Computed tomography in evaluation of patients with stage III melanoma

Background: Metastatic disease is detected infrequently by computed tomography (CT) in early stage melanoma. The diagnostic yield of routine CT for stage III melanoma is less established, despite extensive use in clinical practice. Methods: Charts from 347 asymptomatic patients with stage III melanoma were reviewed. Findings suggestive of metastatic melanoma identified by head or body CT, chest radiography, bone scan, or liver function studies were confirmed histologically or by progression of disease. Results: Individual CT scans identified 33/788 (4.2%) instances of metastatic melanoma, with 66/788 (8.4%) false positive studies. No metastases were identified among 104 head CT scans. Chest CT had the highest yield in patients with cervical adenopathy (7/35, 20%), and the lowest yield with groin adenopathy (1/50, 2%). Pelvic CT diagnosed metastases in 7/94 (7.4%) patients with groin adenopathy, but no patients with palpable axillary (n=76) or cervical (n=21) nodes. Metastatic melanoma was diagnosed in 11/136 (8.1%) patients having complete body CT imaging (chest, abdomen, and pelvis), including six patients (4.4%) identified by CT alone. Conclusions: Routine CT in patients with clinical stage III melanoma infrequently identifies metastatic disease. Head CT in the asymptomatic patient, chest CT in patients with groin adenopathy, and pelvic CT in the presence of axillary or cervical adenopathy are not indicated. Selective use of chest CT in patients with cervical adenopathy or pelvic CT in the presence of groin disease may be useful. Presented at the 49th Annual Cancer Symposium of The Society of Surgical Oncology, Atlanta, Georgia, March 21–24, 1996.     

Accuracy of computed tomography in nodal staging of colon cancer patients

AIM: To predict node-positive disease in colon cancer using computed tomography(CT).METHODS: American Joint Committee on Cancer stage Ⅰ-Ⅲ colon cancer patients who underwent curavtiveintent colectomy between 2007-2010 were identified at a single comprehensive cancer center. All patients had preoperative CT scans with original radiology reports from referring institutions. CT images underwent blinded secondary review by a surgeon and a dedicated abdominal radiologist at our institution to identify pericolonic lymph nodes(LNs). Comparison of outside CT reports to our independent imaging review was performed in order to highlight differences in detection in actual clinical practice. CT reviews were compared with final pathology. Results of the outside radiologist review, secondary radiologist review, and surgeon review were compared with the final pathologic exam to determine sensitivity, specificity, positive and negative predictive values, false positive and negative rates, and accuracy of each review. Exclusion criteria included evidenceof metastatic disease on CT, rectal or appendiceal involvement, or absence of accompanying imaging from referring institutions.RESULTS: From 2007 to 2010, 64 stageⅠ-Ⅲ colon cancer patients met the eligibility criteria of our study. The mean age of the cohort was 68 years, and 26(41%) patients were male and 38(59%) patients were female. On final pathology, 26 of 64(40.6%) patients had nodepositive(LN+) disease and 38 of 64(59.4%) patients had node-negative(LN-) disease. Outside radiologic review demonstrated sensitivity of 54%(14 of 26 patients) and specificity of 66%(25 of 38 patients) in predicting LN+ disease, whereas secondary radiologist review demonstrated 88%(23 of 26) sensitivity and 58%(22 of 38) specificity. On surgeon review, sensitivity was 69%(18 of 26) with 66% specificity(25 of 38). Secondary radiology review demonstrated the highest accuracy(70%) and the lowest false negative rate(12%), compared to the surgeon review at 67% accuracy and 31% false negative rate and the outside radiology review at 61% accuracy and 46% false negative rate.CONCLUSION: CT LN staging of colon cancer has moderate accuracy, with administration of NCT based on CT potentially resulting in overtreatment. Active search for LN+ may improve sensitivity at the cost of specificity.     

