Bešlić, Šerif

Dalagija, Faruk

Ibralić, Muris

Lovrinčević, Antun

Merhemić, Z.

English

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Radio/ Oncol 1992; 26: 125-9. Possibilities and limitations of computed tomography m diagnosis of thoracic organs Šerif Bešlic, F. Dalagija, A. Lovrinčevic, M. Ibralic, Z. Merhemic University Medica! Center, Institute of Radiology and Oncology, Sarajevo, Bosnia and Hercegovina During a period of 6 years and based on own material and experience with 1012 examined patients, the authors have presented the contribution of computed tomography (CT). The examinations were performed on Somatom SF "Siemens" unit. According to the coded CT diagnoses stored at computer in the Department of lnformatics, CT showed the important contribution in the diagnosis of fluid, solid, cystic and jat formations in the chest. A considerable part of the findings, about 16.5 % related to the mediastinal and hilar adenopathies. The diagnostic role of CT in the analysis of vascular mediastinal structures is interesting. Key words: thoracic radiography; tomography; x-ray computed Introduction CT is a new, relatively expensive diagnostic method. It changed our previous practice and algorithm of diagnostic methods and enabled improved analysis of the mediastinum, Jung parenchyma, pleura and phrenico-costal sinus­es. Since the end of 1978, it has been performed at our Institute. On the basis of our clinic material and data from literature, we tried to present the pathology which can be proved by this method, as well as the problems related to this diagnostics. Correspondence to: dr. Šerif Bešlic, Institute of Radio­logy and Oncology, University Medica! Center, Moše Pijade 25, 71000 Sarajevo, Bosnia and Hercegovina. UDC: 616.2-073.756.8 Material and method Clinical material From the end of 1986 to January 1, 1992, we investigated 1012 patients. Out of this number, the clinicians requested the examination in: 686 cases - CT of lungs, 227 cases - CT of mediastinum, 78 cases - CT of thorax, 28 cases - CT of other chest organs, 12 cases - CT of the heart etc. The analysis included patients of ali ages and both sexes. Method of work Since 1978, we have worked on the third gene­ration Somatom SF "Siemens" scanner with 512 detectors and 2.6 and 4.8 sec. scan tirne, 4 and 8 mm thick slices and immediate image reconstruction. Density leve! is measured 126 Bešlic š et a/. aeeording to Hounsfield: -1024 to + 1024 HU, where water is O. Eleetronie image enlargement is 2.5 times. The tube is pulsed superrotalix with graphite anode, eooled by oil. The image analysis has been performed at two levels, with the window for the analysis of mediastinum and eostal pleura in one, and for the analysis of parenehyma in another. Plain images were ob­tained in the first series, the seeond after in­fusion of water-soluble eontrast material ( 60 ml. i. v. in bolus and 100 ml in perfusion), for abetter presentation of vaseular struetures.Rarely, a reinjeetion of eontrast material in the area of speeial interest was performed. After i. v. applieation of eontrast material fast mood seanning was performed in the following positions: deeubitus, lateral deeubitus and proeubitus. We applied eontrast material perorally ( esophagus). The thorax was investigated from the apex to the phrenieoeostal sinuses (20 seans). The suspeeted regions required additional seans with eontrast bolus. Seanning was made after eonventional radio­graphy with possible additions. The results were evaluated surgieally, by CT­guided transthoraeie biopsy, clinieally and by laboratory data. Results Out of the total number of examined patients CT findings showed as follows: The most of our CT diagnoses related to pleural exudations (25 % ) , mediastinal and hilar adenopathies (16.5 % ) , lung tumors (12.5 % ) , thymus diseases (2.47 % ), esophageal neo­plasms (1.97 % ), solitary metastases, infiltra­tions and eehinoeeoeal lung eysts (1.9 % ), fat deposits in mediastinum and retrosternal struma (1.48 % ) ete. In those eases, CT made the deeisive eontri­bution. Our results are presented on Tables 1 and 2, showing that besides the mentioned pathology, CT enabled the diagnosing of eysts and pulmonary abseesses, perieardial effusions diaphragmatie hernia, pleural tumors, traeheal Figure l. Echinococcus cyst left ( density leve! + 14 HU). neoplasms, eongenital vaseular malformations and aortie aneurysms. Discussion The analysed material shows that CT offers speeial possibilities in the analysis of all thoraeie struetures (ribs, spine, mediastinum, Jung pa­renehyma ete.) in the transversal plane. It is possible to analyse bony and museular struetures of the ehest (meta ehanges in ribs), with the advantage in the presentation of nor­mally radiotransparent struetures, as in lesions of the ehondrosternal joint ( abseess) .1-4 Figure 2. The solid expansive process of the superior mediastinum (density leve! + 53 HU). Compuled lomography in diagnosis of thoracic organs 127 Transversal seans enable a good analysis of Jung parenchyma with confirmed solid, cystic and liquid metastatic formations. 