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High resolution computed tomography and broncho-alveolar lavage cell profiles in fibrosing alveolitis: A correlation
Clinical Radiology (1992) 45, 48 66
Abstracts Abstracts o f radiodiagnosis papers presented at the R o y a l College o f Radiologists Annual General Meeting held on 25 28 September 1991 in Dublin AN E V A L U A T I O N O F E X T R A T H O R A C I C M E T A S T A T I C DISEASE IN L O C A L L Y O P E R A B L E B R O N C H O G E N I C C A R C I N O M A ; A C L I N I C A L A U D I T AND REVIEW OF L O C A L STAGING P O L I C Y L. G O M E R S A L L , K. D U N C A N , D. G L E N and J. W E I R
Aberdeen Royal Infirmary, Aberdeen The presence of extrathoracic disease is generally accepted to be a contraindication for the surgical resection of primary lung tumour. The staging process ideally consists of a sequentially performed series of examinations designed to estimate the anatomic extent of disease, in a m a n n e r that is time efficient, cost effective, has low morbidity and high patient acceptance, the purpose being to reduce inappropriate exploratory thoracotomies. Our local policy in those patients considered operable clinically, on computed tomography (CT) of the chest and at bronchoscopy is to proceed with a radionuclide bone scan, ultrasound of upper abdomen and CT head scan. The role of these imaging studies was retrospectively evaluated in 1065 patients, presenting with bronchogenic carcinoma. Potentially resectable disease was found in 361 patients. Ultrasound in 233 of the 361 patients showed a 4.7°/,, positive rate for metastatic disease. Radionuclide bone scan in 265 patients suggested skeletal involvement in 15.5%. C T head scan in 224 patients showed a 6.7°/`, positive rate which was reduced to 1.9% when used as a final screening procedure. The implications of these figures, full data analysis including correlation with clinical findings, and a cost/benefit analysis will be presented and discussed.
M E D I A S T I N A L L Y M P H A D E N O P A T H Y IN T H E F1BROSING A L V E O L I T I S OF S Y S T E M I C S C L E R O S I S S. J. G A R B E R , D. M. H A N S E L L , A. U. WELLS and R. M. D U BOIS
The Royal Brompton National Heart and Lung Hospital, London Lung disease in systemic sclerosis (SSc) and cryptogenic fibrosing alveolitis (CFA) have similar radiographic features. Characteristic findings on high resolution computed tomography (HRCT) include reticular abnormalities, corresponding to fibrotic change, and patchy parenchymal opacification, representing cellular infiltration. It is now recognized that mediastinal lymphadenopathy (ML) may occur in C F A without associated neoplastic disease. The aim of this study was to determine the incidence of ML in SSc and to relate this to extent and activity of lung disease. H R C T appearances were recorded in 60 patients with lung involvement from SSc. An assessment was made of the percentage of lung involved and appearances were categorized into two groups: predominant reticulation (group A) and parenchymal opacification equal to or exceeding reticulation (group B). Fifteen patients from each group were matched for sex, smoking history and percentage lung involvement M L was then assessed on soft tissue window settings. Significant lymphadenopathy was present in 7/30 (23%). The incidence of M L did not vary significantly between group A (5/15) and group B (2/I 5). In the cases with M L lung involvement was significantly more extensive (46.2±15.1% vs 23.3_+12.0%, P<0.001); six of the seven patients with the most extensive disease had ML. We conclude that mediastinal lymphadenopathy occurs frequently in systemic sclerosis if lung involvement is extensive, irrespective of the H R C T pattern.