直肠内充气CT在直肠癌诊断和临床分期中的意义

目的探讨直肠内充气CT在直肠癌诊断和临床分期中的意义。方法回顾性分析52例经手术病理证实直肠癌患者的直肠内充气CT表现,评价直肠内充气CT在直肠癌诊断和临床分期中的价值。结果直肠内充气CT患者直肠及乙状结肠充分扩张,包绕直肠周围脂肪密度结构,与相对较高密度的肠壁及极低密度肠腔对比清晰。直肠内充气CT对直肠癌TNM分期总的准确率为84.6%（44/52）,T分期的准确率为90.4%（47/52）,N分期的准确率为86.5%（45/52）,M分期的准确率为98.7%（51/52）。结论直肠内充气CT能够清晰显示直肠癌的大小,形态,浸润深度,淋巴结转移情况,与周围器官关系及远处转移情况,获得清晰的直肠系膜影像学特征。直肠内充气CT与TNM病理分期有较高的一致性,是直肠癌术前诊断与临床分期的重要方法。     

黄色肉芽肿性胆囊炎的CT检查表现

Xanthogranulomatous cholecystitis (XGC) is benign and chronic, which is rarely seen in clinical practice.The clinical and imaging presentation of XGC is similar to that of chronic cholecystitis, cholecystolithiasis and gallbladder cancer.Summarizing the computed tomography (CT) presentations of XGC is helpful in improving the diagnostic accuracy. According to the result of a retrospective analysis based on the clinical data of 17 patients with XGC, we concluded that rim enhancement sign and hypodense band sign in the arterial phase of contrast enhanced CT, and clear in interface between liver and gallbladder and trimness of internal wall in gallbladder are the CT characteristics of XGC.     

结直肠癌局部淋巴结浸出液癌胚抗原含量与淋巴结分期的关系

目的 探讨结直肠癌局部淋巴结浸出液癌胚抗原(CEA)含量与该淋巴结分期的关系.方法 2006年1月至2009年12月结直肠癌根治性切除术病例共92例.每例整块切除的新鲜标本中分别摘取原发灶肠管旁淋巴结和顶端淋巴结各2枚,分别测定CEA浓度,并送组织学检查,其余标本全数取出淋巴结送组织学检查.结果 pN 0期48例,CEA浓度30.16 ng/mg;pN 1期22例,CEA浓度93.26 ng/mg;pN 2期22例,CEA浓度359.74 ng/mg,3组比较差异有统计学意义(P＜0.01).结论 结直肠癌局部淋巴结浸出液CEA浓度与pN分期显著相关,可用于指导术后辅助化疗.

Abstract：

Objective To study the relationship between carcinoembryonic antigen (CEA) level of the regional nodes extract and pN staging in patients with colorectal cancer. Methods From Jan. 2006 to dex. 2009 radical resection was performed in 92 patients with colorectal cancer. Intraoperatively, two paracolonal regional lymph nodes and two predominate nodes were bisected, preserved in normal saline,and the extracts were sent for CEA assay. The same bisected node was fixed in Formalin for histopathologic examination. Results In the pN0, pN1 and pN2 stages, the mean CEA concentrations were 30. 16,93.26 and 359.74 ng/mg respectively ( P ＜ 0.01). Conclusion The concentration of CEA in the node extract is significantly correlated with pN stageing in patients with colorectal cancer, and it can be used to guide the adjuvant chemotherapy postoperatively before the final pN result obtained.     

What is the role of CT staging in the management of patients with clinical stage 1 and 2 malignant melanoma?

There is a lack of evidence to support CT staging for distant disease in patients with Clinical Stage I and II melanoma. Staging scans, undertaken prior to Sentinel Lymph Node Biopsy (SLNB) in 115 patients with melanoma, between October 2004 and October 2006 were reviewed. CT imaging failed to identify distant site disease in any patient. 67 patients were diagnosed with non-melanoma related abnormalities necessitating further imaging and investigation, ultimately without identifiable benefit in all but one patient. The results of this study further question the need for distant site imaging of melanoma patients prior to SLNB.     

