An assessment of the value of spleen scanning in the staging of Hodgkin's disease.

The value of non-invasive spleen scanning with 51Cr-chromate heat damaged red cells has been assessed in 68 patients with histologically proved Hodgkin's disease in whom pre-treatment laparotomy with splenectomy was performed. The scans were reported independently by two observers. Following this, the uptake pattern of the radioactive tracer and size of organ on the scan were compared with the post-operative weight and pathology of the spleen. From these results it is concluded that this method of spleen scanning is an unreliable technique in staging Hodgkin's disease.     

The value of ultrasonic scanning of the spleen in lymphoma

In 40 patients assessed for splenic enlargement prior to splenectomy, clinical examination and ultrasonic scanning gave equally accurate results when compared with splenic weight after removal. In the 22 patients having staging laparotomy and splenectomy for Hodgkin's disease, ultrasound was unable to assess accurately the presence of tumour deposits.     

The CT appearance of pleural and extrapleural disease in lymphoma.

OBJECTIVE: Pleural effusions in patients with lymphoma that are assumed to be related to malignancy are attributed to either lymphatic obstruction by tumour with resultant decreased clearance of pleural fluid, or direct tumour involvement of the pleura. The purpose of our study was to determine how often pleural or extrapleural disease was detected by computed tomography (CT) of patients with pleural effusions and primary or recurrent lymphoma. METHODS AND MATERIALS: We reviewed CT examinations showing evidence of pleural effusion in 61 patients with a diagnosis of primary or recurrent lymphoma and no history of other systemic disorders, including infection. The study population consisted of patients with non-Hodgkin's lymphoma (n = 44) or Hodgkin's disease (n = 17); both primary disease (n = 11) and recurrent disease (n = 50) were represented. Each CT examination was evaluated for the presence of disease involving the visceral and parietal pleura and extrapleural space, mediastinal adenopathy, and pulmonary parenchymal disease. RESULTS: Fourteen patients (23%) (nine with non-Hodgkin's lymphoma and five with Hodgkin's disease) had parietal pleural disease (thickening or nodules). Eighteen patients (30%) (14 with non-Hodgkin's lymphoma, four with Hodgkin's disease) had tumour or enlarged lymph nodes in the extrapleural space. Forty-three patients (70%) had mediastinal lymphadenopathy. Patients who received intravenous contrast did not have evidence of visceral pleural abnormalities or underlying pulmonary parenchymal disease. CONCLUSION: Forty-one percent of the patients with lymphoma and pleural effusions had CT evidence of pleural and/or extrapleural disease. The majority of the patients with extrapleural disease had adjacent posterior mediastinal disease.     

Nuclear magnetic resonance (NMR) imaging in the evaluation of the liver: a preliminary experience

To determine the usefulness of nuclear magnetic resonance (NMR) in evaluation of the liver, 19 examinations were performed. A variety of pathological conditions were examined, and correlation was obtained with computed tomography, ultrasound, and radionuclide liver/spleen scanning. Nuclear magnetic resonance was as sensitive as the correlating imaging modalities in the detection of focal disease. Parenchymal abnormalities could be detected only in hemochromatosis. Several patients with diffuse disease did demonstrate evidence of portal hypertension, but no characteristic findings were noted within the liver parenchyma. Our preliminary investigation did not include T1 and T2 values and it is hoped that these will allow greater diagnostic utility in the detection of diffuse parenchymal disease.     

CT-guided biopsy with cutting-edge needle for the diagnosis of malignant lymphoma: experience of 267 biopsies

AIM: We performed a retrospective study of 267 core needle aspiration biopsies in order to estimate the accuracy of CT-guided aspiration core needle biopsies for the diagnosis and subsequent treatment of malignant lymphoma. MATERIALS AND METHODS: Between 1989 and 1999, 267 CT-guided core needle biopsies were performed in 241 patients with either primary or recurrent malignant lymphoma. Patients age ranged from 4--88 years. One hundred and sixty-six (62.2%) nodal and 101 (37.8%) extranodal aspiration biopsies were performed using either 18G or 20G Turner needles. Statistical method used was Chi-square analysis. RESULTS: An accurate histological diagnosis was made in 199 (82.5%) patients, the remaining 42 (17.4%) patients had non-diagnostic CT biopsies. Thirty-seven of them were diagnosed by a surgical biopsy, four by bone marrow biopsy and in one patient by paracentesis. One hundred and seventy-nine patients had non-Hodgkin's lymphoma (NHL) and 62 had Hodgkin's disease (HD); 23 (9.54%) patients underwent repeated CT biopsy which was diagnostic in 17 (73.9%) and non-diagnostic in six (26%). CONCLUSION: CT-guided aspiration core biopsies were sufficient to establish a diagnosis in lymphoproliferative disorders in 82.5% of cases. In the light of this experience we suggest that imaging-guided core needle biopsy be used as the first step in the work up of many patients with lymphoma.     

