Hepatocellular carcinoma with sarcomatous change: characteristic findings of two-phased incremental CT

Background: Because of its poor prognosis, the diagnosis of hepatocellular carcinoma with sarcomatous change (HCCSC) is clinically important. The purpose of this study is to elucidate the characteristic CT findings of HCCSC. Methods: Two-phased dynamic incremental CT images of six histologically proven HCCSC were retrospectively reviewed. Results: All tumors (100%) exhibited peripheral enhancement on delayed CT images. Lymphadenopathy was observed in 100% (six of six patients); intrahepatic metastases, in 83% (five of six). Both metastatic lesions showed findings similar to those of the primary hepatic tumors, such as peripheral enhancement. Histopathologically, delayed and/or prolonged peripherally enhanced areas consisted of viable cancer cells with sarcomatous changes. Conclusions: The appearance of HCCSC on CT is that of an irregularly demarcated intrahepatic mass with delayed or prolonged peripheral enhancement, frequently with intrahepatic metastases and lymphadenopathy. Received: 5 December 1994/Accepted: 4 January 1995     

Focal hepatic nodules after transcatheter oily chemoembolization; detection with spiral CT versus conventional CT

Background: The objective of this study was to determine if spiral computed tomography (CT) results in increased rate of detection of focal hepatic nodules containing iodized oil after transcatheter oily chemoembolization when compared with conventional CT. Methods: Spiral CT with single 24-s breath-hold technique was compared with conventional sequential CT in 42 patients with suspected hepatocellular carcinomas. Two sets of CT scans obtained after transcatheter oily chemoembolization were independently reviewed by two radiologists. The slice thickness was 10 mm for both data sets. The number and sizes of focal hepatic nodules containing iodized oil were documented. All 42 patients had at least one hepatic nodule. The lesion size varied from 2 mm to 12 cm. Results: In six of the 42 patients, more hepatic nodules could be identified on spiral CT compared with conventional CT. When scans with spiral CT were used, 107 nodules were detected, whereas 98 nodules were detected with conventional CT. Overall, nine (9%) more nodules were detected with spiral CT (<+>p= .002). If lesions larger than 2 cm are excluded, nine (15%) more lesions were detected with spiral CT (<+>p= .002). Conclusion: Spiral CT results in increased rate of detection of focal hepatic nodules after transcatheter oily chemoembolization, particularly in lesions smaller than 2 cm. Received: 11 October 1994/Accepted: 6 November 1994     

Correlation of perfusion abnormalities on CTAP and immediate postintravenous gadolinium-enhanced gradient echo MRI

Background: The purpose of this study was to evaluate patients with wedge-shaped perfusion defects seen on spiral CT arterial portography for the presence of transient increased wedge-shaped enhancement on dynamic gadolinium-enhanced gradient echo MR images. Methods: Nineteen patients underwent CTAP and MRI within a 2-week interval. All patients with wedge-shaped perfusion defects on CT arterial portography were evaluated in a separate review session for the presence of transient increased segmental hepatic enhancement on dynamic gadolinium-enhanced spoiled gradient echo (SGE) MR images. Results: Eight patients were identified to have subsegmental, segmental, or lobar wedge-shaped perfusion defects by CT arterial portography. In 8/8 patients, there was transient wedge-shaped increased hepatic enhancement on MR images which corresponded to the perfusion defects identified on CT arterial portography. Transient increased enhancement on MR images was observed on immediate postgadolinium images as high-signal intensity of the involved subsegment, segment, or lobe. This relatively high-signal area faded to near isointensity in all cases on images obtained at 45 s. Conclusion: Wedge-shaped perfusion defects demonstrated by CT arterial portography corresponded to wedge-shaped increased hepatic enhancement following gadolinium administration on SGE MR images. Received: 29 December 1994/Accepted: 7 February 1995     

