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     

Rectus sheath hematoma: diagnostic classification by CT

A method of classification for hematomas of the rectus abdominis sheath (RSH) is proposed based on findings observed in CT in the 13 cases of RSH in the present study. Type I hematomas (five cases) are slight and do not require hospitalization. Type II (three cases) and type III (five cases) are moderate and severe hematomas, respectively, and do require hospitalization. The patients with type III hematomas were all undergoing anticoagulant therapy and presented with a picture of acute abdomen, and in all five cases blood transfusion was carried out. Ultrasonography and, in particular, CT permitted a correct diagnosis of RSH. RSH should be considered (anticoagulant therapy induced) in females with sudden abdominal pain to avoid unnecessary surgical intervention. Received: 1 May 1995/Accepted: 12 June 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     

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     

CT findings in symptomatic left paraduodenal hernia

Two cases of symptomatic, surgically proven left paraduodenal hernias were shown with computed tomography (CT) imaging. A small bowel loop was seen behind the pancreatic tail in one case, and a ring-oriented bowel loop was shown between the transverse colon and the left adrenal gland in the other. Received: 11 January 1995/Accepted: 4 February 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     

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     

CT of Hodgkin's lymphoma limited to the gallbladder

A complex mass confined to the gallbladder found on CT is unusual, but nor rare, with causes including benign inflammatory disease, early primary carcinoma and metastases. Non-Hodgkin's lymphoma is rare and Hodgkin's disease, prior to the current case, unheard of involving just the gallbladder. Thus, this should be considered part of the differential diagnosis of a complex gallbladder mass. Received: 9 February 1995/Accepted: 4 March 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     

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     

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     

Vascular involvement in pancreatic adenocarcinoma:reassessment by thin-section CT

We defined computed tomographic (CT) criteria of vascular involvement by pancreatic carcinoma and used these criteria to assess vascular involvement in 56 patients with pancreatic adenocarcinoma. CT of the pancreas was performed at 1.5-mm section thickness and 5-mm section intervals during a bolus phase of intravenous contrast enhancement. The type of vascular involvement was correlated with surgical and pathologic findings. When there was fat-plane (type A) or normal pancreatic parenchyma (type B) separating the tumor from adjacent vessels, the tumor could be resected without venous resection in 21 of 22 patients (95%). When the tumor was inseparable from the vessels but the points of contact formed a convexity against the vessel (type C), CT was not reliable in predicting whether or not the tumor was fixed against the vessel. When the tumor was partially encircling (type D) the vessel, the tumor was fixed against the vessels in most cases. The resectable rate was 47%, but resection would also require venous resection. When the tumor was completely encircling (type E) or occluding (type F<+>) the vessel, all tumors were not resectable with a negative margin. Thin-section CT with bolus intravenous contrast enhancement improved the ability to assess vascular involvement in pancreatic adenocarcinoma. Received: 14 April 1995/Accepted: 12 June 1995     

Renal cell carcinoma and tumor thrombus neovascularity:MR demonstration with pathologic correlation

A case of renal granular cell carcinoma with inferior vena cava and right atrium involvement is presented. Spin-echo and single breath-hold gradient-recalled-echo magnetic resonance pulse sequences demonstrate a patchy flow signal within the cavoatrial thrombus. This pattern, in correlation with the histopathologic findings, represents tumoral neovascularity characteristic of renal carcinoma venous invasion, which was previously reported by angiography, computed tomography, and color Doppler duplex ultrasound. Received: 27 April 1995/Accepted: 24 May 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     

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     

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     

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     

Appendiceal stump abscess

Recurrence of traditionally treated appendicitis is rarely reported but known to surgeons and is probably underestimated. We described a case, illustrated by CT, of stump abscess 2 years after laparoscopic appendectomy. Sonography and CT are helpful in detecting pericecal changes, but diagnosis is confirmed by laparotomy. Received: 28 September 1994/Accepted: 22 October 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     

Retroperitoneal amyloidosis,factor IX and X deficiency,and gastrointestinal bleeding

A patient with gastrointestinal bleeding due to amyloidosis-related factor X deficiency had extensive calcified retroperitoneal amyloid deposition that was visible on plain radiographs and then localized by computed tomography. The radiologic findings were important in arriving at the proper diagnosis despite negative biopsies. Received: 14 December 1994/Accepted: 15 January 1995