Choledochal cysts: role of noninvasive imaging, percutaneous transhepatic cholangiography, and percutaneous biliary drainage in diagnosis and treatment.

Choledochal cysts are an uncommon anomaly of the biliary system; findings include cystic dilatation of the extrahepatic biliary tree, intrahepatic biliary tree, or both. In the past 7 years, 13 patients with choledochal cysts have been seen at the authors' institution for evaluation and presurgical intervention. Percutaneous transhepatic cholangiography (PTC) was performed in 13 patients. Sixteen percutaneous biliary drainage (PBD) procedures were performed in 11 patients, computed tomography was performed in six patients, and ultrasound was performed in two. PTC proved to be an important imaging modality because of its superior ability to define the cyst anatomy, site of biliary origin of the cyst, and extent and detail of both extrahepatic and intrahepatic disease, that is, intraductal strictures and calculi. PBD proved valuable in preoperative intervention, as an aid in surgical reconstruction, and in postoperative care. The role of these two modalities in the diagnosis and treatment of patients with choledochal cysts, in addition to clinical aspects of the disease, is discussed.     

Patterns of intrahepatic bile duct dilatation at CT: correlation with obstructive disease processes.

The authors performed a blinded, retrospective analysis of 100 computed tomographic (CT) scans of patients with proved extrahepatic bile duct obstruction, including primary sclerosing cholangitis (PSC), to determine whether certain patterns of intrahepatic bile duct dilatation are suggestive of specific disease processes. Among 30 patients with benign obstructive disease, CT showed pruning of the intrahepatic ducts in four patients (13%), beading in four (13%), and skip dilatations in one (3%). Among 54 patients with malignant obstructive disease, CT illustrated pruning in eight (15%) patients, beading in 11 (20%), and skip dilatations in two (4%). Among 16 patients with PSC, CT demonstrated pruning in four (25%), beading in two (13%), and skip dilatations in five (31%). The majority of patients with malignant or benign obstructive disease or PSC had intrahepatic duct dilatation in both lobes of the liver. It extended into the periphery in 46 of 54 patients (85%) with malignant obstructive disease, in 20 of 30 (67%) with benign obstructive disease, and in 10 of 16 (63%) with PSC. The CT finding of skip dilatations is strongly suggestive of PSC. The CT findings of pruning and beading are nonspecific and may be observed at CT in patients with bile duct obstruction due to a wide variety of causes. The distribution and extent of intrahepatic duct dilatation at CT do not differ among biliary disease processes.     

The value of negative needle biopsy in suspected operable lung cancer

The value of needle biopsy (NB) of pulmonary masses in patients unsuitable for surgery is well established. The presence of malignant cells confirms the diagnosis and thus aids management. We have reviewed 196 patients aged over 40 years with a solitary pulmonary mass suspected of being operable lung cancer to assess the effect of a negative NB result on the management. Malignant cells were discovered in 148 patients and diagnoses of infection were made in a further 10. In 38 patients no malignant cells were identified. Nineteen patients proceeded to thoracotomy and 13 of these had malignant disease. Nine others had further needle biopsies and eight of these had malignancy. Ten patients were followed up without any further intervention and four of these eventually proved to have malignancy. Thus of the 38 patients with no malignant cells on NB but no definite benign diagnosis, 25 had malignancy, six had benign disease and seven had presumed benign disease. In this series NB provided a definite benign diagnosis in 5.1% of patients. From this study it may be concluded that if a solitary pulmonary nodule has a high clinical suspicion of malignancy and the patient is a candidate for surgery, NB is of limited value in management.     

Posterior fossa hemangioblastomas: MR imaging

The magnetic resonance (MR) imaging findings of 18 surgically proved posterior fossa hemangioblastomas (15 patients) were retrospectively analyzed and correlated with computed tomographic (ten patients) and angiographic (eight patients) findings. Thirteen tumors were located in the cerebellar hemisphere, three in the vermis, and two in the medulla with associated syrinxes. Three patients had von Hippel-Lindau disease, two of whom had multiple cerebellar hemangioblastomas. Seven hemangioblastomas appeared as solid tumors, six as solid masses with central cysts, and five as cysts with mural nodules. Abnormal tumor vessels, with characteristic signal void, were demonstrated in 13 tumors. Associated hemorrhage was present in four tumors. Although angiography is usually required for the diagnosis and preoperative assessment of this tumor, MR imaging demonstration of a posterior fossa mass with abnormal vessels should suggest the diagnosis of hemangioblastoma. Moreover, the combination of a peripheral posterior fossa cyst with a mural nodule supplied by enlarged vessels may be pathognomonic.     

