Enlarged Dural Sac in Idiopathic Bronchiectasis Implicates Heritable Connective Tissue Gene Variants.

RATIONALE: Patients with idiopathic bronchiectasis are predominantly female and have an asthenic body morphotype and frequent nontuberculous mycobacterial respiratory infections. They also demonstrate phenotypic features (scoliosis, pectus deformity, mitral valve prolapse) that are commonly seen in individuals with heritable connective tissue disorders. OBJECTIVES: To determine whether lumbar dural sac size is increased in patients with idiopathic bronchiectasis as compared with control subjects, and to assess whether dural sac size is correlated with phenotypic characteristics seen in individuals with heritable connective tissue disorders. METHODS: Two readers blinded to diagnosis measured anterior-posterior and transverse dural sac diameter using L1-L5 magnetic resonance images of 71 patients with idiopathic bronchiectasis, 72 control subjects without lung disease, 29 patients with cystic fibrosis, and 24 patients with Marfan syndrome. We compared groups by pairwise analysis of means, using Tukey's method to adjust for multiple comparisons. Dural sac diameter association with phenotypic and clinical features was also tested. MEASUREMENTS AND MAIN RESULTS: The L1-L5 (average) anterior-posterior dural sac diameter of the idiopathic bronchiectasis group was larger than those of the control group (P < 0.001) and the cystic fibrosis group (P = 0.002). There was a strong correlation between increased dural sac size and the presence of pulmonary nontuberculous mycobacterial infection (P = 0.007) and long fingers (P = 0.003). A trend toward larger dural sac diameter was seen in those with scoliosis (P = 0.130) and those with a family history of idiopathic bronchiectasis (P = 0.149). CONCLUSIONS: Individuals with idiopathic bronchiectasis have an enlarged dural sac diameter, which is associated with pulmonary nontuberculous mycobacterial infection, long fingers, and family history of idiopathic bronchiectasis. These findings support our hypothesis that "idiopathic" bronchiectasis development reflects complex genetic variation in heritable connective tissue and associated transforming growth factor-ß-related pathway genes.

Persistent Left Superior Vena Cava Identified During Central Line Placement: A Case Report.

INTRODUCTION: A persistent left superior vena cava is found in 0.3-0.5% of the general population and in up to 10% of patients with a congenital cardiac anomaly. It is the most common thoracic venous anomaly and is usually asymptomatic. Being familiar with such anomaly could help clinicians avoid complications during placement of central lines, Swan-Ganz catheters, PICC lines, dialysis catheters, defibrillators, and pacemakers. CASE PRESENTATION: We describe a case of persistent left superior vena cava that was noted after placement of a central line. Mr JJ is a 41 year old African American man who was hospitalized for evaluation and management of alcoholic necrotizing pancreatitis. He required multiple central lines placements. He was noted to have a persistent left superior vena cava that was not recognized initially and thus lead to an unnecessary extra central line placement. DISCUSSION: This anatomic variant may pose iatrogenic risks if it is not recognized by the clinician. A central catheter that tracks down the left mediastinal border may also be in the descending aorta, internal thoracic vein, superior intercostal vein, pericardiophrenic vein, pleura, pericardium, or mediastinum. CONCLUSION: Our case is significant because the patient had two extra central venous catheter placements. This case strongly demonstrates the importance of knowing the thoracic venous anomalies.

Transthoracic needle biopsy.

Transthoracic needle biopsy (TTNB) is integral in the diagnosis and treatment of many thoracic diseases, and is an important alternative to more invasive surgical procedures. Both computed tomography and ultrasound may be used as imaging guidance for TTNB, with CT being more commonly utilized. Needle choice depends mostly upon lesion characteristics and location. During the procedure, patients must be able to follow breathing instructions. Common complications of TTNB include pneumothorax and hemoptysis.

Early changes in tumor size in patients treated for advanced stage nonsmall cell lung cancer do not correlate with survival.

BACKGROUND: In clinical trials, change in tumor size is used to stratify patients into response categories. The objective of the current study was to: 1) determine whether early change in the tumor size were correlated with survival in patients with advanced nonsmall cell lung cancer (NSCLC) using modified response categories from the Response Evaluation Criteria in Solid Tumors (RECIST), and 2) to determine whether there was an optimal percentage change in tumor size that could be used to define a partial response that also correlated with survival. METHODS: A total of 99 consecutive patients presenting for the treatment of advanced NSCLC during the year 2003 who had computed tomography (CT) scans before and after treatment available for review were included in the study. The largest target thoracic lesion was measured on CT before treatment, and again 2 months to 3 months after the initiation of treatment. Percent change in tumor size was calculated. The relation between tumor response and patient survival was investigated. RESULTS: There was no definite relation noted between early tumor response and patient survival (P = .754). Patients who had any initial reduction in tumor size were not found to have a significantly different survival compared with patients with initial disease progression (P = .580). In addition, there was no particular percent reduction in tumor size that was found to optimally correlate with survival. CONCLUSIONS: There is no evidence of a relation between early changes in tumor size and survival among patients with advanced stage NSCLC. To predict survival in patients with advanced NSCLC, response criteria other than change in lesion size are needed.