Current status of small bowel radiography

Background: In the past, small bowel examinations were usually ordered for the sake of ``completeness.' As a result, small bowel radiography was performed casually and without attention to detail. This review examines pertinent clinical issues and the recent contribution of small bowel radiography to the evaluation and management of the patient with suspected small bowel disease. Recommendations for the clinical utilization of small bowel radiography are discussed. Methods: Analysis of pertinent citations addressing valid indications for, and technique of, small bowel radiography from 1980 to July 1995 through a computerized bibliographic search (Medline and Current Contents). Results: Accepted clinical indications for small bowel radiography include (1) unexplained gastrointestinal bleeding, (2) possible small bowel tumor, (3) small bowel obstruction, (4) Crohn disease, and (5) malabsorption. The current literature reflects the limitations of the conventional small bowel follow-through, various modifications to improve its clinical yield, the important contribution of enteroclysis in the workup, and subsequent management of patients with possible small bowel disease. A controversy in the radiology literature exists as to whether to use the small bowel follow-through or enteroclysis as the primary method of examining the small bowel. Conclusion: The thoughtful selection of patients by clinicians for small bowel radiography is essential to make radiologic evaluation cost effective. The incidence of disease of the small intestine is low and is associated with nonspecific symptoms. Because of the inherent difficulty of visualizing numerous loops of an actively peristalsing bowel, a reliable imaging method is needed that not only detects small or early structural abnormality but also accurately documents normalcy. The yield of information provided by enteroclysis and its high negative predictive value suggests that it should be the primary method for small bowel examination. The ``overhead'-based conventional small bowel follow-through should be abandoned. The ``fluoroscopy'-based small bowel follow-through augmented when necessary by the peroral pneumocolon or the gas-enhanced double-contrast follow-through method is an acceptable alternative when enteroclysis is not possible. Received: 0/0/00Accepted: 0/0/00     

Restorative proctocolectomy: morphological and functional study with coronal CT

Background: Restorative proctocolectomy with ileal pouch has become the surgical treatment of choice for patients with ulcerative colitis (UC) and familial polyposis of the colon. Defecography is the radiological technique commonly employed to obtain detailed information on function and morphology of the ileal pouch; it allows the direct visualization of the ileal pouch and the anal canal, but it does not provide the visualization of the pelvis. Methods: In all patients, computed tomography (CT) on coronal planes was performed to determine its possibilities as an alternative to defecography; 10 patients with UC submitted to restorative proctocolectomy and were examined. Results: Coronal CT images provided a panoramic vision of the pelvis and demonstrated the morphology of the ileal pouch, the thickness of its walls, and its correlation with the surrounding tissues. Coronal CT also allowed the evaluation of the continence of ileo-anal and ileo-ileal anastomosis and the functional changes of the perineal muscles at rest and during squeezing. Conclusion: CT images acquired on coronal planes allows an easy and clear detection of the major postoperative complications, such as stenosis or dehiscences of the anastomosis, pelvic phlogosis, and fistulae. Received: 29 December 1994/Accepted: 5 February 1995     

Spread of gallbladder carcinoma: CT evaluation with pathologic correlation

Background: To assess the accuracy of computed tomographic (CT) imaging in the detection of spread and staging of gallbladder carcinoma. Methods: CT findings of spread of gallbladder carcinoma in 59 Japanese patients who underwent radical surgery were correlated retrospectively with pathologic findings. Results: The incidence of histologically proven nodal involvement was 54% (32 patients) and the most common spread of gallbladder carcinoma. The sensitivities in CT detection of N1 and N2 nodal involvement were 36% and 47%, respectively; positive predictive values were 94% and 92%, respectively. Direct extension to the liver, extrahepatic bile duct, and gastrointestinal tract or pancreas were histologically confirmed in 24, 18, and five patients. The sensitivities in the CT detection of direct spread to the liver of less than 2 cm, more than 2 cm, the extrahepatic bile duct, and the gastrointestinal tract or pancreas were 65%, 100%, 50%, and 57%, respectively; positive predictive values were 77%, 100%, 90%, and 100%, respectively. The incidence of liver metastases and involvement of interaortocaval nodes were 7% and 16%, respectively. The sensitivities in CT detection of liver metastases and involvement of interaortocaval nodes were 75% and 21%, respectively; positive predictive values were 100% and 86%, respectively. CT could not detect direct spread to omentum and peritoneal seedings. Conclusion: For detecting the spread of gallbladder carcinoma, CT imaging has low to moderate sensitivity; however, CT imaging can help in determining resectability and in planning the treatment, especially in advanced-stage gallbladder carcinoma, because of a high positive predictive value. Received: 5 July 1995/Accepted: 8 August 1995     

Color Doppler imaging of the gallbladder wall in acute cholecystitis: sonographic<+>–<+>pathologic correlation

