Roentgenographic Shadows Research Articles

Transforming growth factor-beta gene polymorphism in sarcoidosis and tuberculosis patients.

Transforming growth factor-beta (TGF-beta) plays an important role in many diseases, influencing as it does such processes as immune responses, fibrosing processes, and angiogenesis. Recently, polymorphisms have been described for TGF-beta that are associated with the risk of several diseases. In this study, we investigated whether TGF-beta 1 polymorphism has an effect on sarcoidosis and tuberculosis. TGF-beta 1 Codon 10 T869C polymorphism was investigated in 110 healthy control subjects, 104 sarcoidosis patients, and 101 tuberculosis patients. The TGF-beta genotype was determined using polymerase chain reaction restriction fragment length polymorphism. We found no significant differences in TGF-beta genotypes between sarcoidosis patients and healthy controls or tuberculosis patients and controls. The long axis of the tuberculin skin test was larger in the CC type compared with the CT type. However, there was no association between the TGF-beta genotype and the roentgenographic stage, the disappearance of shadows, or organ involvement in sarcoidosis, nor any association between genotype, the extent or type of roentgenographic shadow, or detected volume of tubercle bacilli in tuberculosis. From the results, we believe that TGF-beta polymorphisms on the whole do not have a strong influence on disease onset or clinical progression in sarcoidosis and tuberculosis, although this polymorphism might have an effect on the immune response in a tuberculosis host.

Pitfalls in the Assessment of Skeletal Immaturity

Nonoperative treatment protocols in adolescent scoliosis require that growth is still occurring. The open iliac apophyses and vertebral ring apophyses are usually considered evidence that growth remains. Studies of adolescent skeletons are not consistent with this view, and one such example is presented. Of clinical importance is that determinant of immaturity should be based on the secondary sexual characteristics, not roentgenographic shadows.

膵臓結石症のレ線学的考察

The diagnosis of disseminated parapancreatic calculus is relatively easy from its specific roentgenogram, but in those cases with little roentgenographic shadow or with a solitary shadow it becomes quite difficult. Hence in the latter cases it is necessary to distinguish it from bilestone, kidney stone, peritoneal calcified lymph node, splenic venous thrombus, or duodenal diverticulosis. Therefore, for the diagnosis of the parapancreatic calculus it is important to take a single roentgenogram of the entire abdomen as well as lateral views of the abdomen, the combination of which would afford us to identify the parapancreatic calculus from the density of its shadow, its site and its size. We have recently encountered three patients with pancreatic calculus and present our observations of the cases as well as some remarks on them from the aspects of roentgenology.

Vertebral Osteomyelitis

In a series of 24 patients with proved hematogenous, pyogenic vertebral osteomyelitis, the disease was insidious in onset in 20. Because x-ray findings were inconclusive, vertebral-body biopsy was required for an accurate diagnosis, when the blood culture was negative. Despite the frequent presence of abnormal roentgenographic shadows, drainage was required in only two patients. Exploration for abscess cannot be determined on the basis of roentgenographic findings alone. The frequency of a benign course and failure of spontaneous arthrodesis induced speculation concerning possible attenuation of the virulence of the organism, altered host immunity, or perhaps, with regard to spontaneous fusion, merely a modification of an end point of the pathologic process by antibiotic treatment.

Obstructive cholecystopathy or primary roentgenographic shadow of the gallbladder. Report on 262 patients.

Obstructive cholecystopathy or primary roentgenographic shadow of the gallbladder. Report on 262 patients.

Physical aspects of breast radiography.