Computed tomography of the brain in predicting outcome of traumatic intracranial haemorrhage in Malaysian patients

Summary  Head injury is a significant economic, social and medical problem all over the world. Road accidents are the most frequent cause of head injury in Malaysia with highest risk in the young (15 to 24 years old). The associated outcomes include good recovery, possibility of death for the severely injured, which may cause disruption of the lives of their family members. It is important to predict the outcome as it will provide sound information to assist clinicians in Malaysia in providing prognostic information to patients and their families, to assess the effectiveness of different modes of treatment in promoting recovery and to document the significance of head injury as a public health problem.  Results. A total of 103 cases with intracranial haemorrhage i.e. intracerebral haemorrhage, extradural haemorrhage, subdural haemorrhage, intraventricular haemorrhage, haemorrhagic contusion and subarachnoid haemorrhage, following motor vehicle accidents was undertaken to study factors contributing to either good or poor outcome according to the Glasgow Outcome Scale. Patients below 12 years of age were excluded. The end point of the study was taken at 24 months post injury.  The selected variables were incorporated into models generated by logistic regression techniques of multivariate analysis to see the significant predictors of outcome as well as the correlation between the CT findings with GCS.  Conclusion. Significant predictors of outcome were GCS on arrival in the accident emergency department, pupillary reflex and the CT scan findings. The CT predictors of outcome include ICH, EDH, IVH, present of SAH, site of ICH, volumes of EDH and SDH as well as midline shift.     

The impact of computed tomography on pretherapeutic staging in patients with laryngeal cancer: demonstration of the Will Rogers' phenomenon

BACKGROUND: The purpose of this study was to demonstrate that pretherapeutic CT of patients with primary laryngeal cancer results in stage migration, therefore affecting laryngeal cancer outcome data. METHODS: We retrospectively reviewed the medical records of 90 patients with primary laryngeal cancer diagnosed between January 1, 1995, and December 31, 1997, at a university hospital. RESULTS: The disease in 15 (17%) of 90 patients was reclassified into a new TNM stage after pretherapeutic CT. As a result, stage-specific survival rates improved in three of four TNM stages, even though average survival for the entire cohort did not change. CONCLUSIONS: The TNM staging system is not a temporally stable classification and prediction system, because TNM assignment varies on the basis of the type of pretherapeutic evaluation. Outcome data for patients with laryngeal cancer must account for the introduction of new technologies that affect our ability to diagnose and stage this disease.     

Performance characteristics of computed tomography in detecting lymph node metastases in contemporary patients with prostate cancer treated with extended pelvic lymph node dissection

Background

Computed tomography (CT) is a commonly used noninvasive procedure for prostate cancer (PCa) staging. All previous studies addressing the ability of CT scan to predict lymph node invasion (LNI) were based on historical patients treated with limited pelvic lymph node dissection (PLND).

Objective

Assess the value of CT in predicting LNI in contemporary PCa patients treated with extended PLND (ePLND).

Design, setting, and participants

We evaluated 1541 patients undergoing radical prostatectomy and ePLND between 2003 and 2010 at a single center. All patients were preoperatively staged using abdominopelvic CT scan. All lymph nodes with a short axis diameter ≥10 mm were considered suspicious for metastatic involvement.

Intervention

All patients underwent preoperative CT scan, radical retropubic prostatectomy, and ePLND, regardless of PCa features at diagnosis.

Measurements

The performance characteristics of CT scan were tested in the overall patient population, as well as according to the National Comprehensive Cancer Network (NCCN) classification and according to the risk of LNI derived from a nomogram developed on an ePLND series. Logistic regression models tested the relationship between CT scan findings and LNI. Discrimination accuracy was quantified with the area under the curve.

