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Right Heart Catheterization in the Pre-
operative Evaluation of Patients with Lung Cancer. Brundler, H., Chen, S., Peruchoud, A.P. Division of Respiratory Diseases, Depart- ment of Medicine, Kantonsspital, Universi- ty of Basel, CH-4031 Basel, Switzerland. Respiration 48: 261-268, 1985.
The right heart catherization and lung function data of 637 consecutive patients with lung cancer evaluated preoperatively were analysed retrospectively, in order to review our past experience, and to examine, whether a subgroup of patients could be identified, in whom invasive haemodynamic measurements were dispensable due to a predictable normal result. 95 patients (14.9%) had precapillary pulmonary hyper- tension, 44 (6.9%) already at rest, 51 (8.0%) on exercise only. In contrast, 276 patients (43.3%) had pulmonary hypertension secondary to abnormal left ventricular function, 67 (10.6%) at rest, 20q (32.8%) on exercise only. In order to characterize a subgroup of patients, in whom precapil- lary pulmonary hypertension is very unli- kely to be present, and in whom, therefore, right heart catheterization could be regard- ed as dispensable, a discriminant analysis was performed. By these means a discriminant function using FEVrl, Pa-2, DL (CO) - both on exercise - and RV/TLC as discrl- minant variables was obtained which can provide a qualitative prediction of pulmo- nary hypertension with a high sensitivity (at least 95%) and an acceptable specificity (approximately 50%). The usefulness of such a prediction was verified in a subsequent group of 71 patients. Precapillary pulmona- ry hypertension was correctly predicted in all cases; the specificity was 55%. It is concluded, that right heart catheterization has its value in the preoperative evaluation of candidates for pulmonary resection due to a high prevalence of compromised haemo- dynamics, and that patients with a negli- gible risk of having precapillary pulmona- ry hypertension can be identified by means of non-invasive functional measurements.
Transcarinal Mediastinal Needle Biopsy Com- pared with Mediastinoscopy. Brynitz, S., Struve-Christensen, E., Bor- geskov, S., Bertelsen, S. Department of Thoracic Surgery L, Bispebjerg Hospital, Copenhagen, Denmark. J. Thorac. Cardiovasc. Surg. 90: 21-24, 1985.
A total of 183 patients with abnormali- ties on the chest roentgenogram were ex- amined by bronchoscopy in conjunction with transcarinal mediastinal needle biopsy and mediastinoscopy to investigate the agreement between these methods regarding possible metastases. In 37 of the 159 pa- tients with malignant pulmonary lesions,
needle biopsy demonstrated metastases in the sub-
carinal lymph nodes. Mediastinoscopy had the same percentage of positive findings in the subcarinal nodes, but there was only agreement between the two methods in 20 cases. Transcarinal mediastinal needle biopsy as a supplement to conventional bronchoscopy is applicable in the outpatient evaluation of pa- tients with malignant bronchial lesions as a screen- ing for further examination. The method does not carry complications of any kind. Positive biopsy results, combined with other clinical findings, can at times spare the patient a mediastinoscopy. On the other hand, an adequately indicated needle biopsy which yields negative findings should always b@ followed by mediastinoseopy. In the planning of treatment for patients with malignant lesions of the lungs, it is of decisive importance to evaluate the dissemination of the tumor to the mediastinal. structures, primarily to the subcarinal and the contralateral lymph nodes.
Roentgenographic Evaluation of Mediastinal Nodes for Preoperative Assessment in Lung Cancer. McKenna, R.J. Jr., Libschitz, H.I., Mountain, C.E., McMurtrey, M.J. University of Texas System Cancer Center, MD Anderson Hospital and Tumor Institute, Houston, Tx, U.S.A. Chest 88:206-210, 1985.
Evaluation of mediastinal nodal metastases is a critical step in the assessment of potential surgi- cal candidates with lung cancer. Mediastinal tomo- graphy (TOMO) and chest computerized tomography (CT) visualize the mediastinal nodes more clearly than a chest roentgenogram (CXR). A prospective study was undertaken to determine the clinical vaiue of these three tests for mediastinal staging in 102 surgical patients with lung cancer. All patients underwent thoracotomy and mediastinal nodal dissec- tion. The roentgenographic findings were compared with the histologic evaluation of paratracheal, tracheobronchial angle, aortic window, subcarinal, and inferior pulmonary ligament nodes. TOMO, and especially CT, correctly predicted the size and location of mediastinal nodes; however, the overall accuracies were CXR (74 percent), TOMO (74 percent), CT (61 percent). These results demonstrated that the improvement in mediastinal imaging is counter- acted by the fact that enlarged nodes need not con- tain metastases and normal-appearing small nodes may harbor microscopic disease. Computed tomography and TOMO had little clinical impact on the assess- ment of mediastinal nodes in potential surgical candidates with lung cancer.
Bronchogenic Carcinoma: Staging with ~ Compared ~th Staging with CT and Surgery. Webb, W.R., Jensen, B.G., Sollitto, R. et al. Department of Radiology, University of California, San Francisco, CA, U.S.A. Radiology 156: 117-124, 1985.