1•2·5-10 (Figure1,2). Our material includes mediastinal and hilar adenopathies in 16.5 % , solitary meta of the lungs (1-2 metastases) in 1.9 % , pulmonary tumors in 12.5 % , pulmonary cysts in 3.08 % ( out of that echinoccocal cysts in l. 9 % ) , whe­reas pleural effusions were diagnosed most fre­quently - in 25 % , in the total material. This shows the CT sensitivity which depends on the type of pathologic changes. In the changed anatomic relations in the thorax, CT improves the explanation of the conventional radiography, eliminating the su­perposition.1 ·2 CT enables a precise evaluation of the expan­sive process border, with possible analysis of its relation with the surrounding, especially vasculary structures.1•9•11 It enables the evaluation of loco­regional (skin metastases) and metastatic expan­sion of the malignant process in the mediastinum, with good presentation of the retrosternal, retro­caval (Barety louge), subcarinal, back retrobron­chal, posteroinferior mediastinal space (sign "ice hi!!" Felson), azygoesophageal recessus and phre­nicocostal sinuses.1 ·2·11-15Our material includes: thymus pathology in 2.47 % retrosternal struma 1.48 % , esophageal neoplasms 1.97 % , fat collections in mediasti-Figure 3. Fat collections of the superior mediastinum (density leve! - 92 HU). num 1.48 % , diaphragmatic hernia 0.39 % (Fi­gure 3). An adequate analysis of pleura and pleural cavity is possible.12·16 •17 Pleural effusions are found in 25 % , and pleural tumors in 0.29 % of the total material. After intravenous application of contrast ma­terial, CT shows the vascular nature of tumo­rous formations in the mediastinum found by conventional radiography . 18,19 Aortic aneurysms were found in 6 cases (0.59 % ), and aberrant right subclavian artery in one case (Figure 4). It is also possible to check the graft and endarterectomized vascular segment, and to analyse the pericard and heart, as well as to measure heart dimensions.18·20 Pericardial ex­udations were presented in 0.49 % of the cases. The scanner enables a supreme visualization of calcifications, invisible by the conventional radiography. 1 ·18 In some cases CT is suggestive of the tumor _ type histology (fat, liquid, vascular, convolute etc. ). 2·9 •12-14·18 It simplifies the diagnostic pro­cedures by making some investigations op­tional ( angiography, tomography, endosco­PY) _ 1 , 13 ,14 ,18 ,19 CT helps the surgeon in the selection of surgical approach and technique, and offers additional possibility of the therapeutic follow-Figure 4. Thrombotic descendent aortic aneurysm (af­ter contrast medium application). 128 Bešlic š et al. Table l. Distribution of positive and normal CT findings No of positive CT findings Normal CT findings Total 731 281 1012 72.2% 27.8% 100.0% Table 2. Distribution of positive CT findings by diag-noses 0rdinal CT diagnosisnurneral l Pleural effusions 2 Mediastinal and hilar adenopathies 3 Pulmonary tumors 4 Thymoma and thymus hyperplasia 5 Esophageal neoplasms 6 Solitaiy meta of the lung (1 to 2) 7 Pulmona1y infiltration 8 Pulmona1y echinoccocosis 9 Fat deposits in mediastinum 10 Retrosternal struma 11 Pulmona1y cysts 12 Pulmona1y tuberculosis 13 Pulmonary abscess 14 Aortic aneu1ysm 15 Pericardial exudation 16 Diaphragmatic hernia 17 Pleural tumor 18 Tracheal neoplasms 19 Aortic dextroposition 20 Aberrant right subclavian a1te1y 21 Cystic teratoma Total No. of Percen-examined tage patients % --253 25 167 16.5 127 12.5 25 2.47 20 1.97 19 1.9 19 1.9 19 1.9 15 1.48 15 1.48 12 1.18 11 1.08 7 0.69 6 0.59 5 0.49 4 0.39 3 0.49 1 0.098 1 0.098 1 0.098 0.098 731 72.2 up. 1•11 Transthoracic biopsy is also performed under the guidance of CT.1·2 Diagnostic limitations Besides various advantages, CT fails to define the pathologic nature of the lesion (benign or malignant), but enables the prediction of this possibility (lypoma, cyst, Jung sequestra­tion)1·6· 13 · l4 · 19 CT is unable to define the struc­tures (lymphnodes) or diffuse infiltrations of organs (!iver, spleen). 1 • 12 It is difficult to differentiate tumors from the near adenopathies (skin metastasis).1 •11 The evaluation of bacillosis, pneumoconiosis or pul­monary infarction is stili performed by the conventional radiography, whereas analysis by CT has been discussed (the expensiveness of CT). 1 During its first phase prehernial lypoma can be misinterpreted for intrathoracic fat collec­tions.14 It is impossible to differentiate between a primary and a secondary pleural tumor.9· 16, 17 There is a possibility of false positive and false negative results (cervical lymphnode con­sidered as parathyroid adenoma; undetected tuberculoma and metastasis under 1 cm of size, due to the Jack of axial cross-section. 1 There are limitations of the technical nature (impossibility of apnea, thin patients and child­ren, metallic protheses, partial vol ume effect etc.) which can change the image quality and densitometric values.1•5• 18 Conclusion CT is a 11011-invasive technique indispensable in the modem diagnostics. It is frequently the method of choice in the diagnosis of pulmonary and mediastinal diseases, especially in the re­gions traditionally inaccessible by the conven­tional radiography. It simplifies the diagnostic procedure ( excluding the angiographies and to­mographies). Without CT, diagnostics becomes more complex, which is the best defence for this technique. CT does not replace conventional radio­graphy or other techniques, but it is comple­mentary. References l. Treut A, Guibert JL, Dilhuydy MH. Les bonnesindications de la tomodensitometrie en cancerolo­gie. Rev Prat 1987; 37 (36): 2153.2. Chalaoui J, Barral V, Simard P, Lefebvre R,Sylvestre J. Mesotheliome pleural: trois formsevolutives. Ann Radio! 1982; 25 (3): 191--4.3. Prija J, Larde D, Katz M, Yasile N, Vadrot D,Utzmann O. Le diagnostic tomodensitometriquedes anomalies des arcs chez l'adulte. J Radio/1982; 63 (3): 159-65.Computed tomography in diagnosis of thoracic organs 129 4. Smoger BR, Rosenberg HK, Koss J, et al. 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Possibilities and limitations of computed tomography in diagnosis of thoracic organs

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Possibilities and limitations of computed tomography in diagnosis of thoracic organs

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