Because of renewed and widened interest in breast radiography, many additional studies are contemplated to evaluate its clinical potentialities and limitations. It seemed to us that optimum technical procedures are essential to carry out any such program. Previous work on selection of the best technical factors has been largely empirical, with little assistance from those interested in the basic physics of the problem. This has resulted in a variety of technics, difficult to evaluate. For example, those used by two of the best-known investigators in mammography (Table I) differ in every detail! In this paper an attempt is made to provide a physical basis for the selection of acceptable mammography technics. Our approach includes the following: I. Production of a satisfactory breast roentgenogram—analysis II. Studies using a phantom breast6 III. Dosimetry IV. Discussion—technics and practical considerations. I. Production of a Satisfactory Breast Roentgenogram—Analysis Pathognomonic signs of malignant growths of the breast include the following (1–4): 1. Small calcific deposits, in clusters of irregular distribution: Calcium occurs in specks so tiny (frequently less than 1 mm.) that they are clinically observed in only 30 to 50 per cent of proved malignant tumors (2, 3). However, they are reported in up to 70 per cent of proved surgical specimens (5). Unlike soft-tissue lesions, calcium may be detected even in young and cystic breasts. 2. Soft-tissue lesions, both carcinoma and marginally situated fibrous tissue (4): These produce adequate subject contrast primarily in fatty breasts. Three technical requirements must be met if these signs are to be dependably recognized in a roentgenogram. First, very fine detail must be present for detection of calcium deposits and structural detail in and about soft-tissue lesions. Second, high contrast is needed to highlight both small calcium specks and soft-tissue lesions. Finally, exposure times should be preferably three seconds or less, as patient motion blur can destroy an otherwise good roentgenogram. Detection of a Roentgenographic Shadow In all x-ray procedures, recognition of disease involves both detection of significant signs and correlation of those signs with a previous memory pattern (6, 7). The importance of training and specific experience in the second aspect of this process cannot be overemphasized. However, even the most experienced radiologist must first notice significant details. This process of detection involves the following considerations: 1. Optimum film brightness.7 Optimum film brightness is necessary to assure adequate retinal illumination. 2. Adequate size of the image on the film: Separation of the foveal cones sets an absolute limit of about one minute of arc in detection of small objects (8). At a viewing distance of 25 cm. this corresponds to an image on the film of less than 0.1 mm.

Evaluation of xenon as a gaseous roentgenographic contrast material. A preliminary report.

The roentgenographic properties of the chemically inert gas Xe were studied in a phantom whose proportions were designed to simulate a human chest. The experiment was performed utilizing 30-, 60-, and 100-kvp x rays and varying amounts of added Al filtration, ranging from 0.5 to 2.0 mm. A system of densitometry was used that included the pre-exposure of a portion of all roentgenograms with a step wedge to be used as a frame of reference and to determine film response. Xenon, in path-lengths ranging from 1.04 to 9.80 cm, casts a faint roentgenographic shadow relative to air; and differences of radiopacification can be seen visually as well as detected densitometrically. The difference of radiopacification of Xe relative to air, as determined densitometrically, is accentuated in exposures made at 30 and 80 kvp relative to those made at 100 kvp, but no difference can be detected between exposures made at 30 kvp and those made at 60 kvp. Addition of 0.5 to 2.0 mm Al filtration has no effect on the relative radiopacification of Xe and air at 60 to 100 kvp, but diminishes thus relative radiopacification at 3a kvp. Thus, it may be advantageous to make exposures of the chestmore » at 60 kvp with 2.0 mm of added Al filtration when using Xe as a gaseous contrast medium. A linear relation was found between centimeters of Al and centimeters of Xe, obtained by performing a regression analysis on all of the values obtained at 80 kvp, with 0 to 2.0 mm Al filtration, for a chest phantom with an antero-posterior dimension of 20 cm. A pilot study was undertaken to ascertain the actual magnitude of the roentgenographic shadow caused by Xe in the lungs of a patient with clinically normal pulmonary dynamics. The results of this preliminary clinical study indicated that the radiopacification due to Xe is insufficient to be readily useful with ordinary roentgenographic techniques. (BBB)« less

Misleading Thoracic Roentgenograms

Roentgenograms of the thorax in certain cardiovascular conditions may simulate those associated with diseases of the lungs, bony thorax, or mediastinum. It is important to be aware of these similarities, which may be remarkable. Roentgenographic shadows may be produced that look very much like those characteristic of a different disease. The recognition of the real cause of these roentgenologic changes may allow treatment of an apparently hopeless condition or prevent an unnecessary operation. This exhibit presents examples of such misleading roentgenograms under the following categories: shadows produced by abnormal aortic contours; shadows suggesting intrathoracic tumor; shadows produced by intrathoracic fluid, and shadows of diverse origin and complexity. Shadows Produced by Abnormal Aortic Contours (Figs. 1-5) Abnormalities in the shape of the aorta can cause confusion. Abnormal roentgenographic shadows may be produced directly by the aorta or indirectly by its effect on contiguous structures. These variations may be due to

PULMONARY COIN LESION

The problem of the asymptomatic, solitary, coin-shaped, pulmonary lesion was first fully presented by O'Brien and others, 1 who studied 21 patients in whom coin-shaped pulmonary roentgenographic shadows were seen on routine or survey chest roentgenograms. In all instances an exact diagnosis was impossible by clinical methods. Since an appreciable number of the lesions were probably serious in nature, an exploratory thoracotomy was performed on each patient in order to establish a histological diagnosis. Eight, or 38%, of the 21 patients had bronchogenic carcinoma, and the others had tuberculomas or other nonmalignant lesions. The natural conclusion of their study was that all such solitary, benign-appearing, pulmonary lesions should be treated by exploratory thoracotomy rather than by a long period of observation. Subsequent studies of solitary lung lesions by other investigators 2 show considerable differences in the selection of cases and in the types of lesions found at surgery. The percentage

