Does high body mass index obviate the need for oral contrast in emergency department patients?

INTRODUCTION: High body mass index (BMI) values generally correlate with a large proportion of intra-peritoneal adipose tissue. Because intra-peritoneal infectious and inflammatory conditions manifest with abnormalities of the adipose tissue adjacent to the inflamed organ, it is presumed that with a larger percentage of adipose surrounding a given organ, visualization of the inflammatory changes would be more readily apparent. Do higher BMI values sufficiently enhance the ability of a radiologist to read a computed tomography (CT) of the abdomen and pelvis, so that the need for oral contrast to be given is precluded? METHODS: FORTY SIX PATIENTS WERE INCLUDED IN THE STUDY: 27 females, and 19 males. They underwent abdominal/pelvic CTs without oral or intravenous contrast in the emergency department. Two board certified radiologists reviewed their CTs, and assessed them for radiographic evidence of intra-abdominal pathology. The patients were then placed into one of four groups based on their body mass index. Kappa analysis was performed on the CT reads for each group to determine whether there was significant inter-rater agreement regarding contrast use for the patient in question. RESULTS: There was increasingly significant agreement between radiologists, regarding contrast use, as the study subject's BMI increased. In addition, there was an advancing tendency of the radiologists to state that there was no need for oral or intravenous contrast in patients with higher BMIs, as the larger quantity of intra-peritoneal adipose allowed greater visualization and inspection of intra-abdominal organs. CONCLUSION: Based on the results of this study, it appears that there is a decreasing need for oral contrast in emergency department patients undergoing abdominal/pelvic CT, as a patient's BMI increases. Specifically, there was statistically significant agreement, between radiologists, regarding contrast use in patients who had a BMI greater than 25.

Post-treatment (not interim) positron emission tomography-computed tomography scan status is highly predictive of outcome in mantle cell lymphoma patients treated with R-HyperCVAD.

BACKGROUND: Although convincing data exist regarding the prognostic utility of positron emission tomographic (PET)-computed tomographic (CT) imaging in Hodgkin lymphoma and diffuse large B-cell lymphoma, its prognostic utility both during treatment and immediately after treatment have not been systematically evaluated in a large mantle cell lymphoma (MCL) patient cohort to support its use in clinical practice. METHODS: The authors conducted a retrospective cohort study to examine the prognostic utility of PET-CT imaging in a uniform MCL patient cohort undergoing dose-intensive chemotherapy (R-HyCVAD) in the frontline setting. The primary study endpoints were progression-free survival (PFS) and overall survival (OS). PET-CT images were centrally reviewed for the purposes of this study using standardized response criteria. RESULTS: Fifty-three patients with advanced stage MCL with PET-CT data were identified. With median follow-up of 32 months, 3-year PFS and OS estimates were 76% (95% confidence interval [CI], 64%-84%) and 84% (95% CI, 72%-90%), respectively. Interim PET-CT status was not associated with PFS (hazard ratio [HR], 0.9; 95% CI, 0.3-2.7; P = .8) or OS (HR, 0.6; 95% CI, 0.1-2.9; P = .5). Post-treatment PET-CT status was statistically significantly associated with PFS (HR, 5.2; 95% CI, 2.0-13.6; P = .001) and trended toward significant for OS (HR, 2.8; 95% CI, 0.8-9.6; P = .07). CONCLUSIONS: These data do not support the prognostic utility of PET-CT in pretreatment and interim treatment settings. A positive PET-CT after the completion of therapy identifies a patient subset with an inferior PFS and a trend toward inferior OS.

Evidence of acute pancreatitis in a patient with radioresistant-differentiated thyroid cancer.

Peroxisome proliferator-activated receptor (PPAR) agonists are sometimes used in patients with radioiodine-resistant differentiated thyroid cancers in order to effect further differentiation of the tumor and increase the chance of therapeutic success with subsequent doses of radioiodine. PPAR agonists are reportedly protective of the pancreas and have been proposed as agents that might be useful in the prevention of pancreatitis. In this report, we describe a patient treated with the PPAR agonist rosiglitazone for thyroid cancer who showed imaging abnormalities on PET scan and biochemical evidence of acute pancreatitis. Despite evidence of acute pancreatitis, the etiology of which is unclear, the patient remained asymptomatic. It is speculated that the lack of symptoms in this patient was due to the suppression by rosiglitazone of proinflammatory cytokines.