Chemoembolization of liver metastasis from breast carcinoma

Chemoembolization was performed in eight patients with liver metastasis from breast carcinoma. Five of eight patients had some radiographic regression of the liver tumors, one had stable liver disease, and two had disease progression. Two of four patients with pain showed clinical improvement of their symptoms. Only one patient with radiographic response or disease stabilization subsequently had intrahepatic progression (at 3 months). Five patients developed other metastasis, particularly brain metastasis, at a mean of 4.6 months after first chemoembolization (range, 2-12 months). All patients died within 13 months of treatment, with a mean survival of 49 months from primary diagnosis, 20 months from liver metastasis diagnosis, and 6 months from first chemoembolization.     

Ultrasonic demonstration of the pancreatic duct: an analysis of 41 cases.

Ultrasonically visualized pancreatic ducts seen in patients over two and a half years were reviewed. Pancreatic ducts ranging from 2 to 16 mm were identified in 41 patients. All proved to have pancreatic disease. Of these, 25 had inflammatory disease, including acute pancreatitis, chronic pancreatitis, and pancreatolithiasis, and 16 had ampullary or pancreatic head tumors. There was no correlation between the pancreatic duct diameter and the underlying pathology. A careful search for tumor must be made in all patients in whom the pancreatic duct is demonstrated, using current gray-scale instrumentation.     

Transvaginal US-guided aspiration of ovarian cysts and solid pelvic masses.

Sixty-eight transvaginal ultrasound (US)-guided aspirations or biopsies were performed in 61 patients, of whom 48 had ovarian cysts and 13 had solid pelvic masses. In one patient with an ovarian cyst, aspiration revealed malignancy. Thirty-six of the 48 cysts were drained transvaginally in 23 premenopausal and 13 postmenopausal women, with recurrence rates of 48% and 80%, respectively. In seven cases a cyst was aspirated twice. In the 13 patients with solid pelvic lesions, 11 lesions proved to be malignant, with positive biopsy results in nine (sensitivity, 82%). Two benign lesions were correctly identified. No major complication was observed. The authors conclude that the transvaginal route offers simple access to pelvic lesions in pre- and postmenopausal patients. For women with a solid pelvic lesion, transvaginal aspiration biopsy with endovaginal US guidance is a safe and effective alternative to surgery, especially for patients with previously diagnosed malignant disease.     

Stage IV endometrial carcinoma: a 10 year review of patients.

Stage IV endometrial cancer is uncommon, often occurs in elderly patients and has a poor prognosis, which makes the choice of treatment difficult. 18 patients with stage IV endometrial cancer presenting over a 10 year period, between 1987 and 1997, were reviewed with regard to mode of treatment and response. The mean age was 65 years. Five had disease confined to the pelvis and 13 had extra pelvic disease. 15 of 18 patients had a total abdominal hysterectomy (TAH). One patient received radiotherapy alone and five received post-operative radiotherapy. Overall freedom from pelvic symptoms was achieved in seven of 18 patients. All seven had undergone TAH and two had received post-operative radiotherapy. Progestogens were given to 13 patients. Six received progestogens alone, without radiotherapy or chemotherapy. Of these, two responded, one for 9 months and one with verified lung metastases, who had a complete response, is still alive at 6.5 years. Eight patients received chemotherapy, with single agent cisplatin or carboplatin AUC 6. Three patients responded, one for 4.5 years. The overall median survival was 12 months from diagnosis. Actuarial 5 year survival was 15% (CI 3-36). There was no significant survival difference for, hormone therapy or chemotherapy. Stage IV endometrial cancer has a poor prognosis but durable response can be achieved in some patients.     

16层螺旋CT对肾结石并发肾盂癌术前诊断的可行性

目的探讨16层螺旋CT对肾结石并发肾盂癌的术前诊断价值。方法回顾性分析经手术病理证实的14例肾结石并发肾盂癌的B超及多层螺旋CT资料,并将二者的诊断与术后病理诊断对比。结果 B超检查术前有6例漏诊并发肾盂癌,检查漏诊率42.8%(6/14);而多层螺旋CT术前13例诊断明确,仅有1例漏诊,检查准确率达92.8%(13/14)。结论与超声相比,16层多层螺旋CT能显著提高肾结石并发肾盂癌的术前诊断准确率,故可作为肾结石并发肾盂癌术前诊断的首选检查方法。     

CT of colon cancer metastases to the liver using modified RECIST criteria: determining the ideal number of target lesions to measure