Results and limitations

Overall, a CT scan that suggested LNI was found in 73 patients (4.7%). Of them, only 24 patients (32.8%) had histologically proven LNI at ePLND. Overall, sensitivity, specificity, and accuracy of CT scan were 13%, 96.0%, and 54.6%, respectively. In patients with low-, intermediate-, or high-risk PCa according to NCCN classification, sensitivity was 8.3%, 96.3%, and 52.3%, respectively; specificity was 3.6%, 97.3%, and 50.5%, respectively; and accuracy was 17.9%, 94.3%, and 56.1%, respectively. Similarly, in patients with a nomogram-derived LNI risk ≥50%, sensitivity, specificity, and accuracy were only 23.9%, 94.7%, and 59.3%, respectively. At multivariable analyses, inclusion of CT scan findings did not improve the accuracy of LNI prediction (81.4% compared with 81.3%; p = 0.8). Lack of a central scan review represents the main limitation of our study.

Conclusions

In contemporary patients with PCa, the accuracy of CT scan as a preoperative nodal-staging procedure is poor, even in patients with high LNI risk. Therefore, the need for and the extent of PLND should not be based on the results obtained by CT scan.     

Favorable clinical responses in subsets of patients from a randomized,multi-institutional melanoma vaccine trial

Background: A phase III, randomized, double-blind, multi-institutional trial was performed evaluating active specific immunotherapy using vaccinia melanoma oncolysate (VMO) in the surgical adjuvant setting in patients with stage II melanoma (UICC staging). The first interim analysis showed no significant difference in disease-free and overall survival. The data were further analyzed to identify subsets of patients with improved outcome when treated with VMO. Methods: Patients received either VMO or placebo of live vaccinia vaccine virus (V), once a week for 13 weeks and then once every 2 weeks for an additional 39 weeks or until recurrence. Having stratified patients according to sex, age, number of positive nodes, tumor thickness, and clinical stage, data were analyzed for disease-free survival and overall survival. Results: Male patients showed a 17% difference in overall survival at 4 years when treated with VMO (p=0.19). A subset of male patients <57 years of age with one to five positive nodes showed a 30% difference at 4 years with VMO (p=0.06). Patients with clinical stage I but pathological stage II disease (both male and female), who had undergone prophylactic node dissection, showed a 23% difference in survival at 3 years with VMO (p=0.11). Conclusions: This subset analysis shows encouraging survival benefit in certain subsets of patients and an increasing trend in overall survival. Further follow-up of this phase III trial from a second interim analysis will be forthcoming.Results of this study were presented at the 48th Annual Cancer Symposium of The Society of Surgical Oncology, Boston, Massachusetts, March 23–26, 1995.     

CT在Pilon骨折术前评估中的意义

目的探讨CT对胫骨远端Pilon骨折术前评估的意义。方法总结了2000年1月～2005年6月具有完整X线片及CT随访资料的Pilon骨折52例,术前评估结合X线片和关节面CT平扫对骨折进行分型,并描绘骨折线的走行,测量骨折角,分析关节骨块的解剖特点。根据软组织条件、骨折类型、骨折线走行、骨折角、关节骨块位置设计个性化的治疗方案。石膏固定5例,闭合复位经皮螺钉固定加石膏外固定5例,微创钢板接骨术(MIPPO)技术钢板固定治疗17例,外固定结合有限内固定16例,切开复位内固定治疗9例。结果术后平均随访17.2个月。CT改变了9例Rüedi-Allgwer分型,21例发现了新的骨折块。CT平扫中主要骨折线呈冠状面走行的占61.5%,呈矢状面走行的占34.6%,对这两类骨折采用了不同的入路和内固定方式。用Mazur方法评估术后功能:优30例,良13例,可8例,差1例,总优良率82.7%,Ⅲ型的优良率为57.1%,CT显示有冲床死骨的优良率仅为44.4%。结论结合CT对Pilon骨折分型更准确;Ⅲ型骨折只要软组织条件允许,应切开复位关节面骨折;依据主要骨折线的走行和骨块的位置选择切口和内固定方式;对冲床死骨需直视下复位,但此类病例预后较差。     

Computed tomography with multiplanar reformation and three-dimensional image reconstruction in the preoperative evaluation of adult hip disease

