The increasing availability of computed tomography has meant that the number of incidentally detected solitary pulmonary nodules (SPN) has greatly increased in recent years. A reasonable management of these SPN is necessary in order to firstly be able to detect malignant lesions early on and secondly to avoid upsetting the patient unnecessarily or carrying out further stressful diagnostic procedures. This review article shows how the dignity of SPNs can be estimated and based on this how the management can be accomplished taking established guidelines into consideration.

Authors G. Goeckenjan1, H. Sitter2, M. Thomas3, D. Branscheid4, M. Flentje5, F. Griesinger6, N. Niederle7, M. Stuschke8, T. Blum9, K.-M. Deppermann10, J. H. Ficker11, L. Freitag12, A. S. Lübbe13, T. Reinhold14, E. Späth-Schwalbe15, D. Ukena16, M. Wickert17, M. Wolf18, S. Andreas19, T. Auberger20, R. P. Baum21, B. Baysal22, J. Beuth23, H. Bickeböller24, A. Böcking25, R. M. Bohle26, I. Brüske27, O. Burghuber28, N. Dickgreber29, S. Diederich30, H. Dienemann31, W. Eberhardt32, S. Eggeling33, T. Fink34, B. Fischer35, M. Franke36, G. Friedel37, T. Gauler38, S. Gütz39, H. Hautmann40, A. Hellmann41, D. Hellwig42, F. Herth43, C. P. Heußel44, W. Hilbe45, F. Hoffmeyer46, M. Horneber47, R. M. Huber48, J. Hübner49, H.-U. Kauczor50, K. Kirchbacher51, D. Kirsten52, T. Kraus53, S. M. Lang54, U. Martens55, A. Mohn-Staudner56, K.-M. Müller57, J. Müller-Nordhorn58, D. Nowak59, U. Ochmann59, B. Passlick60, I. Petersen61, R. Pirker62, B. Pokrajac63, M. Reck64, S. Riha65, C. Rübe66, A. Schmittel67, N. Schönfeld68, W. Schütte69, M. Serke70, G. Stamatis71, M. Steingräber72, M. Steins73, E. Stoelben74, L. Swoboda75, H. Teschler76, H. W.Tessen77, M. Weber78, A. Werner79, H.-E. Wichmann80, E. Irlinger Wimmer81, C. Witt82, H. Worth83

A chest radiogram, performed on a 60-year-old man with unproductive cough for 3 months, showed a space-occupying lesion in the right upper lobe, and breath sounds were diminished in this area. He had been a heavy smoker. His general condition and nutritional state were good.Computed tomography, skeletal scintigraphy, bronchoscopy with biopsy and mediastinoscopy established the diagnosis of a locally advanced non-small-cell bronchial carcinoma (stage IIIB or T2N3M0).Combined adjuvant treatment was begun in the hope of improving the median survival time of 8 months predicted for this tumour stage. After two cycles of a combined chemotherapy scheme (ifosfamide, carboplatin, etoposide) he received hyperfractionated-accelerated radiotherapy (total dose 45 Gy; 1.5 Gy twice daily) together with carboplatin and vindesine. This was followed by a right upper lobectomy with lymphadenectomy. Full remission was confirmed in both the resected specimen and the lymph nodes. The patients remains free of tumour 30 months after the diagnosis.Neoadjuvant treatment can significantly improve the prognosis of non-small-cell bronchial carcinoma in stage III. Such patients should therefore be treated according to the appropriate study protocol, if possible.