OBJECTIVE: We sought to define the ideal number of target lesions to be measured to assess disease response in patients undergoing chemotherapy for colon cancer metastases to the liver. MATERIALS AND METHODS: Thirty consecutive patients were recruited for this study. Patients were part of a multisite, randomized, double-arm, phase 3 clinical trial involving chemotherapy with an investigational drug for metastatic colon cancer. Patients were recruited from U.S. and international sites. Institutional review board approval was obtained, and informed consent was obtained from all patients. Our study included CT measurements of hepatic metastases. All patients (n = 30) had a minimum of five target lesions in the liver. Target-lesion size was defined by Response Evaluation Criteria in Solid Tumors (RECIST) criteria. We calculated the patient response at 2 months and at 6 months (complete response, partial response, stable disease, and progressive disease) using RECIST. Patient response was calculated based on the percentage increase or decrease at 2 and 6 months in the greatest diameter of the single largest lesion, two large lesions, three large lesions, four lesions, and five lesions, respectively. The concordance between five-target-lesion measurement and lesser numbers of lesions was analyzed using kappa statistics (StatView, 5.0). RESULTS: In 93.33% of patients (n = 28/30), there was agreement on patient response irrespective of the number of measurements made on CT. Of these 30 patients, 47% had a partial response (n = 14/30), 43% had stable disease (n = 13/30), and 10% had progressive disease at 2 months (n = 3/30). At 6 months, 43% had a partial response (n = 13/30), 47% had stable disease (n = 14/30), and 10% had progressive disease (n = 3/30). Agreement in response evaluation between lesion groups for multiple measurements was high, with values of 1.0 for multiple-lesion measurements and 0.88 for single-lesion measurements at 2 months. The concordance values were the same at 6 months. CONCLUSION: In the majority of patients with hepatic metastases of colorectal cancer, measuring the maximal diameter of the single largest lesion yielded the same treatment-response classification as measuring up to five target lesions. This result suggests that it may be possible to reduce the number of lesions measured in clinical trials.     

MR imaging of syringomyelia and hydromyelia

The relative effectiveness of plain computed tomography (CT), metrizamide CT, conventional myelography, and magnetic resonance (MR) imaging was compared for the examination of cystic spinal cord lesions. Intramedullary cavities in 18 patients were demonstrated by MR imaging: cavities were uncomplicated in 13 patients, associated with spinal tumors in two, and studied after occipital craniectomy for treatment of Chiari malformation and syringomyelia in two. Cavities were shown by MR imaging in all enlarged spinal cords, but a cavity was shown in only one of four small cords. The rostral limits of the cavities were demonstrated better than were the caudal extensions. Ventricular communication was not demonstrated. Chiari malformation was shown only in cavities that did not involve the medulla. Syringes associated with tumor were indistinguishable from uncomplicated cavities, but the tumor had abnormal signal on long spin-echo sequences in two cases. Cystic cord tumor (one case) had an inhomogeneous appearance. Caudal displacement of the cerebellar hemisphere through the surgical defect associated with compression of the fourth ventricle was shown in two cases after posterior fossa craniectomy. Thirteen patients were studied with metrizamide CT also. MR imaging proved to be as accurate as metrizamide CT in the diagnosis of intramedullary cavities that result in spinal cord enlargement, but it was less sensitive in detecting cavities within normal-sized or diminished spinal cords. It had the advantage that tumor tissue could be distinguished from associated syrinx cavities by differences in signal characteristics; and cerebellar ectopia was evaluated easily on sagittal MR views.     

Sonography of the salivary glands

In a blinded retrospective study of the efficacy of sonography of the salivary glands, we obtained sonograms on 849 patients. The patients were referred over the last 5 years from the ear, nose, and throat department of our university hospital. Eight-eight percent of the patients had symptoms related to the salivary glands. One hundred fifty-six of the patients (18%) were subsequently proved to be normal. The remaining 693 patients had diseases confirmed by histologic examination (332 patients), sialography (274 patients), or clinical follow-up (87 patients). Of these, 289 had salivary gland tumors (231 benign, 58 malignant), 185 had calculi, 154 had inflammation, 48 had autoimmune disease, 14 had cysts, and three had trauma. Two hundred eighty-seven (95%) of the 302 space-occupying lesions could be completely delineated by sonography, and the benign or malignant nature of the lesions was correctly assessed in 272 (90%). Of the 185 patients with calculi, the calculi were visualized and localized (intraductal vs intraglandular) on the sonograms in 174 (94%) patients. Abscesses were shown on the sonograms in 13 patients, and acute inflammation was shown on the sonograms in 84 patients. These results indicate that sonography is a useful procedure for diagnosis of diseases of the salivary glands.     