The prevalence of carcinoma in palpable vs impalpable, mammographically detected lesions.

Concern over excessive numbers of false-positive mammograms, leading to unnecessary investigations and surgical interventions, has been cited as a barrier to mammographic screening for breast cancer. We compared the biopsy results from palpable vs impalpable, mammographically detected lesions from one experienced breast surgeon's practice from July 1980 through July 1989. Overall, there were 372 biopsies in 346 women. Of 143 biopsies for palpable abnormalities, 48 (34%) yielded a primary malignant lesion. The length of the palpable cancers averaged 3.7 cm (median, 2.8 cm). Sixteen (33%) of the 48 biopsies were in patients who had positive axillary lymph nodes, and five (10%) were in patients who had distant metastases at the time of biopsy. Of 229 biopsies for impalpable, mammographically detected lesions, 72 (31%) yielded a primary breast carcinoma. Excluding 34 carcinomas that had only calcifications, the length of the mammographically detected tumors averaged 2.0 cm (median, 1.5 cm). Eleven (15%) of the 72 biopsies were in patients who had positive axillary nodes, and none were in patients who had distant metastases at the time of biopsy. The positive predictive values (number of cancers detected divided by the number of biopsies recommended) were not significantly different when comparing biopsies indicated for palpable, clinically detected (34%) vs impalpable, mammographically detected (31%) abnormalities (p = .669). However, the mammographically detected cancers were smaller, more often noninvasive (32% vs 4%), less often associated with axillary metastases (15% vs 33%), and without distant metastases (0% vs 10%).     

Functional asplenia in patients with chronic graft-versus-host disease: concise communication

Liver/spleen images were performed with technetium-99m sulfur colloid in 53 patients who had undergone bone-marrow transplantation. The spleen was not seen in the images in five out of the ten patients with chronic graft-versus-host disease (GVHD). None of the five had a history of splenectomy. In two of these patients, anatomical presence of the spleen had been documented earlier by scintigram. The spleen was visible in all seven patients with acute and in all 36 patients without GVHD. Neither the differences in methods of treating the patients before bone-marrow transplantation nor the time lapse between transplantation and the liver/spleen image correlated with the observed effect among these three groups of transplant patients. We conclude that there is a high association between chronic GVHD and functional asplenia.     

Safety and efficacy of a spring-propelled 18-gauge needle for US-guided liver biopsy.

Two hundred three liver biopsies were performed on 114 patients suspected of having diffuse liver disease. More than one-half of the biopsies (107 of 203) were performed in liver allografts. Biopsies were performed under ultrasound (US) guidance with use of a spring-propelled 18-gauge cutting needle. Half of the biopsies were performed in patients with abnormal coagulation studies, decreased platelet counts, or both. The left lobe was chosen for biopsy over the right lobe in the majority of cases (112 vs 91). Sufficient tissue for diagnosis was obtained in 197 cases (97%). Four complications (2%) occurred that required treatment: one vasovagal reaction and three episodes of bleeding. All bleeding complications occurred in patients with coagulopathy. There was no difference in safety or efficacy between biopsies of native and transplanted livers; similarly, there was no difference in safety or efficacy between biopsies of the left and right lobe. Pain occurred less frequently with biopsies of the left lobe. US-guided biopsy with a spring-propelled 18-gauge needle is safe and efficacious in the diagnosis of diffuse liver disease.     

