes mellitus, coronary artery disease with a history of myocardial infarction, hypertension, chronic renal insufficiency, and history of deep venous thrombosis (DVT). He described the pain as sharp and stabbing in the left side of the chest that was made worse with movement and inspiration. The pain came on suddenly the day before and had remained constant since. The patient had taken nitroglycerin and proproxephene with little relief of his symptoms. The pain was confined to the chest and had no radiation to the arms or jaw. The patient also complained of generalized weakness, nonfocal in nature, that had prevented him from performing the activities of daily living. The patient denied any trauma, fevers, cough, chills, hemopytsis, shortness of breath, or leg swelling. Physical examination revealed an elderly man in no respiratory distress. Cardiovascular examination showed a regular rate and rhythm without murmurs, rubs or gallops. Pulses were equal bilaterally. Pulmonary examination demonstrated mild bilateral crackles. The chest wall was nontender to palpation. The lower extremities had no edema, pain, cords or swelling. The initial work-up of this patient was directed towards a cardiac pathway, considering the patient’s past medical history. Initial management with nitroglycerin, aspirin, and morphine made no improvement in the patient’s symptoms. The patient’s original electrocardiogram (EKG) was unremarkable, as were the laboratory studies. However, the patient’s portable AP chest X-ray study revealed a left-lung-based wedge-shaped opacity not previously seen on prior radiographs (Figure 1). There was also a new small left-sided pleural effusion present. The radiologist thought this opacity was consistent with an infectious process, or a “Hampton’s hump.” Although a pneumonia could explain the chest pain and weakness, the acute onset, history of a DVT, and the finding of a “Hampton’s Hump” prompted a work-up for a pulmonary embolus. With the patient’s history of chronic renal insufficiency, a ventilation-perfusion scan was ordered to establish the diagnosis. A perfusion defect in the same area was deemed a high probability for an acute pulmonary embolism. The diagnosis of pulmonary embolism remains a diagnostic challenge. Standard chest radiographs are often obtained in the initial work-up of pulmonary embolism but are often unrevealing (1). Before newer techniques were discovered, the chest radiograph was the only imaging technique available for aiding in the diagnosis of pulmonary embolism. Multiple radiographic abnormalities have been described by the early radiologists in the diagnosis of pulmonary embolism. In 1940, Hampton and Castleman first described a pleural-based area of increased opacity associated with pulmonary embolism,

Osteoarthritis of the scaphoidtrapezium joint: an early sign of calcium pyrophosphate dihydrate disease.

The aim of this study was to determine the value of scaphoidtrapezium osteoarthritis (ST osteoarthritis) as an early sign of calcium pyrophosphate dihydrate disease (CPDD) in a cohort of patients undergoing surgery for osteoarthritis of the first carpometacarpal joint. We examined whether patients with cartilage calcification of the wrist at the time of operation had ST osteoarthritis, indicating CPDD at an earlier time (retrospective study), and whether patients with ST osteoarthritis but without cartilage calcification at the time of surgery develop radiological or clinical signs of CPDD at a later time (prospective study). From 1 January 1989 to 31 December 1995 a total of 169 patients (from an orthopaedic clinic) with a diagnosis of osteoarthritis of the first carpometacarpal joint were included in the study; 167 underwent surgery and two were treated without. Of the 16 patients showing calcification on surgery and therefore included in the retrospective study, 12 had prior radiographs, of which eight showed ST osteoarthritis. Among these, four had no concomitant cartilage calcification in the prior radiographs. Of the 32 patients in the prospective group having ST osteoarthritis but no calcifications at the time of surgery, 27 could be clinically examined. Of these, two showed cartilage calcifications on the follow-up radiographs of the hands. The presence of ST osteoarthritis is a helpful diagnostic finding for the diagnosis of CPDD, especially in cases without radiographic cartilage or fibrocartilage calcification of the wrist. ST osteoarthritis may then point to the correct diagnosis.

Primary bronchogenic carcinoma after heart or lung transplantation: radiologic and clinical findings.

Chronic immunosuppression in organ transplant recipients predisposes to the development of malignant disease. The authors describe their 29-year institutional experience of bronchogenic carcinoma developing after heart and lung transplantation. Seven cases of bronchogenic carcinoma were diagnosed in 1,119 heart and lung transplant recipients. Computed tomography scans and radiographs at time of diagnosis, as well as prior radiographs available in six patients were retrospectively analyzed by two radiologists in consensus. The seven cases involved six heart and one lung transplant recipients. Six patients were smokers with a mean smoking history of 66 pack-years. Mean time interval from transplantation to cancer detection was 25 months. Radiologic findings consisted of a solitary pulmonary nodule (n = 3), mass with satellite nodules (n = 1), and obstructive pneumonitis (n = 1). In the sixth patient, the cancer was not radiographically visible because of obscuration by adjacent fibrosis. On review, radiographic abnormalities were present a mean of 12 months prior to diagnosis in 66% of patients. In the heart or lung transplant population, bronchogenic carcinoma develops in recipients with extensive smoking histories. It presents radiographically as a nodule, mass, or obstructive pneumonitis, and is usually visible on radiographs before the time of diagnosis.