Failure of gated SPECT and echocardiography to detect large apical aneurysm secondary to hyperdynamic left ventricular wall at the aneurysm neck.

We present a patient with a history of coronary artery disease and exertional angina after an acute anterior myocardial infarction. Angiography and ventriculography revealed multivessel coronary artery disease and a large apical aneurysm. Echocardiography and gated SPECT studies were performed for further evaluation of ischemia and assessment of left ventricular function. Gated SPECT and echocardiography failed to detect a large apical aneurysm due to a hyperdynamic left ventricular wall at the neck of the aneurysm. This case demonstrates the importance of using multiple imaging modalities in the evaluation of ventricular function in the setting of coronary artery disease.

Noninvasive evaluation of liver disease severity.

In assessing the severity of chronic liver disease, one measures either the fibrotic structure of the liver or liver function. This article reviews the methods for evaluating the severity of liver disease noninvasively by estimating function or structure.

Enhanced radioiodine uptake in a patient with poorly differentiated papillary thyroid cancer after treatment with rosiglitazone.

The effect of pretreatment with the peroxisome proliferator-activated receptor (PPAR) agonist, rosiglitazone, on radioiodine uptake and serum thyroglobulin levels in a patient with radioiodine-resistant papillary thyroid cancer is described. Treatment with rosiglitazone resulted in enhanced radioiodine uptake in areas of presumed metastatic disease in the neck that were previously only faintly seen, and serum thyroglobulin fell from a pretreatment level of 41 ng/mL to less than 2 ng/mL.

Impaired myocardial SPECT imaging secondary to silicon- and saline-containing breast implants.

Early detection of coronary artery disease (CAD) in women has been challenging. Women are more likely to present with atypical symptoms, and non-invasive evaluation for CAD has been less accurate. Myocardial SPECT imaging is a well-established technique that provides important physiologic, anatomic, and prognostic information in women. Attenuation artifacts secondary to breast tissue are a common problem in women and can lead to decreased specificity of gated SPECT imaging. Cosmetic breast implants are increasing in popularity. The presence of a foreign object overlying the anterior wall of the heart in addition to native breast tissue can significantly increase attenuation artifacts. There is only one report to date describing attenuation artifact due to silicon breast implants in comparison to control, and there are no reports regarding saline breast implants. Here we report three cases of impaired myocardial SPECT imaging in women with breast implants: one patient with silicone implants, and two with saline-containing implants. Clinicians should be aware of this problem and women should be educated regarding the potential future diagnostic problems that may occur with breast implants before considering this cosmetic surgery.

Flattening of the interventricular septum (D-shaped left ventricle) in addition to high right ventricular tracer uptake and increased right ventricular volume found on gated SPECT studies strongly correlates with right ventricular overload.

BACKGROUND: Flattening of the interventricular septum (D-shaped left ventricle) detected during echocardiographic examination is correlated with significant right ventricular (RV) overload. There are no reports of this finding with cardiac gated single photon emission computed tomography (SPECT) imaging. We report an observational study correlating this finding with the presence of RV overload. METHODS AND RESULTS: Retrospectively, we compared 8 cases with flattening of the interventricular septum on cardiac gated SPECT imaging for which echocardiographic correlations and clinical data were available regarding the presence of RV overload. All patients but 1 had pulmonary hypertension ranging from 42 to 52 mm Hg measured by echocardiographic Doppler studies. All patients but 1 had reasons for RV overload (chronic obstructive pulmonary disease in 3, history of atrial septal defect in 3, pulmonary embolism in 1, and obstructive sleep apnea in 1). Septal flattening present on gated SPECT images was seen in 50% of the cases by echocardiography. Other signs of RV overload (RV enlargement, RV hypertrophy) were observed by echocardiography in 5 patients and by the gated SPECT in 7 patients. CONCLUSION: The presence of interventricular septal flattening on gated SPECT studies correlates with RV overload and should be routinely assessed during interpretation of gated SPECT studies.