Magnetic resonance imaging in the initial staging of Hodgkin's disease and non-Hodgkin lymphoma

Seventy-four consecutive previously untreated patients with Hodgkin's disease (HD) and non-Hodgkin lymphomas (NHL) were evaluated with chest, abdominal and pelvic magnetic resonance (MRI) for initial staging. All patients underwent routine radiological staging procedures which included chest radiographs and lymphography (LAG). These studies were followed in most of cases by laparoscopy, during which biopsies of the liver and the spleen were taken, and bone marrow aspiration and histology. A correlation of the results of MRI with both other imaging studies and histopathologic diagnoses was performed, and discordant cases were assessed to determine the impact on clinical staging. Additional evidence of disease involvement was provided mainly in the chest, where MRI demonstrated the presence of unsuspected disease in 21% of involved patients (9 of 42). Retroperitoneal lymph nodes were correctly assessed in 97% of cases if MRI was compared with LAG. Extranodal abdominal disease was identified both in the spleen (14%) and in the liver (1%). Bone marrow abnormalities were detected in 19% of patients (14 of 74). MRI findings influenced the staging of HD and NHL patients in 11 of 74 cases (15%).     

Cutting needle biopsy in the diagnosis of clinically suspected non-carcinomatous disease of the lung

Most patients referred for lung biopsy have a focal lesion that is likely to be a carcinoma, and fine needle aspiration is usually sufficient to confirm the diagnosis. When non-carcinomatous disease is suspected, tissue architecture is important and potential diagnostic techniques include percutaneous cutting needle biopsy (CNB). We retrospectively reviewed 37 CNBs performed for clinically suspected non-carcinomatous disease; recording the biopsy result, final diagnosis, radiological nature of the pulmonary abnormality, distance from the pleura of the lesion biopsied and biopsy complications. 9 patients had a single pulmonary nodule/mass; 13 had multiple nodules/masses; 8 had a lobar consolidation/mass; and 7 had multifocal consolidation. The lesion abutted the pleura in 31 cases, lying within 1 cm in the other 6 cases. The minor complication rate was 14%, with no major complications. Specific malignant diagnoses were made in 9 patients, and specific benign in 23, in all of whom clinicoradiological follow-up was concordant. CNB did not yield a specific diagnosis in five patients, including two lymphomas and one case of unsuspected tuberculosis in which the sample was not cultured. The overall accuracy of CNB was 32/37 (86%). CNB is a safe and accurate means of achieving a tissue diagnosis for patients with peripheral pulmonary parenchymal disease thought not to represent carcinoma.     

CT- or sonography-guided biopsy of the liver in the presence of ascites: frequency of complications

The presence of ascites has been considered a contraindication to percutaneous biopsy of the liver. To determine the validity of this assumption, we performed percutaneous biopsies of the liver under CT or sonographic guidance in 28 patients who had ascites and in 28 patients who did not have ascites and compared the complication rates in the two groups. Twenty-two patients (79%) in the group with ascites and 19 patients (68%) in the group without ascites had biopsies to determine the cause or extent of chronic liver disease. The remainder were oncologic patients who had biopsies to determine the cause of a focal hepatic mass. The complication rate in the patients who had ascites (32%) was less than that in the patients who did not have ascites (43%) (the difference did not reach statistical significance, p less than .30). In the ascites group, complications included transient hypotension (five patients), a mild-to-moderate fall in hematocrit (three patients), and a small leak of ascites from the biopsy site (one patient). In the control group, minor complications included transient hypotension (three patients), a mild-to-moderate fall in hematocrit (seven patients), and a small subcapsular hematoma (one patient). One major complication occurred in the control group: a patient required a blood transfusion because of the fall in his hematocrit. We conclude that the complication rate in liver biopsies guided by CT or sonography in the presence of ascites is not higher than similar biopsies done in the absence of ascites. Ascites should not be considered a contraindication for performing such biopsies.     

Percutaneous image-guided splenic biopsy in the oncology patient: an audit of 156 consecutive cases