A previously healthy 58-year-old woman was admitted with rapidly worsening dyspnoea, dry cough and subfebrile temperature. Chest radiogram showed spotty infiltrations, especially in the bases of both lungs. She was dyspnoic with mild tachypnoea (24/min) and mild cyanosis of the lips. Fine, non-resonant rales were heard over the middle and lower lobes bilaterally.Erythrocyte sedimentation rate was markedly raised (97/110 mm), arterial oxygen partial pressure slightly decreased (45 mm Hg), CO2 partial pressure was 32 mm Hg. Bronchoalveolar lavage was unremarkable.Because of the respiratory impairment broad antibiotic treatment was at once commenced empirically with gentamycin, cefotaxim, erythromycin, rifampicin and fluconazole. As the response was poor, a transbronchial lung biopsy was performed. This merely showed nonspecific lymphoplasmacellular bronchitis. An open biopsy then revealed bronchiolitis obliterans with organizing pneumonia (BOOP). Treatment with initially 75 mg prednisone daily quickly brought about improvement and the patient was entirely well after 6 months.The described constellation of history and clinical as well as radiological findings should strongly suggest BOOP. With adequate treatment the prognosis is excellent.

Ziele: Die Effektivität, mit der der Benutzer von CAD Software (computerunterstützter Detektion) Lungenrundherde detektiert wird von der Benutzeroberfläche des Systems beeinflusst. Visuell dominante Markierungen der vom System automatisch detektierten Herde können den auswertenden Radiologen von anderen Bildabschnitten ablenken. Ziel war die Analyse des Einflusses verschiedener CAD Marker auf die Performance des Radiologen Methode: 10 Radiologen analysierten 150 Lungen CT Bilder. Auf jedem Bild war eine CAD Markierung zu sehen; es existierten fünf verschiedenen Markerarten (1: dickes Quadrat,2: dünner Kreis,4: kleiner Pfeil,5: sehr subtile Farbänderung) auf jeweils 30 Bildern. Auf 100 Bildern war ein Lungenrundherd abgrenzbar: Die CAD Marker markierten diesen in 50 Fällen, in weiteren 50 Fällen einen falsch positiven Befund. Die übrigen 50 Fälle beinhalteten keinen Herd aber einen Marker, welcher somit ebenfalls einen falsch positiven Befund markierte. Die Radiologen mussten bei jedem Bild entscheiden, ob ein Rundherd vorhanden war, und diesen markieren. Sensitivität und Spezifität wurden für jeden CAD Marker berechnet Ergebnis: Die mittlere Sensitivität betrug 59%, 62%, 64%, 65% und 64% in der Reihenfolge für die Marker 1–5, die Spezifität betrug 50%, 51%, 64%, 45% und 67%. Bei den nicht korrekt gesetzten Markern wurden 41%, 58%, 59%, 49% und 54% der Herde korrekt identifiziert. Schlussfolgerung: Unter den getesteten Markern erwies sich die Darstellung als kleiner Pfeil als am effektivsten für die Präsentation der CAD Ergebnisse an den Radiologen.

Besides smoking as the main risk factor for lung cancer several occupational risk factors like exposure to asbestos, polycyclic aromatic hydrocarbons, uranium and dust containing nickel or silica have to be considered. Due to lack of effort in smoking prevention and cessation, lung cancer screening is an important issue. A number of pitfalls has to be considered when evaluating the efficacy of screening procedures. In this paper, we summarize the results of the major studies including chest X-ray, sputum cytology and low dose computed tomography. Randomized controlled studies involving low dose CT in about 100 000 subjects are on the way. Around the year 2010 we will be able to define whether or not lung cancer screening including new techniques and standardized algorithms yields a decrease in mortality. If diagnostic algorithms are used which have been applied in published feasibility studies, the mean percentage of invasive diagnostic measures revealing benign lesions is about 34 % and thus below those obtained in, e. g., breast cancer screening trials.

Besides smoking as the main risk factor for lung cancer several occupational risk factors like exposure to asbestos, polycyclic aromatic hydrocarbons, uranium and dust containing nickel or silica have to be considered. Due to lack of effort in smoking prevention and cessation, lung cancer screening is an important issue. A number of pitfalls has to be considered when evaluating the efficacy of screening procedures. In this paper, we summarize the results of the major studies including chest X-ray, sputum cytology and low dose computed tomography. Randomized controlled studies involving low dose CT in about 100 000 subjects are on the way. Around the year 2010 we will be able to define whether or not lung cancer screening including new techniques and standardized algorithms yields a decrease in mortality. If diagnostic algorithms are used which have been applied in published feasibility studies, the mean percentage of invasive diagnostic measures revealing benign lesions is about 34 % and thus below those obtained in, e. g., breast cancer screening trials.