Summary Computed tomography (CT) with multiplanar reformation and three-dimensional (3D) image reconstruction was used pre-operatively to outline the bony morphological changes and femoral-acetabular relationships in 25 adult patients suffering from hip disease. Diagnoses included ischaemic necrosis of the femoral head, osteoarthritis, rheumatoid arthritis, calcium pyrophosphate dihydrate (CPPD) crystal deposition disease, previous trauma and chronic dislocation. Polyethylene models of the femora and acetabula were constructed from three-dimensional contouring of CT data and compared with resected specimens in patients subjected to subsequent total hip arthroplasty. Information provided by this imaging technique was useful in both selecting and guiding the most appropriate surgical procedure and it was found that models depicted the actual bony contours with reasonable accuracy. CT combined with multiplanar reformation and 3D analysis may be the optimal pre-operative means of assessment of the diseased adult hip.

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Résumé La tomodensitométrie (TDM) avec reconstruction multiple et tri-dimensionnelle (3 D) des images a été utilisée avant l'intervention afin de visualiser les modifications de la morphologie osseuse et les rapports entre le cotyle et la tête du fémur chez 25 sujets adultes présentant une hanche pathologique. Les diagnostics étaient nécrose de la tête fémorale, arthrose, arthrite rhumatoïde, chondrocalcinose, séquelles de traumatismes et de luxation congénitale. Des modèles en polyéthylène du fémur et du cotyle ont été réalisés à partir des données tri-dimensionnelles fournies par la TDM et comparées avec les pièces opératoires réséquées chez les patients traités par arthroplastie totale. Les informations apportées par cette technique d'imagerie ont été utiles à la fois pour indiquer et effectuer le meilleur procédé opératoire et on a trouvé que les modèles représentaient les véritables contours osseux avec une précision satisfaisante. La TDM avec reconstruction multiple et tri-dimensionnelle (3 D) pourrait être le meilleur moyen pré-opératoire d'évaluation d'une hanche pathologique chez l'adulte.

     

Computed tomography appearance of Hem-o-lok clips in patients who have undergone laparoscopic nephrectomy or nephroureterectomy

Background and Objectives:

Hem-o-lok clips are safe and reliable for controlling the renal vasculature. We retrospectively evaluated the CT appearance of Hem-o-lok clips in patients who had undergone laparoscopic radical nephrectomy (LRN) or nephroureterectomy (LRU) as well as their appearance on ex vivo CT scans.

Methods:

Between January 2006 and December 2006, 19 patients underwent LRN or LRU, and their CT images were reviewed within 5 postoperative months. The Hem-o-lok clips were radiopaque in all of the patients’ CT images, and their radiodensity value was 222 Hounsfield Units (HU). To confirm that Hem-o-lok clips are radiopaque on CT images, an ex vivo CT scan was performed.

Results:

We confirmed that these clips are radiopaque on CT images and that they have a radiodensity of 223 HU.

Conclusion:

We conclude that the Hem-o-lok clips are radiopaque on CT images. It is important for urologists and radiologists to be aware of the CT appearance of Hem-o-lok clips when following up patients who have undergone LRN or LRU.     

Computed tomography versus ureteroscopy in identification of renal tract stone with ureteral stent in situ

INTRODUCTION

The aim of this study was to validate the use of non-contrast computed tomography (CT) with a ureteral stent in situ instead of ureteroscopy for identification of renal tract stones.

METHODS

All patients who had stents inserted for renal tract stones and underwent non-contrast CT with the stent in situ followed by ureteroscopy between May 2008 and October 2009 at The Canberra Hospital, Australia, were analysed retrospectively. Statistical analysis was performed to compare any differences between CT and ureteroscopy in the identification of stones.

RESULTS

Overall, 57 patients were included in the study. The difference between CT and ureteroscopy findings was statistically significant. CT identification of stones with a stent in situ had a sensitivity of 86%, a specificity of 46%, a positive predictive value of 63%, a negative predictive value of 76% and an accuracy of 67%.

