Evaluation of muscle atrophy after axillary lymph node dissection.

INTRODUCTION: Axillary node status is the most important prognostic factor for patients with primary breast carcinoma, making axillary lymph node dissection (ALND) a standard surgical treatment of breast cancer. Postoperative sequelae to ALND is frequently reported. In this study we aimed to find out objectively, how much damage is caused to these nerves during ALND. PATIENTS AND METHODS: A total of 50 breast cancer patients who underwent surgical treatment in our Breast and Endocrine Surgery Unit between March 1998 and July 2004 were included in the study. Surgical treatment of these patients consisted of breast conserving surgery or total mastectomy combined with ALND. To compare operated patients with non-operated patients as a control, only patients who had undergone unilateral surgery were included in the study so that the non-operated side served as the normal control for each patient. All patients had a postoperative review with an anatomical and functional examination at least 6 months after the operation. Computed tomography was then performed and the M. latissimus dorsi (MLD), M. pectoralis major (MPM) and M. serratus anterior (MSA) thicknesses were measured. RESULTS: On physical examination, the aforementioned muscles in all the patients were found to be intact and functional. Sixty-four percent of the operated patients group were found to have various degrees of hypoesthesia. MLD, MPM and MSA amongst the non-operated patients group were found to be significantly thicker than the corresponding muscles amongst operated patients group. CONCLUSION: We conclude that a significant amount of reduction in the thickness of the MLD, MPM and MSA occurs after ALND. Also, sensory deficit occurs, especially on the upper medial portion of the arm, showing damage to the intercostobrachial nerves.

Two dose levels of ifosfamide in malignant mesothelioma.

Thirty-one consecutive patients with histologically proven and symptomatic malignant mesothelioma were treated with two dose levels of ifosfamide. The first group of 15 patients were given 2.3 g/m2/day for 5 days (group A) and the following 16 patients were treated with 1.2 g/m2/day for 5 days of ifosfamide (group B). Treatment cycles were repeated every 3 weeks. While the partial response rate (PR) in group A was 38.5%, it was only 6.25% in group B (P > 0.05). The 95% confidence interval for the difference in PR rates was 3.3-61.2% > The overall survival (OAS) of groups A and B were similar (8 months and 9 months, respectively). Higher Grade 3-4 myelotoxicity was observed in group A when compared to group B (30.8% vs. 18.7%; P > 0.05). In conclusion, a favourable response rate could be achieved in malignant mesothelioma with high dose ifosfamide at the cost of increased toxicity.

Large craniopharyngioma extending to the posterior cranial fossa.

Craniopharyngiomas are most commonly located extra-axially in the sellar or suprasellar area. They are benign but aggressive neoplasms. This paper reports an 8-year-old girl with a large craniopharyngioma originating from the suprasellar region and extending to the posterior cranial fossa down to the region of the foramen magnum.

Case report: computed tomography findings in lipoid proteinosis: report of two cases.

Lipoid proteinosis (Urbach-Wiethe disease (Urbach, E and Wiethe, C, Lipoidosis cutis mucosae, Virchows Arch. Patholog. Anat., 273, 285-319 (1929)) is a rare generalized disease with autosomal recessive inheritance. It most often involves the skin and mucosal membranes of the aerodigestive tract; but also involves the central nervous system, lung, lymph nodes and striated muscles. We present the computed tomography findings in the cranium and larynx of two siblings with lipoid proteinosis.

Comparison of effective doses obtained from dose-area product and air kerma measurements in interventional radiology.

In this study, measurements of dose-area product (DAP) and entrance dose were carried out simultaneously in a sample of 162 adult patients who underwent different interventional examinations. Effective doses for each measurement technique were estimated using the conversion factors that have been determined for specific X-ray views in a mathematical phantom. Exposure conditions used in clinical practice never match these theoretical models exactly, and deviations from the assumed standard conditions cause uncertainties in effective dose estimations. Higher effective dose values are found if the air kerma results are used rather than DAP readings, both for patient and Rando phantom studies. Comparison of DAP, fluoroscopy times and skin doses were made with published data. DAP measurement for the effective dose calculation and thermoluminescent dosimeter for the skin dose estimates are found to be the most reliable methods for patient dosimetry.

Abscess formation due to dropped gallstone after laparoscopic cholecystectomy.

Laparoscopic cholecystectomy is a popular treatment modality of symptomatic gallstones with decreased major complications and shortened hospital stay. Complications following laparoscopic cholecystectomy, most of them involving strictures of biliary tract have been well described in recent reports. However, there are only a few reported cases about dropped gallstones after the procedure, all of which were opaque and easily demonstrated with multiple imaging modalities. An unusual complication of laparoscopic cholecystectomy; abscess formation due to a dropped non-opaque gallstone is described in which diagnosis was suggested with the combination of ultrasound and computed tomography findings and confirmed by surgery.

Multiple organ involvement in tuberous sclerosis.

Tuberous sclerosis is an uncommon heredito-familial disease. A rare case of multiple organ involvement is reported.