The Reliability of Chest Roentgenography and Its Clinical Implications

The interpretation of chest roentgenograms, like any other human activIty, is subject to considerable variation. It has been demonstrated that competent and experienced physicians are likely to disagree with each other in a significant proportion of roentgenographic interpretations. These inconsistencies were found when single roentgenograms were interpreted for the presence or absence of abnormal shadows. Even greater discrepancies were demonstrated in attempts to classify single roentgenographic shadows according to character, extent, and probable “activity” of the lesion. The implications of these findings to mass case finding programs have been discussed in a number of publications.’-5 More recently inconsistencies of similar magnitude were found to exist in the Interpretation of serial roentgenograms. It was shown that in evaluating film pairs for evidence of progression, regression, or stability of disease, well qualified radiologists and phthisiologists disagreed significantly with each other. Moreover, a physician did not always agree with himself In two independent interpretations of a set of serial roentgenograms.6 These findings are of great importance in clinical phthisiology In view of the universal employment of the procedure as an aid in the clinical management of tuberculosis patients. It is no doubt superfluous to state that, in spite of these difficult problems of interpretation, serial roentgenograms are among the most valuable criteria for assessing the course of disease in a patient with pulmonary tuberculosis. The most reliable estimate of changes in the extent and character of a lesion is provided by roentgenography and is perceived by a comparison of serial chest films. The evidence provided by roentgenography, however, must be integrated with other clinical findings and results of other tests. For the proper evaluation of these, and for the derivation of the most probable diagnosis, it Is desirable to have knowledge of the limitations of each test. What is wanted Is a quantitative evaluation of the errors inherent in each. Unfortunately, our knowledge of the subjective error in clinical medicine and of the variations In the different diagnostic tests is meager. The quantitative data which have recently been accumulating on the evaluation of roentgenographlc interpretations are, it may be hoped, the forerunner of similar data which will be forthcoming In other fields of medicine. One of the advantages which results from the demonstration of the existence of observer errors is the stimulation which It provides for devising

Observations on Paragonomiasis at the Quezon Institute

It would be presumptuous to draw conclusions on the basis of such meager data as we have so far on hand. But for those who care to follow whatever lead may be hinted in this article it may not be amiss to recapitulate the basic features encountered by us during our observations of these cases. There seem to be three main features shared by all the patients included in this study, namely, the origin of the patient, which is the Island of Leyte on the southeastern part of the Philippines, and the common presenting symptom for which they were confined to the Quezon Institute, which is hemoptysis. No two of the five cases presented received the same treatment. One was given Fuadin injections alone, another both Fuadin and Lipiodol, a third Prontosil, a fourth emetine hydrochloride, and one received no treatment in the hospital because of an expressed desire to be treated by a private physician of his own choosing. All told only the patient who received emetine hydrochloride injections manifested clinical cure. This is by no means a blanket indorsement of emetine as the best remedy for these lung-fluke infestations but it does pave the way for further studies on this interesting disease which in our opinion deserves to be included in Dr. King's list of conditions giving rise to roentgenographic shadows (pp. 536–38, October 1949 issue of the American Review of Tuberculosis), similar to that of tuberculosis.

SILENT PHASE OF CANCER OF THE LUNG

Fate has challenged physicians in a peculiar way with respect to primary cancer of the lung. The problem is magnified by an astounding increase in numbers, yet it is simplified by facilities for early detection. In fact, of all internal cancers, those originating in the lung should be the most readily discovered while still locally confined. The lesions not only can be found but can be properly labeled. Excision of the cancer-bearing lung has been shown to be feasible, relatively safe and effective. Therefore physicians have the tools with which to find, label and successfully treat cancer in this location. EXTENT OF PROGRESS Cure of cancer of the lung was never seriously considered prior to 1933, when total excision of the lung was shown to be possible. During subsequent years, correlated studies of symptoms, roentgenographic shadows, bronchoscopic observations, cellular elements of sputum and surgically detected pathologic conditions have been made.