Background: The purpose of this study was to evaluate the usefulness of color Doppler imaging (CDI) in suspected cases of acute cholecystitis. Methods: Twenty-two patients suspected of having acute cholecystitis were prospectively evaluated over a 12-month period using gray-scale and color Doppler technique. Gallbladder wall thickness was greater than 2 mm in all patients included in the study. Pathologic correlation was obtained in 17 patients, with clinical or sonographic follow-up in five for a period of 6<+>–/011001/months. CDI was considered positive only if the mid to fundal wall demonstrated flow. Sonographic Murphy's sign and laboratory values were recorded. Results: Eight patients had acute cholecystitis. All had positive color Doppler flow. Wall thickness in these patients ranged between 4 and 10 mm. Three patients with necrotizing acute cholecystitis had no flow within 6<+>–<+>8-mm walls. Six patients with pathologically proven chronic cholecystitis had no evidence of increased flow within thickened walls. Five patients with presumed chronic cholecystitis (thickened wall without increased color flow) were treated medically, and their symptoms resolved. CDI was more sensitive in predicting acute cholecystitis than was the sonographic Murphy's sign and/or laboratory values. Conclusion: CDI demonstrates hyperemic changes in thickened gallbladder walls and is an important adjunct in the diagnosis of acute cholecystitis. Received: 3 February 1995/Accepted: 24 March 1995     

Suprapubic versus transrectal ultrasonography in assessing the volume of the prostate and the transition zone in patients with benign prostatic hyperplasia

The reliability of suprapubic ultrasonography (SU) in assessing the size of the prostate was examined in 95 patients with benign prostatic hyperplasia (BPH). Volumetric measurements of the prostate and the transition zone of the prostate (TZP) performed by SU were compared with corresponding measurements obtained by transrectal ultrasonography (TU). A very strong correlation was found between suprapubically and transrectally performed measurements for both the total prostate gland (r= 0.948, p < 0.001) and the TZP volume (r= 0.953, p < 0.001). According to the results of this study, SU appears to be as reliable as TU in assessing the size of the prostate and the TZP and may be used effectively in the evaluation of patients with BPH, as it is less cumbersome, better tolerated, and a widely available examination technique. Received: 21 October 1994/Accepted after revision: 12 December 1994     

Significance of the computed tomography finding of subcapsular hepatic necrosis in liver transplantation

Background: To evaluate the clinical significance of the computed tomographic finding of subcapsular hepatic necrosis following liver transplantation. Methods: 105 computed tomography scans performed in 50 allografts, 6 days to 4 years following transplantation, were retrospectively reviewed and divided into two groups: those with and those without the computed tomographic finding of subcapsular hepatic necrosis. Extrahepatic fluid, biliary dilatation, circumcaval rings, periportal collar, biochemistry, and random biopsies were correlated with the computed tomographic finding of subcapsular hepatic necrosis. Results: Computed tomographic finding of subcapsular hepatic necrosis was demonstrated at some point in 21 (42%) patients and was never demonstrated in 29 (58%) patients. The association of periportal collar with the computed tomographic finding of subcapsular hepatic necrosis was significant; there was no significant association with other computed tomographic findings. There was no significant difference in serum transaminases between the two groups. There was no significant difference in necrosis on biopsy between the two groups; however, the association of acute cellular rejection with the computed tomographic finding of subcapsular hepatic necrosis was significant. Conclusions: Computed tomographic finding of subcapsular hepatic necrosis is a common finding following liver transplantation, which has little clinical prognostic significance. Received: 13 December 1994/Accepted: 5 January 1995     

The frequency,appearance, and significance of splenic perfusion defects on CT arterial portography

Background: The purpose of this study was to determine the frequency, appearance, and significance of splenic perfusion defects on computed tomographic arterial portography (CTAP). Methods: CTAP was performed with dynamic scanning at 1-cm increments on 46 consecutive patients prior to laparotomy. Two readers retrospectively reviewed these studies in consensus and recorded the number, size, and shape of focal splenic perfusion defects. These defects were later correlated with surgical findings and at least one of the following imaging modalities: delayed CT 4<+>–<+>6 h after CTAP, intravenously enhanced CT, sonography, or magnetic resonance imaging (MRI). Results: Splenic perfusion defects were present in 14 of 46 CTAP studies (30%), and in seven patients these defects were multiple. Most defects were wedge-shaped and peripherally located, although several round defects simulating metastases were also present. The spleen was normal at surgery in all patients, and comparison imaging revealed only a small splenic infarct in one patient on MRI. Conclusions: Splenic perfusion defects occur in about one-third of patients referred for CTAP, are usually wedge-shaped but may be round, and should not be interpreted as metastases without other evidence of a space-occupying mass. Received: 11 October 1994/Accepted: 6 November 1994     

Peritoneopleural communication associated with cirrhotic ascites: scintigraphic demonstration

Demonstration of peritoneopleural communication in patients with cirrhotic ascites has an important impact on treatment planning. We studied 12 such patients and found presence of peritoneopleural communication in five. Two had bilateral, one right-side and two left-side, pleural effusion. Pleural fluid protein content was less than 2 g/dL in all patients. Received: 30 January 1995/Accepted: 4 March 1995     

