Computed tomography (CT) was used to guide percutaneous fine-needle biopsy in 150 cases of difficult thoracic lesions; in 76 cases, nondiagnostic bronchoscopy (n = 62) and fluoroscopic biopsy (n = 14) had previously been performed. CT was indicated for guidance when the pulmonary or pleural lesions were small (0.3-2.5 cm); in a juxta-vascular location, either hilar or mediastinal; not seen or poorly visualized on conventional radiographs; or considered inaccessible. A diagnosis was made in 124 of 150 cases (82.7%) (107 of 124 malignant and 17 of 26 benign lesions), including 86 of 107 lung nodules (80.4%), 28 of 31 mediastinal lesions (90.3%), and ten of 12 pleural masses (83.3%). Complications included pneumothorax (n = 64), hemoptysis (n = 5), hemothorax (n = 2), and pericarditis (n = 1). The high rate of pneumothorax, its treatment, and advantages of its immediate radiologic management are discussed. Use of CT guidance considerably expands the scope of thoracic lesions amenable to percutaneous biopsy.

During the approximately 20 years that percutaneous abscess drainage (PAD) has been an extant procedure and as the millennium begins, PAD has become, by consensus, the treatment of choice for abscesses. Indications for PAD continue to expand, and currently almost all abscesses are considered amenable. On occasion, PAD is an adjunctive procedure that provides a beneficial temporizing effect for the surgeon who eventually must operate for a coexisting problem such as a bowel leak. Simple unilocular abscesses are cured almost uniformly by PAD; more complicated abscesses, such as those with enteric fistulas (e.g., diverticular abscess) or pancreatic abscesses, have cure rates ranging from 65% to 90%. Various catheters and insertion techniques have proven effective. Ultrasonography, computed tomography, and fluoroscopy are the staple modalities that guide PAD. PAD is the prototype interventional radiology procedure, providing detection of the abscess by imaging, needling for diagnosis, and catheterization for therapy.

Percutaneous drainage of 101 pancreatic pseudocysts (51 infected, 50 noninfected) in 77 patients is described. In this group of patients, 91 of 101 pseudocysts were cured by means of catheter drainage (90.1%) (noninfected, 43 of 50 [86%]; infected, 48 of 51 [94.1%]). Six patients underwent operation after percutaneous treatment due to persistent drainage. In patients with infected pseudocysts, the infection was eradicated by percutaneous drainage before operation. Four pseudocysts recurred and were redrained percutaneously. The mean duration of drainage was 19.6 days (infected pseudocysts, 16.7 days; noninfected, 21.2 days). Various access routes were used for catheter drainage: transperitoneal, retroperitoneal, transhepatic, transgastric, transduodenal, and transsplenic (inadvertent). Four major (superinfections) and six minor complications occurred. An unexpected finding in seven patients was spontaneous fistulization of the pseudocyst into the gastrointestinal tract. Percutaneous drainage is an effective front-line treatment for most pancreatic pseudocysts; cure is likely if fluid collections are drained adequately and if sufficient time is allowed for closure of fistulas from the pancreatic duct.

Lung abscesses were drained by means of catheters guided by computed tomography (CT) in 19 patients who still had sepsis despite standard medical therapy; all patients had received antibiotics for at least 5 days, and 11 of the 19 patients had undergone bronchoscopy. The abscess was cured (by clinical and radiographic criteria) in all 19 patients (100%), and surgery was avoided in 16 of the 19 patients (84%). Three patients underwent surgery for removal of organized tissue or decortication after the lung abscess was evacuated. Complications included a hemothorax that required a chest tube in one patient and three minor complications (a clogged catheter in two patients and transient elevation of intracerebral pressure in one patient). The hemothorax occurred in one of two patients in whom the catheter traversed normal lung. The percutaneous drainage catheters traversed juxtaposed abnormal pleura on route to the abscess in 17 of the patients. CT-guided drainage of lung abscess is an effective method to treat lung abscesses that are refractory to conventional therapy; the procedure should obviate major operation in most patients. A catheter route through abscess-pleural syndesis is preferable, and CT is useful for planning this route.

Twenty-five patients who had lymphoceles underwent sectional imaging and interventional radiologic procedures. Viewed using sonography, lymphoceles were hypoechoic to anechoic, occasionally with internal septa and debris. Low numbers (occasionally negative values) were observed using computed tomography (CT); these numbers strongly suggest the diagnosis of lymphocele. Calcification was observed on CT images of one patient. Diagnostic aspiration revealed tan to yellow fluid containing many lymphocytes; pathognomonic fat globules were observed in four cases. Malignant cells were found in two collections, an unusual occurrence. Therapeutic needle aspiration and short-term catheter drainage were usually unsuccessful (only one of five patients [20%] was cured). Long-term (1-5-week) catheter drainage cured 11 of 14 patients (78.6%). Sclerosing agents may have been beneficial for lymphocele obliteration in three of four patients. For most patients, lymphoceles may be diagnosed and treated successfully using radiologic means.

An intravertebral vacuum phenomenon was observed within 19 vertebrae of 17 patients. It represents a non-healing vertebral fracture. Three possible pathologic mechanisms are discussed: ischemic bone necrosis, trauma with ensuing ischemic necrosis, and intraosseous disc prolapse. The intravertebral vacuum phenomenon was found in two patients with multiple myeloma and thus does not exclude the presence of malignancy in the affected bone. Radiographs obtained during traction or extension may be of diagnostic value.

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