Epipericardial Fat Shadows in Differential Diagnosis

As any one who has seen an appreciable number of autopsies can testify, the accumulation of sizable quantities of adipose tissue outside the pericardium of obese individuals is a commonplace occurrence. It is also common knowledge that these epipericardial fat pads frequently are visible roentgenologically along the left heart border, at times completely obliterating the left cardiophrenic angle. What is apparently not so widely recognized is the fact that large extrapericardial fat deposits occasionally produce well defined roentgenographic shadows adjacent to the right heart border. In this location they sometimes present particularly difficult diagnostic problems. The literature on the subject of pericardial fat is widely scattered and surprisingly meager. As long ago as 1910, Schwarz (1) described the frequent fluoroscopic observation of triangular shadows of increased density obscuring the left cardiophrenic angle in some of his obese patients. Because these shadows were less dense than that produced by the heart itself, Schwarz concluded that they represented fat tissue, a fact which he repeatedly confirmed at autopsy. A few additional references to Schwarz's observations followed (2, 3, 4), and then, in 1936, McGinn and White (5) re-emphasized the importance of recognizing epipericardial fat deposits to avoid errors in roentgenologic estimation of heart size. During the same year, Kautz and Pinner (6) stated that “after reviewing a large roentgenologic material and evaluating the very few observations in the literature, we reached the conclusion that under certain circumstances extrapericardial fat bodies may be visualized roentgenologically.” These authors then presented the roentgenologic and anatomic findings in a patient with prominent fat shadows at both cardiophrenic angles and listed some of the intrathoracic conditions with which these fat bodies might be confused. Our current interest in right epipericardial fat deposits is largely centered around the problem they present in photofluorography. The opportunity to view literally thousands of chest roentgenograms afforded by the increasingly popular mass survey methods employing miniature film has made the roentgenologist acutely aware of a number of insignificant normal variations in the appearance of intrathoracic structures. At times, some of these findings are extremely difficult to distinguish from clinically important lesions. The wide anatomic and physiologic variations in the size and shape of the heart, the frequent unexplained accentuation of the undivided portion of the pulmonary artery or of peripheral vascular markings in the upper portions of the lungs, and the startling prominence of the innominate artery buckled outward by a tortuous thoracic aorta, are just a few of many examples which might be mentioned.

Kidney Stones Simulating Biliary Concretions

The roentgenologist usually experiences little difficulty in differentiating on a routine plain film of the abdomen between roentgenographic shadows produced by urinary concretions and gallstones. In some cases, additional views postero-anteriorly or laterally are needed, supported, if necessary, by stereoscopic, cholecystographic, or urographic studies to clarify the condition. In a third group, the routine plain abdominal plate is not only insufficient for differential diagnosis but is actually misleading. Upon reviewing 12 modern textbooks on urology, roentgen diagnosis, and urologic-roentgenologic diagnosis, this possibility was mentioned but once (13). There was also a conspicuous absence of illustrations bearing upon this point. The literature of the last decade, likewise, fails to give this subject the consideration which it unquestionably deserves. Publications (10) can be found quoting cases in which the situation was reversed, namely, biliary concretions being erroneously diagnosed as kidney stones. The practical considerations involved in these differential diagnostic problems occur mainly on studying survey films of the abdomen, lumbar spine, or urinary tract, when the roentgenologist's attention has not been primarily directed to the kidneys. When observing “typical” shadow configurations as accidental findings, the roentgenologist may commit himself to a definite but incorrect diagnosis. However, in those cases in which renal disease is suspected and the patient is sent primarily for urologic-roentgenologic workup, such misinterpretations are less likely to occur. The characteristics of biliary concretions are their location over the area of gall bladder and biliary ducts, their ring-shaped or laminated structure with or without a dense nucleus, and facet formation. In multiple concretions, the stones may be homogeneous but their arrangement is such as to outline the shape of the gall bladder. The purpose of this paper is to present three cases which clearly demonstrate these properties but which were proved to be cases of kidney concretions. Case 1. A female, aged 36, was admitted to the hospital with a history of vomiting, severe pain in the right lumbar region and loin, and localized tenderness over the right wing of the os sacrum and over the right gluteal region. There were no typical urinary symptoms. The temperature curve showed high intermittent fever up to 105°. The leukocyte count was 16,200 and sedimentation rate 100 mm. per hour. A tentative clinical diagnosis of acute osteomyelitis was made. Roentgenographic study showed a unilateral sacralization, with marked asymmetry of the fifth lumbar vertebra and consecutive lateral tilting of the lumbar spine against the os sacrum. A high degree of compensatory scoliosis of the middle lumbar spine was visualized, associated with marked torsion and far advanced chronic hypertrophic arthrosis of the spine.

