Calcification and fibrosis in mesenteric carcinoid tumor: CT findings and pathologic correlation.

OBJECTIVE: The purposes of this study were to determine the frequency and characteristics of calcification and fibrosis in mesenteric carcinoid tumor as seen on CT scans and to evaluate their possible role in diagnosis. MATERIALS AND METHODS: The CT findings in 29 cases of proved mesenteric carcinoid tumor were analyzed retrospectively. Tumors were assessed for size, margin, density, radiating strands, calcification, and associated thickening of the small-bowel wall. Matching histologic sections were available for 21 of the cases. They were reviewed independently for histologic pattern, degree of fibrosis, degree of infiltration along neurovascular bundles, necrosis, lymph node architecture, and calcification or ossification within the mass. CT and pathologic findings were then assessed for possible relationships. RESULTS: Calcification was detected by CT in 70% (21 of 30) of mesenteric masses. Three patterns of calcification were noted: small, stippled calcification (n = 11); coarse, dense calcification (n = 7); and diffuse calcification (n = 3). All calcification was localized within areas of poorly cellular mature fibrous tissue. The degree of radiating strands detected by CT tended to increase with the degree of fibrosis seen histopathologically (p = .06). CONCLUSION: Calcification in mesenteric carcinoid tumors was observed by CT in most cases of this series. The triad of a calcified mesenteric mass, radiating strands, and adjacent bowel-wall thickening should be considered highly suggestive of carcinoid tumor.

Inflammatory conditions of the stomach and duodenum.

Upper gastrointestinal inflammatory processes are exceedingly common and have a wide spectrum of causes and manifestations. The broad category of acid-peptic disease incorporates the most common and important conditions. Concepts of pathophysiology of gastritis and duodenitis and their relationship to ulcers and neoplasm continue to evolve. The role of infection, especially H. pylori, remains under intense investigation. The spectrum of gastroduodenal inflammation in the immunocompromised host continues to expand and becomes increasingly important. A variety of granulomatous processes, both infectious and idiopathic, involve the upper gastrointestinal tract in overlapping patterns. Although investigation of ulcers and syphilis occupied the attention of the earliest gastrointestinal radiologists, related problems continue to challenge today's radiologic imagers, clinicians, and investigators.

Gastric syphilis: radiologic findings.

Syphilis, a venereal infection caused by the spirochetal bacterium Treponema pallidum, has long been considered a primary public health concern in the United States. With the onset of the antibiotic era, the prevalence of the disease dramatically plummeted, as did interest in its radiologic manifestations. Rolfs and Nakashima [1] have shown that the prevalence of primary and secondary syphilis increased 34% from 1981 to 1989, to its highest level since 1949. Given this dramatic increase, classic manifestations of syphilis may warrant renewed attention. In its secondary and tertiary stages, syphilis can cause a wide range of gastric lesions that can mimic many other entities, from gastritis or benign ulcer disease to gastric carcinoma. Indeed, the acute gastritis of early secondary syphilis produces the earliest radiologically detectable signs of the disease. Cases of gastric syphilis submitted to the Armed Forces Institute of Pathology and cases drawn from the University of Cincinnati teaching file are used to illustrate the varied findings in this disease.

Peutz-Jeghers syndrome.

The Peutz-Jeghers polyp is an unusual type of hamartomatous polyp; its characteristic feature is a smooth muscle core arising from the muscularis mucosae and extending into the polyp. Peutz-Jeghers polyps vary in size and shape; are found in the stomach, small bowel, and colon; and are usually multiple. Peutz-Jeghers syndrome is an inherited condition that often remains undiagnosed until after the polyps are identified, despite mucocutaneous pigmented lesions on the lips and mouth of children or young adults. In the past, standard therapy involved removal of the polyps that produced intussusception, but now endoscopic removal of all polyps is recommended. The polyps are not premalignant, but a definite association exists between Peutz-Jeghers syndrome and gastrointestinal carcinoma. Evidence shows that the syndrome is associated with an increased risk of extraintestinal malignancy, especially carcinomas of the pancreas, breast, and reproductive organs.