Rationale and Objectives: To evaluate a large area, cesium iodide amorphous silicon flat-panel detector (CsI/a-Si) at 3 tube voltages to detect simulated interstitial lung disease, nodules, and catheters. Methods: Simulated interstitial lung disease, nodules, and catheters were superimposed over a chest phantom. Images were generated at 125 kVp, 90 kVp, and 70 kVp at the same surface dose and reduced effective dose equivalent for 90 kVp and 70 kVp and printed on hard copies. Fifty-four thousand observations were analyzed by receiver operating characteristic (ROC). Results: Detectability of linear, miliary, reticular pattern, and nodules over lucent lung as well as of catheters and nodules over obscured chest areas increased at 90 and/or 70 kVp with higher Az values; however, only it was statistically significant for reticular pattern at 70 kVp and nodules at 90 kVp compared with 125 kVp (P <0.05). The detection of ground-glass pattern was worse at lower kVp (P >0.05). Conclusion: For most simulated patterns, differences in diagnostic performance at 70 kVp/90 kVp and 125 kVp were not significant, except for reticular pattern and nodules over lucent lung.

Ziele: Vergleich der Übereinstimmung dreier Befunder bei der Detektion von Lungenrundherden mit Niedrigdosis- sowie mit Standarddosis-MSCT. Methode: Bei 10 Patienten mit bekannten Lungenmetastasen solider Tumoren wurde zusätzlich zu einem klinisch indizierten Standarddosis-MSCT (SDCT) (Siemens Somatom VZ, Röhrenspannung 120 kVp, effektiver Röhrenstrom 100 mAs, rekonstruierte Schichtdicke 5mm, Rekonstruktionsinkrement 4mm, Standard-Lungenkernel) ein Niedrigdosis-MSCT (NDCT) durchgeführt (effektiver Röhrenstrom 20 mAs, übrige Parameter unverändert). Drei Radiologen markierten mittels Monitorbefundung unabhängig voneinander alle von ihnen detektierten Lungenrundherde mit einer Größe <2cm, wobei zwischen der Befundung des SDCT und des NDCT desselben Patienten ein zeitlicher Abstand von mehreren Wochen eingehalten wurde. Die Detektionsrate von NDCT und SDCT wurde mittels McNemar-Test verglichen. Die Übereinstimmung der drei Befunder wurde mit Venn-Diagrammen dargestellt. Ergebnis: Insgesamt wurden 448 Rundherde mit 1 bis 18mm Durchmesser (Mittelwert 3,3±3,5mm, Median 2,0mm) von mindestens einem Befunder bei mindestens einem Protokoll (SDCT oder NDCT) detektiert. Der Unterschied der Detektionsrate zwischen NDCT und SDCT war weder für alle Herde (p=0,14) noch für Herde <5mm Durchmesser signifikant (p=0,24). Beim SDCT wurden 44 und beim NDCT 60 Herde nicht detektiert. Lediglich 152/404 (37,6%) Herde beim SDCT und 158/388 (40,7%) Herde beim NDCT wurden von allen drei Befundern übereinstimmend detektiert (nicht signifikant). Beim SDCT wurden 132 (32,7%) Herde von einem und 120 (29,7%) Herde von zwei Befundern detektiert, beim NDCT waren es 86 (22,2%) bzw. 144 (37,1%) Herde. Schlussfolgerung: Die Detektion von kleinen Lungenrundherden im CT ist untersucherabhängig; weniger als die Hälfte aller Herde wurde übereinstimmend von allen Befundern detektiert. Hinsichtlich der Detektionsrate war das NDCT dem SDCT gleichwertig.