Hepatocellular carcinoma missed on gadolinium enhanced MR imaging, discovered in liver explants: retrospective evaluation.

The main purpose of this study was to determine if hepatocellular carcinomas (HCCs) missed on prospective magnetic resonance (MR) study could be identified on retrospective MR analysis, and to determine the cause for misdiagnosis. Among 555 patients who underwent liver transplantation between 1993 and 2004, 279 were imaged with MR imaging and four of these revealed HCCs in explanted livers that were not reported on prospective MR reading. The main cause of missed lesions were suboptimal image quality due to inability of patients to suspend respiration; other causes were HCC misinterpreted as high-grade dysplastic nodule and isoenhancement of HCC on early phase images.

Magnetic resonance evaluation of pregnant patients with acute abdominal pain.

Acute abdominal pain in a pregnant patient is associated with a long differential diagnosis, and diagnostic imaging is often required to guide management. Ultrasound is safe and widely available; however, maternal structures may be difficult to evaluate during pregnancy due to anatomic changes. Computed tomography is accurate but exposes the fetus to ionizing radiation. Magnetic resonance (MR) imaging provides excellent anatomic resolution and tissue characterization without ionizing radiation, and MR diagnosis frequently requires no contrast administration. Using an appropriate combination of sequences, MR imaging can reliably demonstrate many causes of acute abdominal pain during pregnancy.

Suspected pancreatic cancer: evaluation by dynamic gadolinium-enhanced 3D gradient-echo MRI.

OBJECTIVE: The objective of our study was to determine the sensitivity and specificity of gadolinium-enhanced 3D gradient-echo (GRE) MR images in the detection of pancreatic cancer. CONCLUSION: Dynamic gadolinium-enhanced 3D GRE images are both sensitive and specific in the detection of pancreatic cancer. Our study shows that the identification of pancreatic cancer using these images can be performed with a high degree of confidence and accuracy, making them very useful in the detection of pancreatic cancer.

MRI of acute abdominal and pelvic pain in pregnant patients.

OBJECTIVE: The purpose of this study was to show the usefulness of MRI in the evaluation of pregnant women with acute abdominal or pelvic pain. SUBJECTS AND METHODS: All MRI studies of pregnant patients who were referred for examination because of acute abdominal or pelvic pain between June 2002 and May 2004 were included in this study (n=29). The use of MRI was at the discretion of the clinician. Fetal sonography was performed in all patients before any other imaging. A complete abdominal sonographic examination was performed in six patients before MRI. In the remaining 23 patients, MRI was the choice for primary imaging. Multiplanar multisequence MR images of the abdomen and pelvis were obtained in each patient. Unenhanced images were reviewed by an experienced radiologist to determine whether a diagnosis could be made without the administration of gadolinium. In 22 of 29 studies, gadolinium was not administered. The prospective clinical MR interpretations were compared with follow-up medical, surgical, and obstetric records to determine the correctness of the interpretation. All patients were followed up until the date of article submission or until the date of final chart entry. RESULTS: Correlation of prospective clinical MR interpretations with follow-up medical records showed correct identification of disease entities in all but one patient. In one patient, torsion of the ovary was neither described prospectively nor seen in retrospect. The following disease processes were correctly identified using MRI: appendiceal abscess (n=1), appendicitis (n=2), intraabdominal and rectus muscle abscess (n=1), intussusception (n=1), pancreatitis (n=1), ulcerative colitis (n=1), Crohn's disease with diffuse peritoneal inflammation (n=1), bilateral adrenal hemorrhage (n=1), pyelonephritis (n=2), hydronephrosis (n=1), uterine fibroid degeneration (n=2), degeneration and torsion of a submucosal uterine fibroid (n=1), simple ovarian cysts (n=1), and ovarian torsion (n=1). Twelve of the 29 patients had normal findings on MR examinations and unremarkable follow-up. CONCLUSION: The intrinsic safety of MRI and its ability to accurately show abdominal and pelvic disease in pregnant patients make it highly useful in the evaluation of these patients.

Fecal incontinence in the postreproductive woman.

Magnetic resonance imaging (MRI) of the pelvic floor specifically to evaluate causes of fecal incontinence is relatively new. Along with physical examination and endoanal ultrasound, recently developed MRI techniques can be used to more accurately diagnose and characterize pelvic floor disorders leading to fecal incontinence. All three compartments of the pelvic floor can be evaluated simultaneously using MRI. During an MRI study, images are rapidly obtained in the sagittal plane at rest and during strain, and in the axial plane at rest. In symptomatic patients, abnormal descent of pelvic viscera is indicative of muscle or fascial weakness. Abnormal descent of pelvic viscera is readily detected on sagittal MR images. Muscle and sphincter tears can also be visualized, although most fascial damage is incurred secondarily. The detailed information gained from an MRI can be used to plan optimal treatment, surgical or otherwise.