A T Y P I C A L M A N I F E S T A T I O N S OF FIBROSING ALVEOLITIS ON H I G H R E S O L U T I O N C O M P U T E D TOMOGRAPHY R. J. DAVIES, D. M. H A N S E L L , A. V. W E L L S and R. M. DU BOIS
Royal Brompton National Heart and Lung Hospital, London The features of fibrosing alveolitis on high resolution computed tomography (HRCT) are now well recognized and include a predominantly sub-pleural reticular pattern at the lung bases in the early stages progressing to a widespread honeycomb pattern denoting end-stage
disease. However, not all patients show these appearances and this group may cause diagnostic difficulties. A study was performed to investigate this group o f patients further to define the nature and relative frequency of these atypical H R C T features. The CT reports were reviewed of 142 patients attending the Brompton Hospital over the last 6 years with biopsy-proven fibrosing alveolitis, including those with the lone cryptogenic form and those with scleroderma and rheumatoid arthritis. Twenty-one out of 142 (14.8%) patients had one or more unusual radiological feature and the images in these cases were reviewed. Nine out of 21 (43%) cases showed atypical distribution of the parenchymal opacification, notably focal disease or an asymmetrical or upper zone distribution. Significant pleural thickening was present in 7/21 (33%). Non-specific air-space opacification containing air bronchograms was found in 7/21 (33%). Two cases (10%) showed hyperinflation due to coexisting p u h n o n a r y emphysema. No specific diagnosis from the H R C T appearances was suggested in approximately half of this group of patients and thus an awareness of these atypical features m a y be of value in the H R C T diagnosis of fibrosing alveolitis.
HIGH RESOLUTION COMPUTED TOMOGRAPHY AND B R O N C H O - A L V E O L A R LAVAGE CELL P R O F I L E S IN FIBROSING ALVEOLITIS: A C O R R E L A T I O N D. M. H A N S E L L , A. U. WELLS, P. C U L L I N A N , C. M. B L A C K and R. M. DU BOIS
Royal Brompton National Heart and Lung Hospital, London It is now recognized that both the extent and activity of disease (significant inflammation vs established fibrosis) in fibrosing alveolitis can be identified by high resolution computed tomography (HRCT). Inflammatory cell profiles obtained by broncho-alveolar lavage (BAL) have also been used to assess disease activity; a BAL neutrophilia or eosinophilia is associated with a worse prognosis, suggesting either extensive or active disease. The purpose of this study was to determine whether disease extent or activity on H R C T correlates with BAL abnormalities. Thirty-eight patients with systemic sclerosis, including 24 with associated fibrosing alveolitis, underwent H R C T and BAL. An assessment of the per cent involvement on H R C T of the lavaged lobe was made and the lobes were divided into two groups: those with no involvement (group A, 14/38), those with < 50% involvement (group B, 14/38), and those with > 50% involvement (group C, 10/38). H R C T appearances of 18/24 lavaged lobes were graded on a five point scale from parenchymal opacification alone (taken to reflect increased cellularity) through to a reticular pattern (reflecting fibrosis). The mean BAL neutrophil count was markedly increased in group C (19.9± 15.3) compared with group B (3.9 ± 4.8) and group A (5.7 ± 8.7) (P < 0.02). A reticular appearance on H R C T was independently associated with a BAL neutrophilia (P<0.05). The mean BAL eosinophil count was increased in group B (2.7_+2.1) (P<0.005) and group C (4.5±3.7), compared with group A (0.6 ± 1.0) (P < 0.005). The mean BAL lymphocyte count did not change significantly with the extent or appearance of disease on H R C T . We conclude that a BAL neutrophilia, but not eosinophilia or lymphocytosis, is independently associated with extensive and fibrotic disease on H R C T . This has implications for the interpretation of BAL cell profiles in fibrosing alveolitis.