Esophageal inflammation and stricture: complication of chronic granulomatous disease of childhood.

Esophagitis in children with immunodeficiency is most commonly due to opportunistic infection. The authors describe three patients with chronic granulomatous disease (CGD) of childhood who developed esophageal strictures that were believed to be complications of the primary disease. At radiologic examination, all three patients initially had a focal narrowing of the upper thoracic esophagus. Endoscopy showed no signs of opportunistic infection or Barrett esophagus. Biopsy of the strictures in two patients revealed findings consistent with CGD. In two of the three patients, inflammation extended to involve the middle and distal esophagus. Long-term response to balloon dilation was poor in the first two patients. The third patient was lost to follow-up after a partial clinical and radiographic response to dilation.

Benign cecal villous adenoma presenting as a bladder mass.

Involvement of contiguous organs by a neoplasm is ordinarily evidence of aggressive malignant behavior. A patient presented with a bladder mass found to be arising in the cecum and diagnosed as a benign villous adenoma. Growth down a diseased appendix is proposed to explain the apparent extension of a relatively nonaggressive lesion into an adjacent organ.

Radiologic evaluation of mass casualty victims: lessons from the Gander, Newfoundland, accident.

This study describes the use of radiologic methods in the identification of 256 bodies after the crash of an airliner in Gander, Newfoundland. Two hundred thirty-one (90%) of the victims were identified positively with dental and/or fingerprint comparisons. Radiologic data confirmed identification in 29 of these victims. Seventeen bodies without dental or fingerprint identification were presumptively identified with a variety of data, which included radiologic characteristics in four cases. Eight bodies were identified with an exclusion matrix. Radiologic input was critical in two of these. The procedures described provide practical information for radiologists in a mass casualty disaster investigation.

Hepatoblastoma: radiologic-pathologic correlation in 50 cases.

Fifty cases of hepatoblastoma were reviewed. Virtually all patients were infants or young children with hepatomegaly or a mass. Calcification seen on 11 of 20 radiographs was often in a pattern of small chunks, and eight of these correlated with osteoid formation in histologically mixed hepatoblastomas. Angiography generally showed tumor vascularity, sometimes with a spoke-wheel pattern. Suggestion of tumor nodularity or lobulation on sonography or computed tomography (CT) correlated with the gross appearance. The tumor was usually echogenic and occasionally had small hypoechoic or anechoic areas representing necrosis or hemorrhage. On CT it was usually hypodense, with minimal if any enhancement. The calcification pattern and demonstration of tumor lobulation with septation may help differentiate hepatoblastoma from other liver neoplasms in infants and children under 5 years of age.

Natural history of the obstructed rabbit appendix: observations with radiography, sonography, and CT.

Chronic (1-3 months' duration) appendiceal obstruction was induced in 11 rabbits to assess the pathologic consequences and to study the associated radiologic, sonographic, and CT findings. Three pathologic/radiologic groups resulted with approximately equal frequency. In group A, the abscess was characterized by inflammatory cells in the lumen and wall of the appendix without mucin production. Calcification was shown radiographically, and sonography showed an anechoic or complex pattern. Group B, the "mixed response," was characterized by an intact hyperplastic mucosa, mucin secretion, and inflammatory debris in the lumen. Occasional calcification was present radiographically, and sonography showed a complex or hypoechoic pattern. In group C, true mucoceles had an intact hyperplastic mucosa, a mucin-filled lumen, and minimal inflammation. These were anechoic on sonography except for mobile foci of inflammatory debris. Chronic obstruction of the appendix results in a spectrum of pathologic responses with varying degrees of either inflammation and mucosal destruction or mucosal hyperplasia and mucin secretion. An abscess results when infection overwhelms the host's inflammatory responses. If the bacteria are destroyed by these defenses, a mucocele forms. An intermediate situation occurs when there is a mixed response with chronic inflammatory changes and an intact mucosa. This finding supports the existence of chronic appendicitis in humans.

