The value of CT scanning in the management of patients with gynecologic malignancies.

The management of gynecologic malignancies is exceedingly complex, requiring thoughtful coordination of surgery, radiation therapy and chemotherapy. Despite the fact that the natural history and clinical course of these cancers are generally well understood, the scarring caused by surgery and/or radiation, and the marked limitations of pelvic examination make clinical staging and evaluation of limited value and known inaccuracy in following women with ovarian, cervical, uterine, vulvar and vaginal cancers. Understandably, the development of computerized axial tomography (CT), and its ability to visualize the abdomen and pelvis, lead to rapid acceptance of CT scans in defining extent of cancer and following patient response to various therapeutic interventions (Chen et al. 1980; Feigen et al. 1987; Photopoulos et al. 1977). Authors have compared the accuracy of CT findings with physical examination, surgical findings, lymphography, conventional radiography or ultrasound (Clarke-Pearson et al. 1986; Vercamb et al. 1987; Amendola 1981; Kerr-Wilson et al. 1984). However, little has been written on the effect of CT scanning on patient management. If we define and accept the accuracy of CT scanning in detecting pelvic and abdominal disease, can we show a benefit in patient management? Or, does CT scanning provide us with expensive information, or misinformation, which fails to translate into better patient care. Do complex imaging modalities compliment thorough examination and experienced clinical judgement, or only duplicate findings and provide extraneous information? To answer these questions, eighty-one months experience in using CT scanning in managing patients with gynecologic malignancies was reviewed.

Phantom gallbladder. A variant of the rim sign.

Nonvisualization of the gallbladder is the primary finding in cholescintigraphy for acute cholecystitis. Recent investigators have described a useful secondary finding of increased pericholecystic hepatic activity (PCHA). A case of acute cholecystitis is presented in which the PCHA was round in configuration and appeared in the first 5 minutes of the study. This may be a source of diagnostic error if it is interpreted as visualization of the normal gallbladder. Appearance of the PCHA has not been previously described before 30 minutes. This case of early appearance raises the possibility that hyperemia may play a role as the cause in some forms of the PCHA. The phantom gallbladder was correctly identified as PCHA by observing the peak of activity of the PCHA occurring before the appearance of intrahepatic biliary radicals.

Asymptomatic perforation of the small intestine by a copper-7 intrauterine device.

PIP: The case of a 32-year old woman (gravida 3 para 2) in whom a Copper-7 IUD perforated the uterus, lodging both within the myometrium and the lumen of the small intestine is described. The patient presented in the emergency room 18 months after IUD insertion with heavy vaginal bleeding and passage of tissue. A diagnosis of spontaneous abortion was made. In this case, the small bowel had to be resected and side-to-side anastomosis was performed. This patient was asymptomatic until 3 weeks prior to admission. Other cases demonstrate acute symptoms of peritonitis and intestinal obstruction or more chronic complaints of vague abdominal pain and diarrhea. An IUD string that is not visible at the external os of the cervix generally reflects upward retraction of the string or unnoted spontaneous expulsion of the IUD. However, on occasion it can be associated with uterine or even intestinal perforation, as occurred in this case. Pain on insertion, also noted in this case, can serve as a warning sign of perforation. In this patient, the device was inserted 5 weeks after delivery, lending support to the recommendation that puerperal insertion be avoided. It is important to know the exact location of an ectopic IUD to prevent dangerous attempts at removal through the vagina. Laparoscopy and ultrasound are generally helpful in localizing the IUD and preparing the patient for laparotomy and possible bowel resection.^ieng

Neurosonographic recognition of subependymal cysts in high-risk neonates.

Serial neurosonography was performed in 210 high-risk, preterm neonates. Eleven (5.8%) demonstrated small cystic formations in the subependymal lining of the lateral ventricles. These subependymal cysts were unilateral and were detected at the exact site of a previous subependymal hemorrhage in two cases. These 11 infants were not significantly different in maturity, size, or clinical parameters from our main high-risk newborn population. Ten survivors had marked motor retardation at follow-up ages of 9-13 months, and one died from neonatal sepsis.

Distribution of placental grade in high-risk gravidas.

One hundred twenty-eight high-risk gravidas and 62 normal gravidas who had undergone placental sonography were compared retrospectively according to placental grade, risk category, and stage of pregnancy at the time of the examination. Pregnancies ranged from 28 weeks of gestation to term. For analysis, the group of high-risk patients was subdivided into four categories representing specific disease states: chronic hypertension and/or preeclampsia, intrauterine growth retardation, maternal diabetes, and Rh sensitization. To eliminate gestational age bias, both the normal group and the high-risk subgroups were further subdivided into preterm and term pregnancies. Placental grade distribution was similar between the high-risk group overall and the normal group, but specific disease entities were associated with widely varying distributions of placental grade. In particular, hypertension and intrauterine growth retardation showed a strong correlation with accelerated placental maturation, whereas diabetes and Rh sensitization were associated with delayed maturation of the placenta. These differences were more pronounced in the preterm population.

Second-trimester placental changes associated with elevated maternal serum alpha-fetoprotein.

Measuring maternal serum alpha-fetoprotein (AFP) levels in the second trimester is an effective screening test for identifying pregnancies at increased risk for neural tube defects. In the absence of a neural tube defect there are many nonpathologic and pathologic causes for elevated AFP including underestimated gestational age, twin gestation, impending fetal death, and rare fetal malformations. In this series, intraplacental sonolucent spaces were detected in a significant percentage of second trimester pregnancies with elevated serum AFP in the absence of any other cause for the elevation. It is postulated that these cystic spaces are a conduit for the transfer of fetal blood into the maternal circulation, thus accounting for the nonpathologic AFP elevation in the maternal serum.

Computed tomography of absent left pericardium.

Pericardial defects rarely cause clinical symptoms and thus are not often recognized. A case is reported in which the CT appearance of complete absence of the left pericardium reflects the abnormal relationship of the heart, pericardium, lung, and great vessels.

Interhemispheric cyst of neuroepithelial origin in association with partial agenesis of the corpus callosum. Case report and review of the literature.

The authors report an adult patient with a symptomatic interhemispheric cyst demonstrated by computerized tomography (CT), angiography, and at surgery. Choroid plexus epithelium was identified arising from the inner aspect of the cyst wall. Partial agenesis of the corpus callosum is postulated on the basis of the CT findings and the presence of choroid plexus in the interhemispheric cyst.

Ultrasonic assessment of the fetal spine before 20 weeks' gestation.

The ultrasonic appearance of the normal and abnormal fetal spine before 20 weeks' gestation was reviewed in 121 pregnances. A model was constructed to establish the mechanism of production in the various configurations seen. The relative roles of ultrasonography, alpha fetoprotein assay, and fetoscopy in the diagnosis of spina bifida are discussed.