The use of indocyanine green for lateral lymph node dissection in rectal cancer-preliminary data from an emerging procedure: a systematic review of the literature.

INTRODUCTION: Lateral lymph node dissection (LLND) for rectal cancer is still not a widely established technique owing to the existing controversy between Eastern and Western countries and the lack of well-designed studies. The risk of complications and the paucity of long-term oncological results are significant drawbacks for further applying this technique. The use of indocyanine green (ICG) near-infrared (NIR) fluorescence for LLND appears as a promising technique for enhancing postoperative and oncological outcomes. This review aims to evaluate the emerging role of ICG during LLND and present the benefits of its application. MATERIALS AND METHODS: Systematic electronic research was conducted in PubMed and Google Scholar using a combination of medical subject headings (MeSH). Studies presenting the use of ICG during LLND, especially in terms of harvested lymph nodes, were included and reviewed. Studies comparing LLND with ICG (LLND + ICG) or without ICG (LLND-alone) were further analyzed for the number of lymph nodes and postoperative outcomes. RESULTS: In total, 13 studies were found eligible and analyzed for different parameters. LLND + ICG is associated with significantly increased number of harvested lateral lymph nodes (p < 0.05), minor blood loss, decreased operative time, and probably decreased urinary retention postoperatively compared with LLND-alone. CONCLUSIONS: The use of ICG fluorescence during LLND is a safe and feasible technique for balancing postoperative outcomes and the number of harvested lymph nodes. Well-designed studies with long-term results are required to elucidate the oncological benefits and establish this promising technique.

Mixed tumor of the vagina: sonographic and magnetic resonance imaging findings.

Mixed tumor of the vagina is a rare benign neoplasm that is composed of epithelial and mesenchymal cells. The majority of tumors are asymptomatic and simple tumor excision is curative. We report a case with pathological confirmation that was seen in a 42-year-old woman. On ultrasound examination the lesion appeared as an ovoid hypoechoic mass, 2.0 x 2.7 cm in size, arising from the lower third of the vagina. The lesion was well defined, solid and showed diffuse hypervascularity on color flow images. Magnetic resonance imaging of the pelvis showed a well-circumscribed ovoid mass (2.0 x 2.5 cm) on the left lateral vaginal wall. On T2-weighted images the mass appeared as a homogeneous hyperintense lesion, while on T1-weighted images it was difficult to discern the mass from the vaginal wall. After intravenous administration of gadolinium the mass showed progressively increasing homogeneous enhancement. The lesion was excised without complication and there was no evidence of recurrence at the 10-month follow-up.

Diagnostic efficacy and safety of MRI of the liver with superparamagnetic iron oxide particles (SH U 555 A).

The purpose of this study was to evaluate the diagnostic efficacy and safety of an intravenous injection of magnetic resonance imaging (MRI) contrast agent, SH U 555 A, in adult patients with known focal liver lesions. Pre- and post-contrast image sets were obtained in 19 patients after injection of SH U 555 A as a part of a phase III clinical trial (patients <60 kg body weight received 0.9 mL and patients >60 kg received 1.4 mL). Three blinded readers evaluated the post-contrast images. Blood pressure and heart rate were recorded and laboratory tests were performed at baseline, during and immediately after the procedure, and four and 24 hours after the MR procedure. On post-contrast MRI, there was statistically significant improvement in diagnostic confidence, visualization, delineation, and contrast between the lesions and the healthy parenchyma in comparison to precontrast. Twenty more lesions were detected on post-contrast images. The management in six patients (31.7%) was changed after post-contrast imaging. Changes in vital signs and laboratory tests were minimal and did not affect the patients' clinical condition. Only a moderate allergic reaction (diffuse erythematous rash) was recorded. SH U 555 A is an effective and safe contrast agent for MRI of the liver.

Imaging and localization of pancreatic insulinomas.

For pancreatic insulinomas, the treatment of choice is surgical excision, which when successful is curative. Intraoperative palpation combined with ultrasonography theoretically depict almost all tumors, however the accuracy of palpation is improved by the preoperative localization. All recent advances in imaging have improved the likelihood for curative surgical resection. Our purpose is to demonstrate the characteristics of all modalities, which may be used in the preoperative localization algorithm.

MR imaging of tuberculous vertebral osteomyelitis: pictorial review.