PURPOSE: To assess the safety and diagnostic accuracy of percutaneous image-guided splenic biopsy in patients known to have or suspected of having malignancy. MATERIALS AND METHODS: Data from all image-guided splenic biopsies performed at a single institution from January 1992 to March 2007 were retrospectively reviewed. One hundred fifty-six splenic biopsies were performed in 147 patients (78 male and 69 female patients; mean age, 54.9 years; age range, 13-81 years). The most common indications for biopsy were suspected recurrent lymphoma (n = 101, 64.7%), suspected metastatic disease (n = 39, 25%), and unknown diagnosis (n = 16, 10.3%). All biopsies were performed with computed tomographic (n = 86), ultrasonographic (n = 68), or fluoroscopic (n = 2) guidance. Most biopsies (91%) were performed with 22-gauge needles, with a mean of 2.8 passes. The mean lesion size was 3.2 cm (range, 0.8-13 cm). Final diagnosis was confirmed with splenectomy (n = 39), histopathologic correlation with concurrent biopsy or surgical specimen (n = 52), or clinical or imaging follow-up ranging from 2 weeks to 14 years (n = 44). Complications were recorded. RESULTS: Sufficient tissue for pathologic analysis was obtained in 144 of the 156 biopsies (diagnostic yield, 92.3%). The overall sensitivity, specificity, and diagnostic accuracy were 83.4%, 87.8%, and 84.7%, respectively. Complications occurred in 26 biopsies (16.7%), with a 1.9% (n = 3) major complication rate and a 14.7% (n = 23) minor complication rate. Splenectomy was necessary in two patients. CONCLUSIONS: Splenic biopsy in the evaluation of new or recurrent neoplasm is a minimally invasive procedure with low complication rates and a high diagnostic yield.     

Evolution of the diagnostic accuracy of CT in clinical staging of patients with Hodgkin's disease

From 1983 through 1989, 141 untreated patients with Hodgkin's disease underwent CT of the abdomen. They subsequently underwent staging laparotomy plus splenectomy and multiple biopsies of liver and lymph nodes, at the Institute of Radiology and Hematology, University "La Sapienza", Rome. CT results were compared with surgical findings to evaluate CT sensitivity, specificity, and overall accuracy. The cases from this series were divided into two groups depending on the characteristics of the CT scanners employed. From 1983 to 1985, 78 patients were examined with 2nd-generation CT units; from 1986 to 1989, 63 patients underwent CT performed with 3rd-generation scanners. The results from the two groups were analyzed according to these parameters. A total number of 622 biopsies were performed, of spleen, liver, and lymph nodes. CT sensitivity, specificity, and overall accuracy were: 22.9% (group I) vs 43.7% (group II), 83.1% vs 92%, and 68.4% vs 81.2% for lymph nodes; 28.1% vs 36.3%, 93.5% vs 98%, and 66.7% vs 87.3% for the spleen, and 12.5% vs 42.8%, 97.1% vs 98.2%, and 88.5% vs 92.1% for the liver. Our results demonstrate an obvious increase in reliability with newer units, even though a high percentage of false-negatives were still observed in our series, which caused understaging in 19.4% of cases vs 24.4% in group I.     

Staging Hodgkin's Disease with 18-FDG PET. Comparison with CT and Surgery

In this prospective study, staging of Hodgkin's disease with 18-FDG PET was compared to CT, needle biopsy and staging laparotomy. Forty nine patients with Hodgkin's disease were studied; forty five with new disease and four being restaged for recurrent disease. Thirty eight patients had confirmation by needle or excisional biopsy, eleven by staging laparotomy including needle biopsy. Sensitivity, specificity, positive and negative predictive values of FDG PET were 100%, 100%, 100% and 100% in the laparotomy group. CT values were 20%, 83%, 50% and 56% in the same group. Overall in both surgical and non surgical patients FDG PET changed stage in 59% (29/49) of patients. FDG PET is a safe and effective method of staging Hodgkin's disease.     

Splenic involvement in lymphomas. Evaluation on serial CT examinations

Purpose: To prospectively evaluate changes in splenic volume (SV) on serial CT of patients with lymphoma and correlate them with other indicators of the disease process.Material and Methods: SV was calculated in 290 abdominal CT examinations of 58 consecutive adults with lymphoma (42 non-Hodgkin's lymphoma, 16 Hodgkin's disease). Each patient had one CT investigation before, 2 during chemotherapy and 2 post-chemotherapy. The changes in SV were correlated with clinical, laboratory and other imaging indicators of the disease process.Results: Three groups of patients were identified. Group A (n=20) presented no changes in SV, showed no splenic parenchymal abnormalities and had normal SV and serum lactic dehydrogenase (S-LDH). Group B (n=25) presented a decrease in SV during treatment suggesting response to therapy. Splenic parenchymal abnormalities (n=5) and other subdiaphragmatic sites of involvement (n=20) underwent remission during treatment. Eighteen patients with high S-LDH at presentation showed normal values during therapy. Group C (n=12) showed an increase in SV post-therapy associated with manifestations of disease recurrence. The S-LDH levels were elevated in 10 patients at the same time.Conclusion: Quantitatively assessed splenic size on CT may serve as an indicator of splenic involvement in the course of lymphomas.     