Concurrent occurrence of three neoplasms including non-Hodgkin's lymphoma, renal cell carcinoma and leiomyoma in the same kidney.

A 53-year-old man with triple renal neoplasms in his left kidney presented. He was initially diagnosed intermediate grade non-Hodgkin's lymphoma (NHL) which involved gastrointestinal tract, left kidney, liver and pancreas. He underwent left nefrectomy because of a persistent renal mass after the completion of chemotherapy. The large renal mass revealed a renal cell carcinoma (RCC). Additionally, multiple small nodules of non-Hodgkin's lymphoma and a solitary leiomyoma were observed.

Diametral measurements of the upper spinal cord for stereotactic pain procedures: experimental and clinical study.

BACKGROUND: Stereotactic percutaneous pain procedures, percutaneous cordotomy, trigeminal tractotomy, and extralemniscal myelotomy are routinely performed with computed tomography (CT) guidance. This new imaging technique enables one to measure the spinal cord diameters for each patient uniquely. Significant differences have been recognized between the measurements obtained with CT and the reference values given for such procedures. METHODS: To confirm the reliability of CT measurements, two experimental models were used. In the first stage, an artificial neck and spinal cord model was set up and diameters of the spinal cord were remeasured with CT. In the second stage, spinal cord diameters of the upper cervical region on 10 mongrel dogs were initially taken with CT, then standard laminectomy was performed and diameters of the same region were measured under the operating microscope. RESULTS: The experimental studies confirmed that CT measurements of the upper cervical cord are reliable. In clinical application, diametral measurements of the spinal cord at occiput C-1 level were carried out in 30 patients who underwent percutaneous trigeminal tractotomy and extralemniscal myelotomy. The anteroposterior diameter at this level was measured at 7.0-12.8 mm and the transverse diameter ranges between 9.3-14 mm. At the level of C-1-C-2, these measurements were performed over 63 patients who experienced percutaneous cordotomy. In this group the anteroposterior (A-P) diameter was measured as 7.0-11.4 mm, and the transverse diameter as 9.0-14.0 mm. CONCLUSIONS: Our clinical experiences and the results of the experimental measurements demonstrate that CT imaging gives accurate diametral values that would favorably influence the surgical procedures, and thus, with CT imaging it is possible to perform main stereotactic destructive pain procedures safely, effectively and selectively.

The jugular foramen: a comparative radioanatomic study.

BACKGROUND: Advances in microsurgical techniques made possible the removal of advanced jugular foramen (JF) lesions, which once had been accepted as unoperable. However, successful surgery requires detailed knowledge of the JF anatomy. METHODS: Sixteen jugular foramina in eight formalin-preserved adult cadavers were scanned with axial and coronal high resolution computed tomography (HRCT) prior to dissection. After craniectomy and removal of brain tissue, the relationships of the neurovascular structures in the JF were determined by drilling the temporal bones from superior to inferior on planes parallel to the skull base. RESULTS: No bony partition of the JF was observed. A dural band consistently divided the JF into two parts. Anterior to it was the glossopharyngeal nerve (IX) while the vagus (X) and accessory (XI) nerves were located posteriorly. There was a notch in which the IX nerve entered the JF. It was also identified on the CT scans and defined as the glossopharyngeal recess. The IX nerve made a genu within the JF in all specimens. Then, it ran inferiorly through a bony canal in three specimens (18.75%), and through an incomplete bony canal in two (12.5%), which were also defined on the CT images. The inferior petrosal sinus ran through a sulcus anteromedial to the glossopharyngeal recess. The posterior meningeal artery was found to be located between the X and XI nerves within the JF. CONCLUSIONS: This study revealed a complex and highly variable pattern of the relationships of the neurovascular structures in the JF, and their HRCT images correlated well with the anatomic microdissections.

Tuberculous fibrosing mediastinitis: CT and MRI findings.

Fibrosing mediastinitis is a rare entity usually caused by granulomatous disease. Most cases develop as a complication of histoplasmosis. Mediastinal involvement caused by tuberculosis most often produces focally enlarged lymph nodes, with diffuse mediastinal involvement a very unusual manifestation of disease. The authors describe a patient with extensive tuberculous fibrosing mediastinitis, in whom fibrotic masses produced compression of airways and vascular structures with resultant parenchymal changes.

CT-guided pain procedures for intractable pain in malignancy.

CT-guided stereotactic percutaneous destructive procedures, i.e. percutaneous cordotomy, trigeminal tractotomy, and extralemniscal myelotomy, have been routinely used for the treatment of localized intractable pain in malignancy since 1987. In 67 cases if local pain due to malignancy, CT guided percutaneous cordotomy was performed and in 97% complete pain control was achieved. In 45 of these cases, a "selective cordotomy" was performed meaning that analgesia was produced only in the painful region of the body. CT guided trigeminal tractotomy was applied to a total of 19 cases in 5 of which pain had been caused by malignancy. The results were satisfactory. 12 cases, suffering from visceral pain due to malignancy, were treated by CT-guided extralemniscal myelotomy and in 10 cases pain relief was achieved.