Computerized analysis of equilibrium radionuclide ventriculography time-activity curve in the assessment of left ventricular performance: comparison of two methods

Two methods for the analysis of left ventricle time-activity curve (TAC) of equilibrium gated ventriculography were compared in three groups of subjects [8 controls, 13 patients with coronary artery disease (CAD), 11 patients with myocardial infarction (MI). The first method was based on third-degree polynomial fitting, the second on Fourier analysis. The following parameters were calculated: peak ejection rate (PER), peak filling rate (PFR), time to PER and PFR, and filling fraction at the first third of diastole. A preliminary study of changing values of PER and PFR and of the mean error with increasing number of harmonics summed in order to obtain the best fitting of TAC demonstrated that beyond the sum of the first four harmonics there was no further significant improvement. The advantages of Fourier analysis are as follows: it is independent of the operator and fits only one function to the whole cardiac cycle; it requires less computer time; it provides better differentiation between controls and CAD patients. All of the 13 CAD patients had abnormal PFR on Fourier analysis, only 9 on polynomial analysis. At rest, 9 of the CAD patients had wall motion abnormalities, while only two had an abnormal ejection fraction.     

Association of prostate-specific antigen levels and patterns of benign and malignant uptake detected. on bone scintigraphy in patients with newly diagnosed prostate carcinoma

The bone scan patterns of benign and malignant uptake in 432 patients with newly diagnosed prostate carcinoma were reviewed in relation to prostate-specific antigen (PSA) levels determined within 4 months of scintigraphy. Scan results were categorized in terms of likelihood of metastatic disease and anatomical locations of benign and malignant lesions were tabulated. At least one suspect focus was identified in 138 scans (32%), and metastatic bone disease was present in 38 (9%). Metastatic disease prevalence increased from 1% for PSA <20 ng x ml(-1) to 58% for PSA>100 ng x ml(-1). Among patients with PSA>20 ng x ml(-1) (n = 157), 70 (45%) had at least one bone scan finding of concern for metastases and 35 (22%) proved to have metastatic disease. Almost all scans with metastases had either limited disease (< or = 5 suspicious lesions; n = 16; 42%) or extensive metastases (> 20 abnormalities; n = 19; 50%). The majority of patients with limited skeletal metastases had PSA < 100 ng x ml(-1) (11/16; 69%), while almost all patients with extensive skeletal involvement had PSA >100 ng x ml(-1) (17/19; 89%). Among those with limited metastatic disease, most (13/16; 81%) had at least one lesion in the pelvis or sacrum; the next most common sites were in the thoracic and lumbar spine (six each; 38%). In scans with a low to moderate suspicion for bone metastases, the only anatomical site with a significantly higher prevalence of malignant than benign lesions was the pelvis.     

Perirectal inflammatory disease: CT findings

The findings on computed tomographic (CT) scans were reviewed in 42 patients with perirectal inflammatory disease and suspected perirectal abscesses. CT was reliable for use in distinguishing perirectal abscesses from cellulitis and in localizing both supralevator and infralevator abscesses. CT allowed correct diagnosis of 13 surgically proved perirectal abscesses in ten patients, including three with residual abscesses after surgical drainage. In three patients with supralevator abscesses, the abscess was missed on initial surgical exploration. In patients without abscesses, CT was helpful in evaluating the extent of perirectal inflammation; however, it was not possible to determine its cause. The anatomy on CT scans of the pararectal spaces is reviewed, with emphasis on useful anatomic landmarks in the axial plane for distinguishing supralevator from infralevator abscesses.     

Directional atherectomy in the treatment of stenotic dialysis access fistulas

Directional atherectomy has proved useful in the treatment of peripheral vascular occlusive disease, and the authors have begun using this modality in the treatment of patients with failing hemodialysis access fistulas. The authors describe their initial experience with 13 patients in whom directional atherectomy was used to treat stenotic hemodialysis fistulas. Directional atherectomy was the sole treatment modality for eight patients. Three patients underwent atherectomy after unsuccessful percutaneous transluminal angioplasty (PTA). In two patients, unsuccessful atherectomy necessitated subsequent PTA. Directional atherectomy was successful in 10 of 13 patients. In seven of these 10 patients who are still alive, the dialysis fistulas remain patent. Directional atherectomy is a safe and useful technique in the percutaneous treatment of hemodialysis fistula stenosis. Early data indicate patency rates that may be higher than those reported with PTA.     