Radiologic-pathologic correlation of inflammatory bowel disease.

The various inflammatory bowel diseases produce a wide spectrum of mucosal and bowel wall changes. No one radiolographic sign, or even combination of signs, is completely pathognomonic. A consideration of the pathophysiology responsible for the radiographic findings is helpful as an aid to understanding and to limit reliance upon matching of nonspecific signs with specific diagnosis. Patterns of mucosal ulceration, polyp formation, and strictures in the common superficial and transmural inflammatory diseases are emphasized.

Colonic varices as a complication of colonic surgery.

Colonic varices are a rare cause of lower gastrointestinal bleeding, with approximately 40 cases reported in the literature. Portal hypertension is by far the most common cause of colonic varices, with local mesenteric vein obstruction constituting a very rare cause. We present a case of colonic varices not associated with portal hypertension but secondary to prior sigmoid resection and inferior mesenteric vein occlusion.

Nonparasitic splenic cysts: a report of 52 cases with radiologic-pathologic correlation.

We reviewed 52 cases of splenic cysts on file at the Armed Forces Institute of Pathology. There were 24 true (epidermoid) and 28 false (posttraumatic) cysts. The history and clinical presentations, including pain, splenomegaly, or mass, were similar in both groups. Radiologic manifestations included splenomegaly and the occasional identification of a distinct mass by conventional radiography even in the absence of calcification. The lesions produced a photopenic defect on nuclear scintigraphy and were avascular on angiography. Sonography and CT demonstrated a cystic lesion with occasional septations, wall trabeculation, and low-level internal echoes. Three false cysts demonstrated solid and cystic components on sonography and CT, corresponding to organizing hematoma within the cyst. Splenomegaly or a splenic mass of a predominantly cystic nature with no clinical evidence of echinococcus suggests the diagnosis of splenic cyst. Reliable radiologic distinction between true or false splenic cyst does not seem possible. Complex mass may represent a "transition" between hematoma and false splenic cyst.

Mesenchymal hamartoma of the liver: radiologic-pathologic correlation.

Mesenchymal hamartoma of the liver (MHL) is an uncommon cystic mass of infancy that is a developmental anomaly rather than a neoplasm. Fourteen cases of MHL were retrospectively reviewed. Grossly, MHL is a solitary mass with cystic spaces of variable size. Patients are seen initially with painless progressive abdominal enlargement. On plain films, MHL appears as a large, noncalcified mass in the right upper quadrant. Scintigraphy is helpful in confirming its hepatic origin. Ultrasonography and computed tomography demonstrate a large multiloculated mass with considerable variation in the size of septa and cystic spaces. Angiographically, MHL is avascular or hypovascular. Recognition of these radiographic findings allows a correct diagnosis to be made in many cases. With resection, the prognosis is excellent.

Fibrolamellar hepatocellular carcinoma.

Fibrolamellar hepatocellular carcinoma (HCC) has recently been separated as a distinct clinicopathologic entity with a better prognosis than the usual HCC associated with cirrhosis. The mean age of our 17 patients was 20 years. Alpha fetoprotein levels were normal, and none of the risk factors for HCC was present. Distinctive histologic features included deeply eosinophilic polygonal hepatocytes and abundant fibrous stroma. Calcification was present on plain films of five of 13 cases. Sonography usually showed a homogeneous, echogenic mass. Computed tomography (CT) demonstrated small, central calcification in four of ten cases. A central echodensity, hypodense on CT scans, was seen in two cases and corresponded to a central scar. By combining clinical and laboratory data with radiologic tests, a correct diagnosis can often be suggested before biopsy is performed.