Vertebral osteomyelitis is one of the most common manifestations of tuberculosis. Magnetic resonance imaging is considered the main imaging modality for the diagnosis, the demonstration of the extent of the disease, and follow-up studies. Vertebral destruction involving two consecutive levels with sparing of the intervertebral disc, disc herniation into the vertebral body, epidural involvement, and paraspinal abscess are the most common MRI findings suggestive of tuberculous vertebral osteomyelitis.

CT appearance of solitary and multiple cystic and cavitary lung lesions.

Cystic and cavitary lung lesions constitute a spectrum of pulmonary diseases diagnosed in both children and adults. We reviewed the CT findings of the most common cystic and cavitary lung lesions and we defined useful morphological criteria that will help radiologists to distinguish benign from malignant cavitary lesions. However, in many cases the considerable overlap in morphological features of benign and malignant cavities renders transthoracic needle biopsy necessary to establish the correct diagnosis.

Tailgut cysts: a rare cause of pelvic outlet obstruction.

Tailgut cysts are unusual cystic tumors of the retrorectal space. We describe the findings of three cases. Constipation, intrapelvic fullness and low abdominal pain were the most prominent clinical manifestations. One patient developed an abscess. Ultrasound, computed tomography and MR imaging demonstrated the presacral lesions. Transabdominal excision of the tumors in two patients resulted in good outcome whereas in the patient with the abscess there was recurrence with a fistula formation.

Focal nodular hyperplasia: imaging findings.

Focal nodular hyperplasia is an uncommon benign hepatic tumor that continues to pose diagnostic dilemmas. Imaging techniques are of great value in diagnosis of this tumor. In this article we present the US, CT, MR imaging, scintigraphy, and angiography findings. The demonstration of a central vascular scar is very helpful. Although the radiologic features may be diagnostic, many atypical cases must be differentiated from other benign or malignant hepatic tumors. In these cases excisional biopsy and histopathologic examination are necessary to determine a definite diagnosis.

Comparison of CT, MRI and CT during arterial portography in the detection of malignant hepatic lesions.

BACKGROUND/AIMS: A prospective study was performed to compare the sensitivities of computed tomography, magnetic resonance imaging and CTAP (CT during arterial portography) in the detection of focal malignant hepatic lesions. METHODOLOGY: Twenty-eight (28) patients with primary and secondary hepatic malignant tumors were evaluated. All of these patients underwent hepatic resection and a lesion-to-lesion imaging-pathological analysis was performed. RESULTS: The overall sensitivities were 53% for CT, 66% for MRI sequences and 88% for CTAP. For lesions smaller than 1 cm the sensitivities were 6% for CT, 17% for MRI and 72% for CTAP. The combination of CTAP and MRI yielded an overall detection rate of 93%. The difference between the sensitivity of CTAP and that of the other two imaging techniques was statistically significant (P < 0.04) according to the McNemar test. CTAP demonstrated four false-positive lesions, two of which were correctly characterized by MRI and one by CT. In 6 patients (21.4%) the surgical plan was modified after CTAP. CONCLUSIONS: We conclude that, CTAP has the highest sensitivity and should be part of the preoperative examination. In some instances, the addition of MR imaging must be considered a helpful adjuvant. Both techniques should be considered complementary in the preoperative diagnostic algorithm.

Splenic abscess. An old disease with new interest.

BACKGROUND/AIMS: To study the demographics, signs and symptoms, causes, risk factors, imaging findings, bacteriologic profile, treatment and outcome of patients with splenic abscess. METHOD: The medical records of 17 patients with splenic abscess at two tertiary-care hospitals between 1989 and 1997 were retrospectively reviewed. The demographic data, physical and radiological findings, treatment, bacteriology reports and outcome of treatment were reviewed. RESULTS: The mean age of patients was 43 years (range 7-79 years). Fever and abdominal pain were the most prominent signs. Seven patients were immunocompromised, three had abscessed hydatic cysts, two were drug users and three suffered from splenic trauma, infarction, and endocarditis, respectively. No predisposing factor was identified in 2 patients. In all cases, CT demonstrated the splenic lesion(s). Staphylococcus species and Bacteriodes were the most common microbes, identified in the blood and abscess cultures. Thirteen patients underwent splenectomy, two medical therapy and two no therapy with respective survival rates of 92, 100 and 0%. CONCLUSION: Splenic abscess is a rare surgical entity encountered mostly in immunocompromised patients. CT scan is the gold standard for the definite diagnosis. Splenectomy is the treatment of choice, while medical therapy should be reserved for unusual pathogens provided that an effective antimicrobial agent is available.