Scintigraphic diagnosis and computed tomographic localization of an accessory spleen following relapse of chronic immune thrombocytopaenia.

Chronic immune thrombocytopaenia is an immunologically mediated disorder resulting in disordered platelet kinetics and potentially life-threatening thrombocytopaenia. Failure of medical therapy is an indication for splenectomy, and responses are seen in 80% of patients following this procedure. An important cause of relapse following splenectomy is the presence of an accessory spleen. We describe a patient with Hodgkin's Disease who developed chronic immune thrombocytopaenia despite previous splenectomy. A remission was induced with immunosuppressive therapy, but he later relapsed. An accessory spleen was detected using 99mTc denatured red blood cells and localized using computed tomography (CT). Resection of the accessory spleen resulted in clinical remission. Accessory spleens are often small in size. Combined modality imaging is recommended in the evaluation of patients with a possible accessory spleen.     

Hemostatic effect of glue-lipiodol mixture plugged in the needle tract after renal biopsies in a high-risk, anticoagulated rabbit model

RATIONALE AND OBJECTIVES: To investigate the hemostatic effect of a glue-lipiodol mixture plugged immediately into the needle tract after renal biopsy of high-risk, anticoagulated rabbits by use of a large-core gun biopsy needle and the subsequent pathological changes of the biopsy tract. METHODS: Twenty-five rabbits weighing 2 kg were divided into five groups (five rabbits each) according to time of sacrifice at 0, 2, 4, 6, and 8 days after biopsy. After anesthesia was induced, both kidneys were exposed and a bolus of 100 U/kg heparin was administered intravenously. Blood sampling was done twice, once before and once after heparinization, and activated partial thromboplastin times were measured for each. Then renal biopsies were performed in 25 pairs of kidneys by using an 18-gauge automated biopsy gun. The glue-lipiodol mixture was not injected into the first biopsy sites (control). Immediately after the second biopsies were done, 0.5 mL of the glue-lipiodol mixture at a 1:3 ratio was plugged into the needle tract through the outer cannula while withdrawing it slowly. Bleeding times of the two biopsies of each pair of kidneys were measured. All rabbits were humanely killed at their previously scheduled times, and histopathological findings were evaluated for the presence of inflammation, necrosis, foreign body reaction, and fibrosis around the biopsy tract. All parameters were classified into four categories according to the degree of severity, from 0 to + + +. RESULTS: Twenty-five cases (100%) of the controls bled after the biopsies were performed. Four of them (16%) showed immediate, massive, pulsatile bleeding. In contrast, only 11 of 25 cases (44%) bled at the second biopsy (plugged) sites and only two of them (8%) showed pulsatile bleeding. Mean bleeding times were 228 seconds in controls and 26 seconds in the glue-lipiodol mixture-plugged sites (P < 0.000). Histopathological examination of the needle tract in the plugged group revealed mild inflammation in the 0- to 2-day groups and moderate inflammation and mild necrosis in the 4- and 6-day groups. In the 8-day group, inflammation was diminished and only mild fibrosis was noted. There was no foreign body reaction in any of the specimens of the plugged group. CONCLUSIONS: We conclude that a glue-lipiodol mixture, when used as a plug material for the renal biopsy tract, is an efficacious method of bleeding control that is associated with a low incidence of pathological alterations in an anticoagulated rabbit model, thus demonstrating its future potential for clinical application.     