T H E R O L E OF H I G H R E S O L U T I O N C O M P U T E D T O M O G R A P H Y IN P A T I E N T S W I T H A N O R M A L C H E S T R A D I O G R A P H AND A B N O R M A L LUNG F U N C T I O N K. A. Y O U N G E R and D. M. H A N S E L L
Royal Brompton National Heart and Lung Hospital, London It is now well recognized that high resolution computed tomography (HRCT) is more sensitive in detecting subtle interstitial lung disease than chest radiography. The role of H R C T in symptomatic patients with or without abnormal lung function tests presenting with a normal chest radiograph is less well established. Approximately 1% of all CT scans performed at the Brompton over the last 4 years were of patients considered to have early interstitial lung
Abstracts Abstracts o f radiodiagnosis papers presented at the R o y a l College o f Radiologists Annual General Meeting held on 25 28 September 1991 in Dublin AN E V A L U A T I O N O F E X T R A T H O R A C I C M E T A S T A T I C DISEASE IN L O C A L L Y O P E R A B L E B R O N C H O G E N I C C A R C I N O M A ; A C L I N I C A L A U D I T AND REVIEW OF L O C A L STAGING P O L I C Y L. G O M E R S A L L , K. D U N C A N , D. G L E N and J. W E I R
Aberdeen Royal Infirmary, Aberdeen The presence of extrathoracic disease is generally accepted to be a contraindication for the surgical resection of primary lung tumour. The staging process ideally consists of a sequentially performed series of examinations designed to estimate the anatomic extent of disease, in a m a n n e r that is time efficient, cost effective, has low morbidity and high patient acceptance, the purpose being to reduce inappropriate exploratory thoracotomies. Our local policy in those patients considered operable clinically, on computed tomography (CT) of the chest and at bronchoscopy is to proceed with a radionuclide bone scan, ultrasound of upper abdomen and CT head scan. The role of these imaging studies was retrospectively evaluated in 1065 patients, presenting with bronchogenic carcinoma. Potentially resectable disease was found in 361 patients. Ultrasound in 233 of the 361 patients showed a 4.7°/,, positive rate for metastatic disease. Radionuclide bone scan in 265 patients suggested skeletal involvement in 15.5%. C T head scan in 224 patients showed a 6.7°/`, positive rate which was reduced to 1.9% when used as a final screening procedure. The implications of these figures, full data analysis including correlation with clinical findings, and a cost/benefit analysis will be presented and discussed.
M E D I A S T I N A L L Y M P H A D E N O P A T H Y IN T H E F1BROSING A L V E O L I T I S OF S Y S T E M I C S C L E R O S I S S. J. G A R B E R , D. M. H A N S E L L , A. U. WELLS and R. M. D U BOIS
The Royal Brompton National Heart and Lung Hospital, London Lung disease in systemic sclerosis (SSc) and cryptogenic fibrosing alveolitis (CFA) have similar radiographic features. Characteristic findings on high resolution computed tomography (HRCT) include reticular abnormalities, corresponding to fibrotic change, and patchy parenchymal opacification, representing cellular infiltration. It is now recognized that mediastinal lymphadenopathy (ML) may occur in C F A without associated neoplastic disease. The aim of this study was to determine the incidence of ML in SSc and to relate this to extent and activity of lung disease. H R C T appearances were recorded in 60 patients with lung involvement from SSc. An assessment was made of the percentage of lung involved and appearances were categorized into two groups: predominant reticulation (group A) and parenchymal opacification equal to or exceeding reticulation (group B). Fifteen patients from each group were matched for sex, smoking history and percentage lung involvement M L was then assessed on soft tissue window settings. Significant lymphadenopathy was present in 7/30 (23%). The incidence of M L did not vary significantly between group A (5/15) and group B (2/I 5). In the cases with M L lung involvement was significantly more extensive (46.2±15.1% vs 23.3_+12.0%, P<0.001); six of the seven patients with the most extensive disease had ML. We conclude that mediastinal lymphadenopathy occurs frequently in systemic sclerosis if lung involvement is extensive, irrespective of the H R C T pattern.