Purpose: To compare selenium-based digital radiography with conventional screen-film radiography of the cervical spine. Materials and Methods: In a prospective study X-ray images of the cervical spine were obtained in 25 patients using selenium-based digital radiography and conventional screen-film radiography. All images were clinically indicated. Selenium-based digital radiography and conventional screen-film radiography were used in a randomized order. Four radiologists independently evaluated all 50 examinations for the visibility of 76 anatomic details according to a five-level confidence scale (1 = not visible, 5 = very good visibility). From the evaluation of these anatomic details scores for the upper and middle cervical spine, the cervicothoracic junction and the cervical soft tissues were calculated. The scores for selenium-based digital radiography and conventional screen-film radiography were compared using Wilcoxon's signed rank test. Results: From a total of 15,200 observations (608 per patient) the following scores were calculated for selenium-based digital radiography and for screen-film radiography, respectively: Upper cervical spine 3.88 and 3.94; middle cervical spine 4.60 and 4.48; cervico-thoracic junction 3.64 and 2.62; cervical soft tissue 4.47 and 3.46. The differences between the last two scores were statistically significant (p < 0.05). Conclusion: The use of selenium-based digital radiography is superior to conventional screen-film radiography in the depiction of anatomic details of the cervicothoracic junction and the cervical soft tissues.

Lung cancer is the leading cause of death from malignancy. Due to a lack of early symptoms patients usually undergo therapy at advanced tumor stages when prognosis is poor. Feasibility studies of low-dose spiral CT screening of heavy smokers have shown that many small, resectable lung cancers can be diagnosed at early stages using simple diagnostic algorithms based on size and attenuation of detected pulmonary nodules with a small proportion of invasive procedures for benign lesions. Preliminary results of repeat screening confirms small size and favourable stage distribution of detected cancers, using even simpler diagnostic algorithms: additional diagnostic procedures are only required in new or growing nodules whereas follow-up with low-dose CT is sufficient in nodules that appear unchanged to exclude slow growth. However, mortality reduction by lung cancer screening with low-dose CT has yet to be demonstrated. Several randomised controlled trials are under way to assess possible mortality reduction by comparison of mortalities in a screening group and a control group. It is hoped that through international cooperation data from these trials can be pooled to allow for statistically significant conclusions as early as possible.

PURPOSE To present prevalence screening data from a nonrandomized screening trial by using low-dose computed tomography (CT) and a simple algorithm based on the size and attenuation of detected nodules to guide diagnostic work-up. MATERIALS AND METHODS Eight hundred seventeen asymptomatic volunteers (age range, 40-78 years; median age, 53 years; median tobacco consumption, 45 pack-years) underwent spiral low-dose CT of the chest without contrast material enhancement. We regarded all noncalcified pulmonary nodules greater than 10 mm in diameter as potentially malignant and recommended histologic examination or follow-up after 3, 6, 12, and 24 months to exclude growth. For noncalcified pulmonary nodules of 10 mm or smaller, repeat low-dose CT was recommended to exclude growth. RESULTS In 43% (350 of 817) of individuals, 858 noncalcified pulmonary nodules were found. Thirty-two nodules in 29 subjects were larger than 10 mm. Biopsy of 15 lesions revealed lung cancer in 12 lesions in 11 subjects (prevalence for all ages, 1.3% [11 of 817 subjects]; >50 years of age, 2.1% [11 of 519 subjects]; >60 years of age, 3.9% [eight of 206 subjects]), with a high proportion of early tumor stages (seven tumors, stage I; two, stage II; and three, stage III); three lesions were benign. In 17 nodules larger than 10 mm, follow-up with low-dose CT for a minimum of 24 months did not demonstrate growth. CONCLUSION Lung cancer screening with low-dose CT demonstrated a prevalence of asymptomatic cancers in 1.3% of a smoking population, including a high proportion of early tumor stages and a 20% (three of 15) rate of invasive procedures for benign lesions.