Bladder pheochromocytoma with ring calcification

A case of a 19-year-old male with a paraganglioma (pheochromocytoma) arising in the prostate and involving the urinary bladder is presented. The radiological studies, including computed tomography, demonstrated ringlike calcification of the tumor, a rare finding that is highly suggestive of the diagnosis of pheochromocytoma. The tumor was excised and found to be malignant at surgery. Received: 17 April 1995/Accepted: 23 May 1995     

Enhancing ascites: an aid to CT diagnosis

Enhancement of ascitic fluid on delayed contrast-enhanced CT has been described as a potential pitfall in diagnosis. We present a case in which the phenomenon was beneficial to diagnosis. Enhancement of ascites was useful in delineating the entire extent of a cystic pelvic mass. We also discuss probable molecular and histologic mechanisms responsible for this unique type of enhancement. Received: 8 August 1994/Accepted after revision: 17 November 1994     

Large lipomas of the colon: CT and MR findings in three symptomatic cases

We report on three patients with large lipomas in the wall of the cecum, causing intussusception. Endoscopy is the preferred modality for small lipomas, whereas CT and MR imaging are more useful in their ability in detecting fatty masses and assessing the location of lesions. Barium enema study may contribute to the preoperative planning in selected cases. Received: 1 November 1994/Accepted after revision: 5 January 1995     

Occult bilateral ectopic vaginal ureters causing urinary incontinence: diagnosis by computed tomography

Diagnosis of an ectopic, infrasphincteric ureter can be difficult because the renal moiety drained by the ectopic ureter is often small and functions poorly. We present a 6-year-old girl with urinary incontinence caused by bilateral vaginal ectopic ureters that were not seen on excretory urography or renal sonography and were diagnosed only by contrast-enhanced computerized tomography. Received: 22 August 1994/Accepted after revision: 22 December 1994     

Arteriocholedochal fistula: an unusual cause of hemobilia

We report an unusual cause of hemobilia in a patient with a transhepatic biliary catheter. Hemobilia was due to an extrahepatic fistula between the gastroduodenal artery and the common bile duct and was responsible for significant blood loss. The fistula was successfully treated with transarterial embolization that resulted in no further episodes of hemobilia during the following 12 months. Received: 22 August 1994/Accepted: 23 September 1994     

Spontaneous rectus sheath hematomas: clinical and radiological features

We reviewed the clinical and radiological features in eight patients with spontaneous rectus sheath hematoma (RSH). The diagnosis was confirmed at surgery in four patients, and spontaneous resolution occurred in the other four. All patients were elderly adults. Acute abdominal pain and a palpable mass after muscular strain, such as coughing or twisting, were features highly suggestive of RSH. Sonographically, these hematomas may be confused with abdominal wall tumors. On CT scans, a hyperdense mass posterior to the rectus abdominis muscle with ipsilateral anterolateral muscular enlargement is considered characteristic of acute RSH, although chronic RSH may be isodense or hypodense relative to the surrounding muscle. MRI is very useful in the diagnosis of RSH, which is demonstrated as a high signal intensity area on both T1- and T2-weighted images, especially when the CT findings are not specific for RSH. Received: 16 August 1994/Accepted: 3 October 1994     

Subcapsular renal spread of a pancreatic pseudocyst

In pancreatitis, the fluid collection may extend to unusual sites and organs and form a pseudocyst. We present US and CT findings of a pancreatic tail pseudocyst extending into the subcapsular space of the left kidney. Received: 23 December 1994/Accepted: 25 January 1995     

Testicular feminization: radiologic considerations in a unique formof cryptorchidism

A case report of complete testicular feminization is presented. The medical and radiological characteristics of this condition which distinguish it from male cryptorchidism and other disorders of sexual differentiation are discussed. To our knowledge, only three previous case reports have been published in the radiology literature. Our report is the first to describe MRI findings. Received: 2 March 1995/Accepted after revision: 28 March 1995     

Jaundice due to afferent loop obstruction following hepatectomy for a hilar cholangiocarcinoma

A case of jaundice due to obstruction of Roux en Y-limb following hepatectomy for a hilar cholangiocarcinoma is presented. Percutaneous transhepatic biliary drainage improved the jaundice but promoted disseminated intravascular coagulopathy. Our limited experience suggested that afferent loops should be drained directly to prevent reflux of enteric contents into the biliary system. Received: 21 February 1995/Accepted: 24 March 1995