A T Y P I C A L M A N I F E S T A T I O N S OF FIBROSING ALVEOLITIS ON H I G H R E S O L U T I O N C O M P U T E D TOMOGRAPHY R. J. DAVIES, D. M. H A N S E L L , A. V. W E L L S and R. M. DU BOIS
Royal Brompton National Heart and Lung Hospital, London The features of fibrosing alveolitis on high resolution computed tomography (HRCT) are now well recognized and include a predominantly sub-pleural reticular pattern at the lung bases in the early stages progressing to a widespread honeycomb pattern denoting end-stage
disease. However, not all patients show these appearances and this group may cause diagnostic difficulties. A study was performed to investigate this group o f patients further to define the nature and relative frequency of these atypical H R C T features. The CT reports were reviewed of 142 patients attending the Brompton Hospital over the last 6 years with biopsy-proven fibrosing alveolitis, including those with the lone cryptogenic form and those with scleroderma and rheumatoid arthritis. Twenty-one out of 142 (14.8%) patients had one or more unusual radiological feature and the images in these cases were reviewed. Nine out of 21 (43%) cases showed atypical distribution of the parenchymal opacification, notably focal disease or an asymmetrical or upper zone distribution. Significant pleural thickening was present in 7/21 (33%). Non-specific air-space opacification containing air bronchograms was found in 7/21 (33%). Two cases (10%) showed hyperinflation due to coexisting p u h n o n a r y emphysema. No specific diagnosis from the H R C T appearances was suggested in approximately half of this group of patients and thus an awareness of these atypical features m a y be of value in the H R C T diagnosis of fibrosing alveolitis.
HIGH RESOLUTION COMPUTED TOMOGRAPHY AND B R O N C H O - A L V E O L A R LAVAGE CELL P R O F I L E S IN FIBROSING ALVEOLITIS: A C O R R E L A T I O N D. M. H A N S E L L , A. U. WELLS, P. C U L L I N A N , C. M. B L A C K and R. M. DU BOIS
Royal Brompton National Heart and Lung Hospital, London It is now recognized that both the extent and activity of disease (significant inflammation vs established fibrosis) in fibrosing alveolitis can be identified by high resolution computed tomography (HRCT). Inflammatory cell profiles obtained by broncho-alveolar lavage (BAL) have also been used to assess disease activity; a BAL neutrophilia or eosinophilia is associated with a worse prognosis, suggesting either extensive or active disease. The purpose of this study was to determine whether disease extent or activity on H R C T correlates with BAL abnormalities. Thirty-eight patients with systemic sclerosis, including 24 with associated fibrosing alveolitis, underwent H R C T and BAL. An assessment of the per cent involvement on H R C T of the lavaged lobe was made and the lobes were divided into two groups: those with no involvement (group A, 14/38), those with < 50% involvement (group B, 14/38), and those with > 50% involvement (group C, 10/38). H R C T appearances of 18/24 lavaged lobes were graded on a five point scale from parenchymal opacification alone (taken to reflect increased cellularity) through to a reticular pattern (reflecting fibrosis). The mean BAL neutrophil count was markedly increased in group C (19.9± 15.3) compared with group B (3.9 ± 4.8) and group A (5.7 ± 8.7) (P < 0.02). A reticular appearance on H R C T was independently associated with a BAL neutrophilia (P<0.05). The mean BAL eosinophil count was increased in group B (2.7_+2.1) (P<0.005) and group C (4.5±3.7), compared with group A (0.6 ± 1.0) (P < 0.005). The mean BAL lymphocyte count did not change significantly with the extent or appearance of disease on H R C T . We conclude that a BAL neutrophilia, but not eosinophilia or lymphocytosis, is independently associated with extensive and fibrotic disease on H R C T . This has implications for the interpretation of BAL cell profiles in fibrosing alveolitis.
T H E R O L E OF H I G H R E S O L U T I O N C O M P U T E D T O M O G R A P H Y IN P A T I E N T S W I T H A N O R M A L C H E S T R A D I O G R A P H AND A B N O R M A L LUNG F U N C T I O N K. A. Y O U N G E R and D. M. H A N S E L L
Royal Brompton National Heart and Lung Hospital, London It is now well recognized that high resolution computed tomography (HRCT) is more sensitive in detecting subtle interstitial lung disease than chest radiography. The role of H R C T in symptomatic patients with or without abnormal lung function tests presenting with a normal chest radiograph is less well established. Approximately 1% of all CT scans performed at the Brompton over the last 4 years were of patients considered to have early interstitial lung