Graft-dependent recurrence of hyperparathyroidism: imaging with frequency amplitude and encoded Doppler sonography.

A 48-year-old woman underwent total parathyroidectomy with autotransplantation into the left forearm due to secondary hyperparathyroidism. Recurrence of hyperparathyroidism was observed 5 years later. B-mode high-resolution ultrasonography of the left forearm demonstrated an ill-defined hypoechoic lesion. Frequency- and amplitude-encoded Doppler sonography revealed marked hypervascularity, which was diagnostic for graft hyperplasia in association with the history of the patient. These findings were confirmed by scintigraphy and histological examination of the excised graft.

Preoperative localization of pancreatic insulinoma by selective intraarterial calcium injection and hepatic venous sampling.

Preoperative localization of insulinomas is desirable by most surgeons. Imaging with ultrasonography, computed tomography, magnetic resonance imaging, nuclear medicine and angiography may fail to demonstrate these small tumors in up to 10%, while a smaller percentage may be missed even after careful surgical exploration and intraoperative ultrasonography. Selective intraarterial injection of calcium with hepatic venous sampling has been reported to be a very accurate technique for preoperative localization of insulinomas. We report such a case where the clinical symptoms were highly suggestive but imaging algorithm failed to reveal any lesion and we review the literature.

Liver invasion by recurrent granulosa cell tumour of the ovary: imaging findings.

Granulosa cell tumour of the ovary is a rare neoplasm of low malignant potential, late recurrences, local spread and high survival rates. We report the MR imaging appearance of invasion of the liver parenchyma by recurrent granulosa cell tumour of the ovary 15 years after initial diagnosis.

Hepatic epithelioid hemangioendothelioma: MR imaging findings.

We describe the sonographic, computed tomography and magnetic resonance imaging findings of two patients with histologically proven hepatic hemangioendothelioma. Both patients presented with multiple liver nodules. Color Doppler ultrasound demonstrated moderate vascularity at the periphery of the nodules, as well as central neovascularity. On enchanced computed tomography images, the lesions showed peripheral enhancement only. On magnetic resonance images, tumor signal was low on T1-weighted and moderately high on T2-weighted images. The distinction between normal liver and tumor was difficult on all sequences. Administration of superparamagnetic iron oxide particles delineated well the tumor by suppressing the signal of the normal liver and better depicted areas of remaining healthy parenchyma.

Cystic pancreatic neoplasms: computed tomography and magnetic resonance imaging findings.

Cystic pancreatic neoplasms include serous cystadenomas (SCA), mucin-producing cystic tumors, cystic islet-cell tumors, and cystic solid and papillary epithelial neoplasms. Imaging techniques are of great value in the demonstration and differential diagnosis of these tumors. In this article we present the computed tomography (CT) and magnetic resonance imaging (MRI) findings of the aforementioned cystic neoplasms. Although the radiological features are in many cases informative, a significant overlap does exist; fine-needle aspiration biopsy and cytology or excisional biopsy and histological examination are necessary to determine a definitive diagnosis.

New frontiers in liver surgery. Two-stage liver surgery for the management of advanced metastatic liver disease.

BACKGROUND/AIMS: To assess the value and the safety of main portal branch transection combined with transarterial targeting locoregional neo and adjuvant immunochemotherapy, 32 patients suffering from advanced metastatic liver disease underwent two-stage hepatectomy. METHODOLOGY: From September 1995 to June 1999, 32 consecutive patients underwent two-stage surgery for advanced metastatic liver disease. Firstly we performed ligation and transection of the main portal branch corresponding to the liver lobe occupied by the tumor and introduction of an arterial jet port catheter towards the hepatic artery. After a locoregional transarterial targeting immunochemotherapy regimen the patient had a 2nd laparotomy for hemihepatectomy. Following surgery, locoregional targeting immunochemotherapy was carried out in all patients via the arterial port of the gastroduodenal artery as an adjuvant treatment. RESULTS: There were no operative deaths. Mean survival was 27 +/- 8 months. CONCLUSIONS: Two-stage liver surgery is an appealing alternative that increases the resectability rate and overall survival in patients with advanced metastatic liver disease and is associated with excellent quality of post-operative life.