Colonoscopy with computed tomography with volume reconstruction. The results and a comparison with endoscopy and surgery

PURPOSE: Virtual CT colonoscopy is a novel technique whose diagnostic accuracy and clinical yield are currently investigated. Several studies have shown its capabilities in detecting colon and rectal cancers. We report the results of a preliminary experience with the volume rendering technique and compare CT colonoscopy with endoscopy and surgery. MATERIAL AND METHODS: Our series consisted of 25 patients with colon cancer confirmed at endoscopy and/or surgery. All examinations were carried out with a spiral CT scanner Philips Tomoscan AVE1. Intestinal preparation was adequate in all patients, consisting in gas insufflated immediately before acquisition, after the injection of 100 mL iodinated contrast agent. All examination were performed in prone position using axial 5 mm slices with 5 mm table feed (pitch 1) and 2 mm reconstruction index; 120 kV and 200-250 mA were used. Images were transferred to a workstation (Easy Vision, Philips, release 4.2.1.1) for processing. We acquired multiplanar (MPR) and virtual endoscopic images with volume rendering; the selected threshold was -250 to -600 Hounsfield Units. Virtual endoscopic images could be obtained in 23 of 25 cases. The results of the radiological study were compared with endoscopic and surgical findings in 25 and 17 cases, respectively. RESULTS: Endoscopy and surgery detected 46 lesions: 29 were malignant and 17 benign. Axial CT and MPR alone detected 35 lesions (76%), 29 of them malignant and 6 benign. The 11 benign lesions missed by axial CT ranged 6-8 mm in diameter. There were no false positives. CT colonoscopy alone detected 66 lesions, but 22 of them were false positive due to residual stool in the colon (21 cases) and to residual barium in the colon (1 case). Combining CT colonoscopy and axial and MPR images enabled to correct the false positive diagnoses made by CT colonoscopy alone and to decrease the false negative ratio of axial and MPR images. Forty-one of 44 lesions (93%) were detected. Thirty-seven lesions were found in the 17 surgical patients; 34 of them were correctly identified combining CT colonoscopy and axial and MPR findings, while endoscopy detected only 31 lesions. Thus, CT had 92% sensitivity, versus 83% of fiberoptic endoscopy. CONCLUSION: In this preliminary experience volume rendering CT colonoscopy exhibited high sensitivity in detecting colon cancers, but their correct evaluation and characterization can be obtained if axial and MPR studies are combined. Further investigation and technological developments are necessary to define the yield of this new technique.     

Bronchogenic carcinoma: staging with MR compared with staging with CT and surgery

Thirty-three patients suspected of having bronchogenic carcinoma were studied prospectively using magnetic resonance (MR). In this group, 30 underwent examination with computed tomography (CT), 15 underwent thoracotomy, six had mediastinal biopsy procedures performed, and eight underwent bronchoscopy. MR studies, which included transaxial spin-echo imaging (TR, 0.5 and 2.0 sec; TE, 28 and 56 msec) of all patients and sagittal or coronal imaging of 18, were performed without knowledge of CT findings, using only plain radiographs as a guide. CT and MR studies were interpreted separately. CT and MR provided comparable information regarding the presence and size of mediastinal lymph nodes. MR better discriminated mediastinal nodes from vascular structures. However, in two of 11 patients who had multiple mediastinal lymph nodes that were normal in size at CT examination and surgery, MR suggested a confluent abnormal mass, probably because of its poorer spatial resolution. MR was superior to CT in showing enlarged hilar lymph nodes, but CT was better for demonstrating bronchial abnormalities. In three of four patients who had a proved hilar mass with distal obstructive pneumonia, MR (TR, 2.0 sec) helped distinguish between the mass and collapsed lung.     

Quantitative evaluation of muscle perfusion with CEUS and with MR

Functional imaging might increase the role of imaging in muscular diseases, since alterations of muscle morphology alone are not specific for a particular disease. Perfusion, i.e., the blood flow per tissue and time unit including capillary flow, is an important functional parameter. Pathological changes of skeletal muscle perfusion can be found in various clinical conditions, such as degenerative or inflammatory myopathies or peripheral arterial occlusive disease. This article reviews the theoretical basics of functional radiological techniques for assessing skeletal muscle perfusion and focuses on contrast-enhanced ultrasound (CEUS) and magnetic resonance imaging (MRI) techniques. Also, the applications of microvascular imaging, such as in detection of myositis and for discriminating myositis from other myopathies or evaluating peripheral arterial occlusive disease, are presented, and possible clinical indications are discussed. In conclusion, dedicated MR and CEUS methods are now available that visualize and quantify (patho-)physiologic information about microcirculation within skeletal muscles in vivo and hence establish a useful diagnostic tool for muscular diseases. Invited review article to European Radiology.     