Thirty-three patients suspected of having bron- chogenic carcinoma were studied prospectively using magnetic resonance (MR). In this group, 30 under- went examination with computed tomography (CT), 15 underwent thoracotomy, six had mediastinal biopsy
procedures performed, and eight underwent bron-
choscopy. MR studies, which included
transaxial spin-echo imaging (TR, 0.5 and 2.0 sec; TE, 28 and 56 msec) of all pa- tients and sagittal or coronal imaging of 18, were performed without knowledge of CT findings, using only plain radio- graphs as a guide. CT and MR studies were interpreted separately. CT and MR pro- vided comparable information regarding the presence and size of mediastinal lymph nodes. MR better discriminated mediastinal nodes from vascular structures. However, in two of ii patients who had multiple mediastinal lymph nodes that were normal in size at CT examination and surgery, MR suggested a confluent abnormal mass, probably because of its poorer spatial resolution. MR was superior to CT in showing enlarged hilar lymph nodes, but CT was better for demonstrating bronchial abnormalities. In three of four patients who had a proved hilar mass with distal obstructive pneumonia, MR (TR, 2.0 sec) helped distinguish between the mass and collapsed lung.
Oblique Hilar Tomography, Computed Tomo- graphy, and Mediastinoscopy for Pretho- racotomy Staging of Bronchogenic Carci- noma. Khan, A., Gersten, K.C., Garvey, J. et al. Department of Radiology, Long Island Jewish-Hillsdale Medical Center, New Hyde Park, NY 11040, U.S.A. Radiology 156: 295-298, 1985.
Preoperative oblique hilar tomography was used to evaluate hilar lymph nodes in 150 patients with clinically resectab- le bronchogenic carcinoma. CT was also used in the evaluation of mediastinal lymph nodes in 50 of these patients. Sub- sequently, all patients underwent media- stinoscopy and/or thoracotomy. Hilar and mediastinal nodes were evaluated for the presence of metastasis, and these findings were then correlated with the radiogra- phic findings of oblique hilar tomography and CT. CT was found to be a reliable method for prethoracotomy staging of bron- chogenic carcinoma and for selecting pa- tients for mediastinoscopy. The sensiti- vity of CT for evaluation of mediastinal nodal metastasis was 83% and the speci- ficity was 90%. Thus patients with nega- tive mediastinal CT need not undergo mediastinoscopy prior to thoracotomy, while mediastinoscopy and biopsy should be done in patients with enlarged media- stinal nodes on CT. Oblique hilar tomo- graphy is an accurate method for evalu- ation of hilar adenopathy and for pre- dicting mediastinal involvement by ex- trapolation.
~diastinal Staging of Bronchial Cat.i-
noma: Can Computed Tomography Replace Mediastino-
scopy? Imhof, E., Perruchoud, A.P., Tan, K.G. et al. Department of Respiratory Diseases, University of Basel, CH-4031 Basel, Switzerland. Respiration 48: 251-260, 1985.
In bronchial carcinoma the assessment of opera- bility requires an accurate evaluation of the re- gional and mediastinal lymph nodes. For this, both mediastinoscopy and computed tomography are often used on a routine basis today. The present work considers the relative value of these two methods of investigation. Fifty-seven patients with bronchi- al carcinoma, in whom both investigations were carried out prior to surgery, were included in this prospective study. In the computed tomogram, lymph nodes with a diameter of more than 1 cm were defined as positive (i.e. suspected malignant in- filtration). Sixteen of the 57 patients had histo- logically confirmed lymph node metastases; in 13 cases the metastases were detected by computed tomography, in 12 cases also by mediastinoscopy and in 3 cases only at thoracotomy. In 41 of the thoracotomized patients, no mediastinal metastases were found. As was to be expected, mediastinosco- py also proved negative in these cases. In 9 of these cases, however, the preoperative computed tomo- graphy findings were false-positive. For computed tomography the specificity was 78% and the sensi- tivity 81%; for mediastinoscopy, on the other hand, the specificity was 100% and the sensitivity 75%. The specificity of computed tomography is too low. Also, lymph nodes which are only inflamed may be considerably enlarged and cannot be differentiated in the computed tomogram from those with malignant infiltration. Mediastinal lymph nodes which appear enlarged in the computed tomogram therefore have to be further investigated by mediastinoscopy. However, in this prospective study, mediastinoscopy provided no additional information in those cases in whom the computed tomography findings were ne- gative (lymph node diameter < or = 1 cm); it did not detect the metastases in the 3 patients with false-negative computed tomography findings. There- fore, in the case of a negative computed tomogram, thoracotomy may be performed immediately, without previous mediastinoscopy.
Role of Computed Tomography and Mediastinoscopy in Preoperative Staging of Lung Carcinoma. Brion, J.P., Depauw, L., Kuhn, G. et al. Depart- ment of Diagnostic Radiology, Hopital Erasme, Universite Libre de Bruxelles, B-1070 Bruxelles, Belgium. J. Comput. Tomogr. 9: 480-484, 1985.
One hundred fifty-three patients with bronchoge- nic carcinoma were evaluated prospectively by CT and mediastinoscopy. Nodes larger than 5 mm were considered potentially metastatic. All results were correlated with surgical findings. Computed tomo- graphy is more sensitive (89%) in the detection of mediastinal metastases than mediastinoscopy (67%). Computed tomography has a poor predictive value (47%); however, a negative examination is highly accurate (89%). Within a group of I00 node sites, 72% of the nodes involved by tumor were larger