Computerized tomography-guided percutaneous extralemniscal myelotomy.

Extralemniscal myelotomy (ELM) is a procedure performed at the cervicomedullary junction of the spinal cord in which the central cord is lesioned to treat intractable pain. The neurophysiological mechanism of pain relief after ELM remains unclear. The authors present a series of 14 patients with intractable cancer pain who were managed by CT-guided, percutaneous ELM. In six of the cases (42.8%), total pain relief was achieved; partial satisfactory pain relief was attained in four cases (28.5%), and no pain control was achieved in four cases (28.5%). No complications due to ELM were observed. The authors believe that ELM is a safe and effective procedure in the management of intractable cancer pain for selected cases; computerized tomography guidance is an essential part of the procedure to achieve morphological localization of the target in the cervicomedullary junction. More research is needed to understand the neurophysiological mechanism of pain relief after ELM and to standardize the lesion volume.

Computerized tomography-guided percutaneous bilateral selective cordotomy.

Percutaneous bilateral cordotomy performed using conventional techniques may cause the patient to develop sleep-induced apnea due to bilateral destruction of the ventrolateral reticulospinal tract. Computerized tomography (CT)-guided percutaneous cordotomy using a newly designed needle electrode system has the advantages of safe, selective, and controlled lesioning under direct visualization in the lateral spinothalamic tract. Given its low complication rate, bilateral selective cordotomy performed with CT guidance using this new needle electrode system may prove to be the treatment of choice for cancer patients with bilateral pain of the lower trunk and extremities. The present series included five cancer patients suffering from intractable pain bilaterally in the lower trunk and extremities. All were treated with CT-guided bilateral selective cordotomy: the results demonstrate that this technique may be used effectively and safely.

Frontal sinus mucocele: a rare complication of craniofacial fibrous dysplasia.

We present plain radiographic, computed tomographic and magnetic resonance imaging (MRI) findings in a 25-year-old female patient with craniofacial fibrous dysplasia (FD). Although FD has a tendency to involve craniofacial bones in a unilateral fashion, the involvement was bilateral and extensive in this case. An additional feature was the presence of a frontal sinus mucocele, presumably due to the involvement of the sinus recess by the dysplastic process. This complication of the craniofacial FD has been reported very infrequently in the literature.

Gadolinium-enhanced three-dimensional MR angiography in jugular phlebectasia and aneurysm.

True jugular vein aneurysms and phlebectasias are very rare abnormalities, which are usually discovered in children. Though their ultrasonographic features have been well described, magnetic resonance angiographic appearance of these lesions has not been reported in the radiology literature. We describe gadolinium-enhanced MR angiographic findings in two patients with internal jugular vein phlebectasia and one patient with anterior jugular vein aneurysm. The jugular venous system and its abnormalities were successfully depicted in the coronal plane, much like the images of coronal angiography.

Radiographic, CT, and MRI findings in primary pulmonary angiosarcoma.

We report a rare instance of primary pulmonary angiosarcoma presenting as a large solitary mass in the left upper lobe with mediastinal invasion. In particular, we emphasize the magnetic resonance (MR) imaging features, which included a markedly heterogeneous pattern consisting of hyperintense areas scattered throughout a background of intermediate signal intensity, rendering the lesion a cauliflower-like appearance especially on T2-weighted images. Being unreported so far in primary pulmonary angiosarcomas, these distinct MR imaging findings may be helpful in the differentiation of these neoplasms from lung cancers.

Cross-sectional imaging in ureter tumors: findings and staging accuracy of various modalities.

We present cross-sectional imaging findings in eight patients with ureter tumors. Eight patients were examined by computed tomography (CT), seven by ultrasonography (US), and five by magnetic resonance imaging (MRI). All the lesions were detected by the three modalities. All modalities were accurate in excluding the periureteral invasion and lymphadenopathy in Stages 1 and 2 tumors. While CT and MRI identified the periureteral invasion and lymphadenopathy in four patients with advanced tumors, US failed to show the local invasion in three of four patients. Nevertheless, enlarged retroperitoneal lymph nodes could be detected sonographically in the three Stage 4 tumors. CT and MRI appear to have a high diagnostic sensitivity and staging accuracy in ureter tumors. Although US detects ureter tumors efficiently, this technique seems to be unreliable in showing local invasion in a substantial number of patients.

Vaginal ectopic ureter in a duplex system with renal dysplasia. A case report.

A 12-year-old girl with vaginal ectopic ureter in a duplex system associated with an extremely dysplastic upper segment who presented with a complaint of vaginal discharge is reported. The diagnostic approach with special reference to ultrasonography and computerized tomography is discussed.

C.T.-guided pain procedures.

C.T.-guided stereotactic destructive pain procedures; percutaneous cordotomy, trigeminal tractotomy-nucleotomy and extralemniscal myelotomy are presented. All procedures were applied in 32 cases without any mispuncture or complication. Advantages of C.T. guidance are direct visualization of target electrode relations, measurements of spinal cord diameters at the lesion site, and demonstration of spinal cord displacement during the procedure.