Thoracic wall involvement by Hodgkin disease and non-Hodgkin lymphoma: CT evaluation

Thoracic computed tomographic (CT) scans of 250 patients with newly diagnosed or recurrent lymphoma revealed thoracic wall involvement in 24 patients (11 with Hodgkin disease, 13 with non-Hodgkin lymphoma). Thoracic wall involvement occurred without contiguous mediastinal or parenchymal involvement in 17 patients. Of these, 13 patients had masses beneath the pectoralis muscles or within the breast, and four had masses arising from the ribs. Five additional patients had mediastinal masses with thymic involvement and parasternal extension through the thoracic wall. Pulmonary parenchymal lymphoma with thoracic wall invasion was noted in the remaining two patients. In five of nine patients receiving radiation therapy, treatment plans were modified by CT demonstration of thoracic wall lymphoma.     

Benign lumbar arachnoiditis: MR imaging with gadopentetate dimeglumine

MR imaging was performed in 13 patients with benign lumbar arachnoiditis both before and after IV injection of gadopentetate dimeglumine. The arachnoiditis was proved by previous myelography in 12 patients and by noncontrast MR imaging in one patient. The disease was presumably the result of previous myelography and/or surgery. It was characterized as mild in two patients, moderate in two patients, and severe in nine patients. Imaging was performed on a 1.5-T unit, and both short and long TR images were obtained before and after contrast administration. Noncontrast MR images demonstrated changes consistent with arachnoiditis in all patients. After contrast, three patients had no enhancement, three patients had minimal enhancement, three patients had mild enhancement, and four patients had moderate enhancement. In no case did contrast enhancement alter the diagnosis or reveal additional findings that could not be seen on the noncontrast images. Gadopentetate dimeglumine enhancement plays little role in the diagnosis of lumbar arachnoiditis. If used for another reason, however, short TR scans may show enhancement of adherent roots in some cases. In addition, administration of gadopentetate dimeglumine will not cause sufficient enhancement to hinder the detection of arachnoiditis on long TR images and may aid in recognition of adherent roots on short TR images.     

MR imaging in the evaluation of isolated limb perfusion: a prospective study of 18 cases

Purpose To prospectively evaluate the use of MRI with dynamic sequences during isolated limb perfusion (ILP) for soft tissue sarcomas, an aggressive local treatment using very high-dose chemotherapy and tumor necrosis factor aimed at avoiding limb amputation.Design and patients Twenty-six patients were referred for ILP over one and a half years; eight were excluded as the lesions were either too proximal or suspicious inflammatory changes without tumor were found on the initial MRI, or the vascular status was poor. The indications for ILP were: vessel nerve involvement (13), multiple lesions (8), tumor size (4) or the presence of pulmonary metastases (2). MRI was performed 1 and 2 months after ILP, immediately prior to surgery and histological analysis. The MR examinations included T1-weighted SE and fast SE T2-weighted fat-saturated sequences, as well as dynamic sequences (T1-weighted SE repeated six times every 40 s), displaying the maximum intensity slope in each pixel.Results The tumor had disappeared in three patients. One patient still had histologically proven isolated widespread tumor cells without a mass. The tumor size had increased in two patients. In six patients, the size of the tumor had not changed but it had become completely necrotic, with a thin wall.In three patients, after an initially good result MRI demonstrated that the tumor wall had become thickened from 1 to 2 months after ILP. Dynamic MRI was mainly useful during the initial examination, demonstrating two patients with inflammatory changes without tumor. Three amputations and a second ILP were proposed based on poor results. Conservative limb-sparing surgery was successful in the other cases.Conclusion MRI proved valuable in demonstrating the variable responses to ILP.     

Benign lumbar arachnoiditis: MR imaging with gadopentetate dimeglumine

MR imaging was performed in 13 patients with benign lumbar arachnoiditis both before and after IV injection of gadopentetate dimeglumine. The arachnoiditis was proved by previous myelography in 12 patients and by noncontrast MR imaging in one patient. The disease was presumably the result of previous myelography and/or surgery. It was characterized as mild in two patients, moderate in two patients, and severe in nine patients. Imaging was performed on a 1.5-T unit, and both short and long TR images were obtained before and after contrast administration. Noncontrast MR images demonstrated changes consistent with arachnoiditis in all patients. After contrast, three patients had no enhancement, three patients had minimal enhancement, three patients had mild enhancement, and four patients had moderate enhancement. In no case did contrast enhancement alter the diagnosis or reveal additional findings that could not be seen on the noncontrast images. Gadopentetate dimeglumine enhancement plays little role in the diagnosis of lumbar arachnoiditis. If used for another reason, however, short TR scans may show enhancement of adherent roots in some cases. In addition, administration of gadopentetate dimeglumine will not cause sufficient enhancement to hinder the detection of arachnoiditis on long TR images and may aid in recognition of adherent roots on short TR images.