Improved long-term survival after resection of colorectal liver metastases following staging with FDG positron emission tomography.

BACKGROUND AND OBJECTIVES: Actual long-term survival of patients with colorectal liver metastases staged by PET CT has not been reported. Objectives were to investigate whether PET CT staging results in actual improved long-term survival, to examine outcome in patients with 'equivocal' PET CT scans, and those excluded from hepatectomy by PET CT. METHODS: A retrospective analysis of patients undergoing hepatectomy for colorectal liver metastases between March 1998 and September 2008. RESULTS: Overall 5- and 10-year survival was 44.8% and 23.9%. PET CT staging resulted in management changes in 23% of patients. PET CT staged patients showed significantly better survival than those staged by CT alone at 3 years (79.8% vs. 54.1%) and at 5 years (54.1% vs. 37.3%) with median survivals of 6.4 years versus 3.9 years (log rank P = 0.018). Patients with equivocal PET CT scans showed worse median survival than those with favourable PET CT (log rank P = 0.002), but may include a subpopulation whose prognosis trends towards a more favourable outcome than those excluded from liver resection by PET CT, whose median survival remains limited to 21 months. CONCLUSIONS: Staging of patients with colorectal liver metastases by PET CT is associated with significantly improved actual long-term survival, and provides valuable prognostic information which guides surgical and oncological treatments.

The CT fish mouth ampulla sign: a highly specific finding in main duct and mixed intraductal papillary mucinous neoplasms.

OBJECTIVE: Main duct and mixed intraductal papillary mucinous neoplasms (IPMN) are pre-malignant cystic pancreatic neoplasms associated with pancreatic duct dilatation. Distinguishing these from benign causes of pancreatic duct dilatation is important in order to allow appropriate surveillance or surgery. A patulous duodenal papilla with extrusion of mucus at endoscopic evaluation, the endoscopic fish mouth ampulla (E-FMA) sign, is reported in main duct and mixed IPMN. We aimed to establish whether a CT correlate (CT-FMA) of this sign exists and whether this was associated with the presence of invasion or high-grade dysplasia. We defined the CT-FMA sign as an uninterrupted column of water attenuation material running from the pancreatic duct to the duodenal lumen. METHODS: A retrospective, blinded review of 44 patients with histologically confirmed IPMN and 87 age-matched controls with pancreatic duct dilatation on CT was undertaken. A case-control series matched for the degree of pancreatic duct dilatation was used to compare the rates of invasion or high-grade dysplasia between main duct and mixed IPMN patients, with and without a CT-FMA sign. RESULTS: The CT-FMA sign could be identified in 18.5% patients with main duct/mixed IPMN with specificity 100%, positive predictive value 100% and negative predictive value 79.8%. A significant association was found between CT-FMA in main duct/mixed IPMN compared to controls, but not with the presence of high-grade dysplasia or invasion. CONCLUSIONS: The CT-FMA sign is a newly reported, highly specific sign of MD and mixed IPMN. ADVANCES IN KNOWLEDGE: If a fish mouth ampulla is identified at CT, a diagnosis of main duct or mixed IPMN is highly likely.

Association between progressive hepatic morphology changes on serial MR imaging and clinical outcome in primary sclerosing cholangitis.

INTRODUCTION: Hepatic morphology changes are well described in Primary Sclerosing Cholangitis and characterised by a combination of atrophy and hypertrophy changes. This study investigates the relationship between progression of these changes over time and clinical outcome in patients with PSC. METHODS: Fifty-three patients with PSC (mean age 44, 28 males and 25 females) who underwent serial MRI liver studies at least one year apart were identified. The first and the last MRI studies were selected for the retrospective analysis. Three radiologists reviewed and compared both studies for changes in hepatic morphology, specifically atrophy and/or hypertrophy. The imaging findings were correlated with adverse clinical outcomes defined as death or liver transplantation and with serum bilirubin. RESULTS: There was a mean interval of 60 months between MRI examinations and a mean clinical follow-up period thereafter of 22 months. Thirty-three (62.3%) patients had stable hepatic morphology, whilst 20 (37.7%) patients showed hepatic morphology changes (atrophy: 13 patients, 24%; hypertrophy: 16 patients, 30%). Eleven patients (21%) died or underwent liver transplantation. There was a significant correlation between interval hepatic atrophy and adverse clinical outcomes (P = 0.001). Significant correlations were found between increasing serum bilirubin level and interval hepatic atrophy, hepatic hypertrophy and combined changes (P = 0.025, P = 0.022, P = 0.027, respectively). CONCLUSION: Hepatic morphology changes over time in patients with PSC are heterogeneous with some patients developing atrophy and/or hypertrophy whilst other patients remain stable. In this retrospective study, progressive hepatic atrophy showed significant association with adverse clinical outcome defined by either death or liver transplantation.

Helical computed tomographic scanning for the evaluation of the cervical spine in the unconscious, intubated trauma patient.

BACKGROUND: Assessment of the spine in the unconscious trauma patient is limited by an inadequate clinical examination. The potential of a missed unstable disc or ligamentous injury results in many patients remaining immobilized in critical care units for prolonged periods. METHODS: This study evaluates helical computed tomographic (CT) scanning of the whole cervical spine as part of a spinal assessment and clearance protocol. RESULTS: Four hundred thirty-seven unconscious, intubated, blunt trauma patients underwent CT scanning of the cervical spine. Sixty-one patients had a cervical spine injury and 31 (7.0%) were unstable. CT scanning had a sensitivity of 98.1%, a specificity of 98.8%, and a negative predictive value of 99.7%. There were no missed unstable injuries. In contrast, an adequate lateral cervical spine film detected only 24 injuries (14 unstable), with a sensitivity of 53.3%. CONCLUSION: Helical CT scanning of the cervical spine allows rapid and safe evaluation of the cervical spine in the unconscious, intubated trauma patient.