Radiotherapy with and without temozolomide in elderly patients with glioblastoma

Background and purpose

The optimal treatment for elderly patients (age ???70?years) with glioblastoma (GBM) remains controversial. We conducted a retrospective analysis in 43 consecutive elderly patients with glioblastoma who either underwent radiotherapy (RT) or radiotherapy plus concomitant temozolomide (TMZ).

Patients and methods

A total of 43?patients (???70?years of age, median age 75.8?years) with newly diagnosed glioblastoma and a Karnofsky performance status (KPS) ???70 were treated with RT alone (median 60?Gy in 2?Gy single fractions) or RT plus TMZ at a dose of 75?mg/m² per day. The two groups were well-balanced; univariate (log-rank test) and multivariate Cox proportional hazards analysis were used to identify relevant prognostic factors.

Results

The median overall survival (mOS) of the entire patient cohort was 264?days (8.8?months) and the median progression-free survival (PFS) was 192?days (6.4?months). The factors age, sex, previous surgery, KPS, and concomitant use of TMZ had no significant influence on OS/PFS; multivariate analysis was performed to obtain adjusted hazard ratios. TMZ use resulted in a trend toward poorer overall survival when applied concomitantly (314?days compared to 192?days within the TMZ group, p?=?0.106). The subgroup analysis revealed that TMZ use resulted in significantly worse survival rates in patients with KPS70 (p?=?0.027), but for patients with KPS80 this difference was not detectable.

Conclusion

TMZ should only be used carefully in elderly patients with unfavorable KPS. In this patient cohort, radiotherapy alone is a reasonable option. Standard RT plus concomitant TMZ may be an advantageous treatment option for elderly patients with newly diagnosed glioblastoma who present with good prognostic factors.     

Intrahepatic arterioportal fistula and its treatment with detachable balloon and transcatheter embolization with coils and microspheres

BACKGROUND: Although intrahepatic arterioportal fistula (APF) due to acquired or congenital causes are infrequent, they are listed among the causes of portal hypertension. PURPOSE: The aim of this study was to present the results of intrahepatic APF treatment with embolotherapy in six cases. MATERIAL AND METHODS: Transarterial detachable balloon and coil embolization was used on six consecutive cases with traumatic intrahepatic APF from 1989 to 2003. Six-month follow-up angiography was obtained in every case. RESULTS: Successful disconnection of hepatic arterial and portal system was achieved in five cases. At least symptomatic improvement was achieved in one. CONCLUSION: Transcatheter embolization may be the first line of treatment for intrahepatic APF.     

肝癌经肝动脉栓塞术后癌灶化脓性感染的诊断和治疗

报道了７例肝癌经肝动脉栓塞术（ＴＡＥ）后合并感染、脓肿的病例。发生此一严重并发症的机率约为１．４％（７／４９５）。诊断主要依靠临床症状及ＣＴ、Ｂ超影像。在ＣＴ导向下的有效引流和对残癌组织用无水酒精冲洗则是最主要的治疗方法。其转归大概可分为：（１）脓肿痊愈、肿瘤姑息；（２）脓肿痊愈，活癌子灶仍存；（３）死于无法控制的感染。     

艾滋病合并肠管淋巴瘤X线、CT表现与病理

目的：探讨艾滋病合并肠管淋巴瘤的影像学特征表现与病理。方法：回顾性分析3例经活检及尸体解剖病理确诊的艾滋病合并肠管淋巴瘤患者的CT与病理资料。3例均经CT检查,其中2例经上消化道造影,1例钡剂灌肠造影。1例剖腹探查,切除部分增厚肠管组织病理证实,1例尸体解剖病理组织分析证实。结果：2例肠管淋巴瘤发生在空肠,1例发生在降结肠,影像与大体病理均表现为肠管壁不均匀增厚,管腔狭窄,充盈缺损,病理分型均为B细胞淋巴瘤。结论：艾滋病合并肠管B细胞淋巴瘤CT表现与病理符合度高。     