Complete transposition of the great vessels: Clinical and pathologic features

We have had the opportunity to study four cases of complete transposition of the great vessels clinically and post mortem. In one case there was, in addition, a patent foramen ovale, a patent interventricular septum, and a patent ductus arteriosus; in the second, a patent interventricular septum; in the third, a patent foramen ovale and a patent ductus arteriosus; and in the fourth, a patent foramen ovale, a patent ductus arteriosus, and complete interruption of the isthmus of the aorta. Each had its own individual variations, but all showed the characteristic features of complete transposition of the great vessels, namely, (1) persistent cyanosis; (2) cardiac enlargement, especially of the right ventricle; (3) a narrow aortic shadow in the anteroposterior roentgenogram; and (4) an increase in the width of the roentgenographic shadow cast by the great vessels when the patient is placed in the left anterior oblique position.

The Roentgenologic Importance of the Left Oblique Position in Cholecystography

THE technical difficulty of obtaining satisfactory visualization of the gall bladder in all instances is the cause of much skepticism in clinicians' minds regarding the reliability of cholecystography. Their criticism of the test is justly correct because they have experienced instances of normal operative findings in cases diagnosed by the roentgenologist as pathologic. The purpose of this presentation is to illustrate that it is not, as a rule, the cholecystographic test that is at fault, but rather the procedure in which the examination is performed. Since most roentgenographs examinations are carried out by technicians in busy laboratories, one must expect a certain small percentage of failures due to technical errors. However, the technician often lacks the experience in knowledge of the technical difficulties which underlie the principle of shadow visualization. It is to be regretted, too, that the roentgenologist often lacks control of the case, especially in hospital routine, and information regarding the patient's reaction to the dye, vomiting, diarrhea, and dosage is rarely given much attention. The routine carried out in the roentgenologic laboratory is of the greatest importance because in most instances it is here that the cholecystographic test is poorly managed. The non-visualizing gall bladder and that overshadowed by the bowel are the types which usually afford the greatest difficulty in diagnosis. There can be no question of doubt that true non-filling of the gall bladder represents a pathologic state in the biliary tract. However, it must be emphasized that in order to obtain the roentgenographic shadow of the gall bladder, sufficient technical knowledge is essential, since the proper roentgen technic plays an important part in the portrayal of the cholecystogram. It has been shown, since the advent of cholecystography, that the gall bladder varies in position, and it also has been definitely established that it moves with respiratory excursions, the distance varying from one to three inches. Attention to the importance of obtaining views of the gall bladder in both inspiration and expiration must be pointed out, as it is often of considerable aid in the elimination of overlying shadows. Its importance is stressed (1) because its movement places the gall bladder in another position where it may be separated from overshadowing loops of colon; (2) by changing the position, gallstone shadow within the gall bladder will normally move with the vesicle, thus determining whether or not it is within or outside of it, and (3) at times the gall bladder is situated close to the spinal column and respiratory movements not infrequently separate them. Shifting of the x-ray tube will not infrequently separate the gall-bladder shadow from the colon; in most instances, however, this maneuver fails to accomplish the desired results. The routine roentgen technic for cholecystography has been fully described on numerous occasions.

A new urographic medium: Emulsified campiodol (an iodized rapeseed oil)

Campiodol is an iodized oil (rapeseed oil) containing approximately 44 per cent elemental iodine. To adapt it to urographic use, a stable emulsion was made, using campiodol, acacia and distilled water. This results in a mixture containing 10 per cent to 11 per cent elemental iodine, making it equal to sodium iodide for roentgenographic use. Emulsified campiodol as an urographic medium is miscible with water (urine), of lowered viscosity, inert, non-toxic, nonirritating and casts excellent roentgenographic shadows as to detail and intensity in all parts of the urinary tract. It has been used in over 250 cases with a minimum of irritative symptoms and therefore possesses some advantages over 12 1 2 per cent sodium iodide in urography.

RICKETS

The accompanying illustration is of interest because of the unusual roentgenographic shadow of the epiphyses, which present the appearance of an epiphysis within an epiphysis. This phenomenon is explained on the basis of a two-stage growth of the epiphysis. REPORT OF CASE A white child, aged 2½ years, was referred by Dr. Julius Hess because of genu valgum. The only significant points in the history were as follows: He was a premature infant by four weeks and was breast fed for three and one-half months. At the age of 5 months, he developed a severe eczema which persisted for seven months and precluded the administration of orange juice, tomato juice, etc. He had an antipathy toward eggs. He was given cod liver oil and phosphorus from the fourth to the twenty-first months. Its administration was then discontinued for three months, when it was resumed. The physical observations of interest were