Staging of thoracic lymphoma by radiological imaging

Thoracic lymphomas, which are very common especially in Hodgkin's disease patients, are characterised by enlargement of mediastinal lymph nodes, parenchymal abnormalities, and pleural, pericardial and chest wall involvement. The use of several imaging techniques has been proposed in order to assess the extent of the disease correctly and to plan therapy. The most relevant results in this field, especially those using computed tomography (CT), magnetic resonance imaging (MRI) and gallium scanning, are summarised in this review. Presently CT is widely and successfully used in staging patients, whereas MRI seems to be preferable, as a second-step technique, if pericardial, pleural and chest wall involvement are suspected. The role of gallium scanning is limited in the staging, although it could be relevant in the follow-up of treated patients. Received 4 April 1996; Revision received 7 November 1996; Accepted 7 November 1996     

Platelet destruction in autoimmune thrombocytopenic purpura: kinetics and clearance of indium-111-labeled autologous platelets

Using autologous 111In-labeled platelets, platelet kinetics and the sites of platelet destruction were assessed in 16 normal subjects (13 with and three without spleens), in 17 studies of patients with primary autoimmune thrombocytopenic purpura (AITP), in six studies of patients with secondary AITP, in ten studies of patients with AITP following splenectomy, and in five thrombocytopenic patients with myelodysplastic syndromes. In normal subjects, the spleen accounted for 24 +/- 4% of platelet destruction and the liver for 15 +/- 2%. Untreated patients with primary AITP had increased splenic destruction (40 +/- 14%, p less than 0.001) but not hepatic destruction (13 +/- 5%). Compared with untreated patients, prednisone treated patients did not have significantly different spleen and liver platelet sequestration. Patients with secondary AITP had similar platelet counts, platelet survivals, and increases in splenic destruction of platelets as did patients with primary AITP. In contrast, patients with myelodysplastic syndromes had a normal pattern of platelet destruction. In AITP patients following splenectomy, the five nonresponders all had a marked increase (greater than 45%) in liver destruction compared to five responders (all less than 40%). Among all patients with primary or secondary AITP, there was an inverse relationship between the percent of platelets destroyed in the liver plus spleen and both the platelet count (r = 0.75, p less than 0.001) and the platelet survival (r = 0.86, p less than 0.001). In a stepwise multiple linear regression analysis, total liver plus spleen platelet destruction, the platelet survival and the platelet turnover were all significant independent predictors of the platelet count. Thus platelet destruction is shifted to the spleen in primary and secondary AITP. Failure of splenectomy is associated with a marked elevation in liver destruction. The magnitude of spleen and liver destruction appears to be of considerable importance in the severity of the disease, as reflected in the platelet survival and platelet count.     

Predictive value of benign percutaneous adrenal biopsies in oncology patients

PURPOSE: Percutaneous CT guided biopsy is accepted as a safe procedure for the diagnosis of indeterminate adrenal masses in oncologic patients. The purpose of this study was to evaluate the accuracy of a 'negative for tumour' adrenal biopsy in the oncologic patient population by assessing subsequent outcome including clinical course, size and imaging characteristics of the adrenal lesions on follow-up imaging studies and pathological findings at re-biopsy or following adrenal mass resection. MATERIALS AND METHODS: Retrospective analysis of 225 oncological patients (FM, 128;87; age range 33-87 years, mean age 66 years) who had undergone CT guided biopsies of an adrenal mass over a 5-year period was performed. Those patients with a report consistent with 'negative for malignancy' were evaluated by reviewing the medical records for patient demographics, primary malignancy, histology of adrenal tumour, subsequent surgical interventions, repeat adrenal biopsy under image guidance, by open surgery or at autopsy, subsequent abdominal imaging in which the adrenal gland was imaged, and long-term outcome including hospital admissions, or death. RESULTS: Of the 225 CT-guided adrenal biopsies performed, 41 (18%) were negative for neoplasm. The primary neoplasm in these 41 patients included lung cancer (n=32), breast (n=5), renal cell carcinoma (n=2), bladder (n=1), and prostate (n=1). The size of the adrenal lesions ranged from 2.8-5 cm. Of the 41 biopsies, which were negative for tumour; 10 were identified as adenomas and the rest showed benign adrenal cortical cells or hyperplasia on cytopathology and histopathology. Repeat biopsies were obtained in 13/41 (31%) patients; whereas 2/41 (5%) had their adrenal gland analyzed on post mortem examination. None of these 15 repeat evaluations yielded tumour. CONCLUSION: In oncological patients, pathological analysis of tissue samples obtained by CT-guided percutaneous biopsy, suggesting benign aetiology, is reliable and predicts a benign course on long-term follow-up. A negative or benign pathology result for a CT guided percutaneous adrenal biopsy can be regarded as a true negative evaluation in oncological patients with no necessity to repeat the biopsy.