Suicide with moclobemide and perazine

A 51-year-old woman who was diagnosed as suffering from depression was found dead in her flat. The autopsy revealed no morphological changes sufficient to explain death. Toxicological analysis was performed and the drugs moclobemide (49.9 mg/l), perazine (1.27 mg/l) and some metabolites were identified in the blood. A combined drug intoxication resulting in synergistic effects to cardiovascular disorders was proposed as the cause of death. Received: 10 November 1997 / Received in revised form: 29 January 1998     

True tracers: comparing FDG with glucose and FLT with thymidine

As PET metabolic imaging becomes routine in clinical practice, there is a tendency to make imaging and data analysis fast and simple, but interpretation of these pictures by visual inspection does not do justice to the power of PET technology. Tissue data and blood data can be analyzed mathematically to provide parametric images of the PET tracer's biochemistry in terms of a transport parameter and a metabolic flux. The methods for parametric imaging with (11)C tracers of glucose and thymidine have been validated, but the short half-life of this radionuclide and the rapid metabolism of these labeled substrates to [(11)C]CO(2) have led investigators to develop (18)F analogs. While (18)F substitution at critical positions in the natural substrate can block metabolism, it has other effects on the transport and metabolism of the analog tracer. The fidelity with which analog tracers mimic tracers of the authentic substrate is critically evaluated for [(18)F]-2-fluoro-2-deoxyglucose and [(18)F]-3'-fluoro-3'-deoxythymidine.     

Three homicides with darts tainted with succinylcholine: autopsy and toxicology

In emergency departments, intoxication with the muscle relaxant succinylcholine (SUX) often leads to a potentially lethal respiratory paralysis or other deleterious side effects. However, homicide cases with SUX poisoning are very rare because the toxic or lethal concentration ranges of SUX have not yet been determined. We described three uncommon homicide cases due to acute poisoning by darts contaminated with SUX. All the victims died quickly (less than 30 min) after being shot by an especially designed dart gun. Succinylmonocholine (SMC), a metabolite of SUX, was used as a marker to detect the latter. HPLC-MS/MS analysis demonstrated the presence of SUX in the droplet residues of the darts and SMC in the blood and urine in all cases. SMC concentrations of 0.45, 14.0, and 17.9 ng/ml were detected in the victims’ blood and 259.0 ng/ml in the urine from the third case. The main pathological changes consisted of hemorrhage of the injured soft tissues, visceral congestion, severe pulmonary edema, and multifocal petechial hemorrhage of the heart and lungs. Taken together, the findings supported a diagnosis of fatal SUX poisoning. Futhermore, our study provided a reference for the lethal concentrations of SUX poisoning.     

Fitness and its association with fatigue in persons with multiple sclerosis

This study compared physical fitness components between fatigued and non‐fatigued persons with MS and examined those components as correlates of fatigue. Sixty‐two ambulatory persons with MS completed the Modified Fatigue Impact Scale (MFIS) and underwent assessments of cardiorespiratory capacity, lower extremity muscle strength (i.e., peak torque and asymmetry), body composition, and static balance over two different sessions 7 days apart. Participants were allocated into fatigue groups based on MFIS scores (non‐fatigued group (i.e., MFIS ≤38), n = 26; and fatigued group (MFIS >38), n = 36). The fatigued group had significantly (P < 0.05) lower cardiorespiratory capacity (VO_2peak) and muscular strength (i.e., knee flexion peak torque) than the non‐fatigued group. VO_2peak and knee extension peak torque were the two physical fitness components significantly correlated with fatigue scores in the fatigued group (P < 0.05), and follow‐up stepwise linear regression revealed that VO_2peak was a significant predictor of fatigue scores (R² = 0.13). Discriminant function analysis further identified VO_2peak as a significant (P < 0.05) correlate of fatigue status. This model explained 21% of variance in group status (i.e., fatigued vs non‐fatigued) and correctly classified approximately 76% of cases into fatigue status groups. The improvement of cardiorespiratory capacity should be considered in rehabilitation programs for persons with MS, especially those presenting with elevated fatigue.     