CONCLUSIONS

Our study suggests that non-contrast CT is inferior to the ‘gold standard’ of ureteroscopy. It lacks sensitivity, specificity, positive predictive value, negative predictive value and accuracy. Therefore, we cannot recommend using non-contrast CT to replace ureteroscopy.     

Computed tomography diagnosis of symptomatic right paraduodenal hernia associated with enteric duplication cyst

Paraduodenal hernias rarely present with symptoms in children. We report a case of a right paraduodenal hernia associated with enteric duplication cyst that caused intestinal suboclussion in a 9-month-old female infant. Paraduodenal hernia was detected by contrast-enhanced computed tomography. In a review of the English-published literature, we have not found other reports of the association of paraduodenal hernia and enteric duplication cyst. A high index of suspicion is required for detecting paraduodenal hernias in children, and abdominal computed tomography is the most specific imaging study for their preoperative diagnosis.     

High-resolution computed tomography accurately predicts resectability in hilar cholangiocarcinoma

INTRODUCTION: Despite the use of radiologic, endoscopic, and laparoscopic staging techniques, the rate of nontherapeutic laparotomies in patients with hilar cholangiocarcinoma remains high. This study evaluated the accuracy of preoperative high-resolution computed tomography (HRCT) to determine resectability in this setting. PATIENTS AND METHODS: Preoperative helical HRCT (2 contrast phases, rapid intravenous contrast bolus, 2.5-mm section thickness) for 32 consecutive patients who underwent laparotomy for the diagnosis of hilar cholangiocarcinoma from 2000 to 2005 were reviewed by a hepatobiliary radiologist. The accuracy of HRCT was determined by comparison of the imaging interpretation to intraoperative and pathologic findings. The chi-square test was used to identify imaging findings that best predicted unresectability. RESULTS: Fourteen of the 32 (44%) study patients were unresectable (extension along bile duct, 4; peritoneal metastases, 4; vascular encasement, 3; noncontiguous liver metastases, 2; N2 lymphadenopathy, 1). HRCT correctly predicted resectability in 17 of 18 patients who underwent therapeutic laparotomy (sensitivity = 94%). HRCT correctly predicted the inability to resect in 11 of the remaining 14 cases (specificity = 79%). In the 3 cases in which HRCT predicted resectability and the patient was unresectable, subcentimeter peritoneal disease, a subcentimeter liver metastasis, and distal bile duct involvement were responsible factors. The negative and positive predictive values of HRCT were 92% and 85%, respectively. Individual radiographic findings that best predicted unresectability were peritoneal spread (P = .015) and hepatic artery (P = .006) or portal vein (P = .002) involvement. CONCLUSIONS: Preoperative HRCT accurately predicts resectability in patients with hilar cholangiocarcinoma. Identification of specific radiographic features, in particular major vascular involvement and peritoneal abnormalities, is now used by our group to avoid unnecessary laparotomy.     

Computed tomography and composition of renal calculi

Summary The attenuation values of computed tomography were studied in 50 recovered renal calculi of more than 10 mm in diameter, in the hope of determining the composition of calculi in situ. The attenuation value of various calculi (mean±s.d.) in a 5 mm slice with a maximal rectangular region of interest was as follow (Hounsfield units); mixed calcium oxalate and phosphate 1,555±193 (n=22), magnesium ammonium phosphate 1,285±284 (n=18), calcium oxalate 1,690 (n=1), calcium phosphate 1,400 (n=2), cystine 757±114 (n=5) and uric acid 480 (n=2). Attenuation values ranging from 500 to 1,600 overlapped for various calculi, except those composed of uric acid calculi. There was no correlation between the attenuation value and the mineral content such as calcium or magnesium per unit weight of calculus. The mineral content per unit volume seemed to be attributable to the attenuation value. From the present results we conclude that the determination of calculous composition by the attenuation value is possible only for oxalate calculi of more than 1,600 and uric acid calculi of less than 500 attenuation value, provided that the proper CT slice location, the region of interest and the appropriate calculus size can be determined.