PURPOSE:To compare selenium-based digital radiography with conventional screen-film radiography of the cervical spine.MATERIALS AND METHODS:In a prospective study X-ray images of the cervical spine were obtained in 25 patients using selenium- based digital radiography and conventional screen-film radiography. All images were clinically indicated. Selenium-based digital radiography and conventional screen-film radiography were used in a randomized order. Four radiologists independently evaluated all 50 examinations for the visibility of 76 anatomic details according to a five-level confidence scale (1 = not visible, 5 = very good visibility). From the evaluation of these anatomic details scores for the upper and middle cervical spine, the cervicothoracic junction and the cervical soft tissues were calculated. The scores for selenium-based digital radiography and conventional screen-film radiography were compared using Wilcoxon's signed rank test.RESULTS:From a total of 15,200 observations (608 per patient) the following scores were calculated for selenium-based digital radiography and for screen-film radiography, respectively: Upper cervical spine 3.88 and 3.94; middle cervical spine 4.60 and 4.48; cervico-thoracic junction 3.64 and 2.62; cervical soft tissue 4.47 and 3.46. The differences between the last two scores were statistically significant (p < 0.05).CONCLUSION:The use of selenium-based digital radiography is superior to conventional screen-film radiography in the depiction of anatomic details of the cervicothoracic junction and the cervical soft tissues.

Zusammenfassung Lungenkrebs ist die häufigste zum Tode führende maligne Erkrankung. Wegen des Fehlens von Frühsymptomen kommen Patienten meist in fortgeschrittenen Tumorstadien zur Behandlung, wenn die Prognose sehr schlecht ist. Machbarkeitsstudien zum Einsatz der Niedrigdosis-Spiral-Computertomographie bei starken Rauchern haben gezeigt, dass sich bei Einsatz simpler, auf Größe und Dichte gefundener Rundherde basierender diagnostischer Algorithmen eine große Zahl kleiner, resektabler Bronchialkarzinome in frühen Stadien diagnostizieren ließ, wobei der Anteil invasiver Maßnahmen wegen benigner Läsionen gering war. Erste Ergebnisse von Wiederholungsuntersuchungen zeigen wiederum eine geringe Größe und günstige Stadienverteilung gefundener Tumoren, wobei die diagnostischen Algorithmen vereinfacht werden können: Weiterführende diagnostische Maßnahmen erscheinen nur bei neu aufgetretenen oder größenprogredienten Rundherden erforderlich, während unveränderte Rundherde lediglich weiterer Verlaufskontrollen zum Ausschluss eines langsamen Wachstums bedürfen. Der Nachweis einer Mortalitätsreduktion durch Lungenkrebsfrüherkennung mittels Niedrigdosis-CT steht jedoch weiterhin aus. Mehrere randomisierte kontrollierte Studien zum Vergleich der Lungenkrebssterblichkeit in einem Screeningarm und einem Kontrollarm sind in der Planungs- bzw. Rekrutierungsphase; aufgrund internationaler Kooperationen werden sich die Daten dieser Studien wahrscheinlich größtenteils gemeinsam auswerten lassen, um so bald wie möglich zu statistisch gesicherten Ergebnissen zu kommen.

Lung cancer is the most common cause of death from malignancy. It is characterized by a favourable prognosis when treated in early stages and a poor prognosis in advanced stages. Populations at risk are relatively well defined, i.e. heavy smokers and workers exposed to asbestos and radon. Therefore, early detection using diagnostic techniques promises reduction of mortality from this tumor. Previous studies using chest radiography and sputum cytology were, however, disappointing due to poor sensitivity of these tests for early tumor stages. The new technique of low-dose computed tomography provides both high sensitivity for small tumors and a comfortable examination. As small benign pulmonary nodules are common reliable non-invasive diagnostic algorithms are required for classification of nodules. Preliminary studies using low-dose CT screening in smokers have provided promising results. Prior to a wide application of the technique in clinical routine more data are required as to inclusion criteria, examination intervals and the effect of screening on mortality reduction.