常染色体显性遗传性脑动脉病伴皮层下梗死和白质脑病患者的MR定量指标及其与临床的关系

目的 对常染色体显性遗传性脑动脉病伴皮层下梗死和白质脑病(CADASIL)患者的白质高信号和脑体积进行定量分析,并探讨其与临床的关系.方法 15例通过病理检查确诊为CADASIL的患者进行常规MR扫描,统计脑半卵圆中心、内囊后肢、外囊、胼胝体和颞极白质受病变累及情况.利用计算机后处理软件计算标准化颅脑体积和白质高信号占颅脑体积的百分比,并与年龄、美国国立卫生研究院卒中量表(NIHSS)和简易精神状态检查(MMSE)量表评分进行Spearman相关性分析.结果 CADASIL患者的白质病变累及部位依次为:半卵圆中心(13/15)、颞极白质(10/15)、外囊(8/15)、内囊后肢(5/15)、胼胝体(4/15).白质高信号占颅脑体积的百分比为(5.7±1.4)%,标准化颅脑体积为(1602±58)×103mm3.年龄与标准化颅脑体积呈负相关(r=-0.555,P＜0.05);白质高信号百分比与NIHSS、MMSE量表评分分别呈正、负相关(r=0.522,P＜0.05;r=-0.679,P＜0.01);标准化颅脑体积与NIHSS评分呈负相关(r=-0.624,P＜0.05).结论 CADASIL患者的白质高信号和脑体积可以定量测量,这两种影像学指标可以在一定程度上反映患者的病情.白质高信号的发展可能预示患者认知功能的下降.     

Tracheobronchial anomalies and stenoses: detection with low-dose multidetector CT with virtual tracheobronchoscopy--comparison with flexible tracheobronchoscopy

PURPOSE: To prospectively assess the sensitivity and specificity of low-dose multidetector computed tomography (CT) with virtual tracheobronchoscopy (VT) for evaluation of suspected airway stenoses and/or abnormalities by using flexible tracheobronchoscopy (FT) as the reference standard. MATERIALS AND METHODS: The study was approved by the local ethics committee; parental consent was obtained. Forty-five patients with clinically and/or radiographically suspected tracheobronchial stenosis and/or anomaly underwent FT and contrast material-enhanced single-phase multidetector CT with VT. CT was performed with an age- and weight-adjusted low-dose protocol: 120 or 80 kV; 120 or 60 mA; collimation, 1.5 or 0.75 mm; gantry rotation, 0.5 second. Mean effective dose was calculated for all examinations. Postprocessing was performed with surface rendering of VT images and multiplanar reformations. CT images were analyzed in consensus by two radiologists who were blinded to FT results. Statistical analysis was performed with 2 x 2 contingency tables; 95% confidence intervals (CIs) were calculated with the Blyth-Still-Casella procedure. RESULTS: Mean patient age was 4.4 years (range, 2 months to 16 years; 53% male patients). Tracheobronchial narrowing and/or abnormality were depicted at FT in 38 of 45 patients. In 33 of 38 patients, multidetector CT with VT depicted a tracheobronchial narrowing and/or anomaly. In 10 of 38 patients, tracheobronchial stenosis was induced by vascular anomalies. Five patients with normal findings at multidetector CT with VT had tracheobronchomalacia with inspiratory airway stenosis at FT. Sensitivity and specificity of CT with VT were 86.8% (95% CI: 73.3%, 94.7%) and 85.7% (95% CI: 44.6%, 99.3%), respectively. Positive and negative predictive values were 97.1% (95% CI: 84.9%, 99.9%) and 54.5% (95% CI: 25.0%, 80.0%), respectively. Overall accuracy was 86.7% (95% CI: 74.3%, 94.0%). Mean effective dose was 1.1 mSv (range, 0.5-1.8 mSv). CONCLUSION: Multidetector CT with VT with a low-dose protocol had high sensitivity and specificity for depiction of tracheobronchial narrowings and/or anomalies. However, tracheal narrowing due to tracheobronchomalacia was difficult to diagnose at single-phase multidetector CT with VT.     

Scintigraphic and MRI studies in a patient with granulocytic sarcoma accompanied with CML and myelofibrosis

Indium bone marrow, bone, and gallium scans and magnetic resonance imaging (MRI) were performed in a patient with granulocytic sarcoma accompanied with chronic myelocytic leukemia (CML) and myelofibrosis. The significance and implications of the findings of these studies are discussed.