Early vs. late enoxaparin for the prevention of venous thromboembolism in patients with ICH: A double blind placebo controlled multicenter study.

BACKROUND: Venous thromboembolism (VTE) after primary intracerebral hemorrhage (ICH) worsens patient prognosis. Administering low-molecular weight heparins (LMWH) to prevent VTE early (24 h) may increase the risk of hematoma enlargement, whereas administering late (72 h) after onset may decrease its effect on VTE prevention. The authors investigated when it is safe and effective to start LMWH in ICH patients. METHODS: In the setting of double blinded, placebo controlled randomization, patients >18 years of age with paretic lower extremity, and admitted to the emergency room within 12 h of the onset of ICH, were randomized into two groups. Patients in the enoxaparin group received 20 mg twice a day 24 h (early) after the onset of ICH and in the placebo group 72 h (late) after onset respectively. Both groups immediately received intermittent pneumatic compression stockings at the ER. Patients were prospectively and routinely screened for VTE and hemorrhagic complications 1 day after entering the study and again before discharge. RESULTS: 139 patients were included for randomization in this study. Only 3 patients developed VTE, 2 in the early enoxaparin group and one in the late enoxaparin group. No patients developed PE. Thromboembolic events (p = 0.901), risk of hematoma enlargement (p = 0.927) and overall outcome (P = 0.904) did not differ significantly between the groups. CONCLUSION: Administering 40 mg/d LMWH for prevention of VTE to a spontaneous ICH patient is safe regardless of whether it is started 24 h (early) or 72 h (late) after the hemorrhage. Risk of hemorrhage enlargement is not associated with early LMWH treatment. Administering LMWH late did not increase VTEs.

Imaging findings and accuracy of core needle biopsy in mucinous carcinoma of the breast.

BACKGROUND: Diagnosis of mucinous carcinoma can be difficult due to its benign appearance on mammograms and ultrasonographic (US) images. In the light of the rather scarce literature, core needle biopsy (CNB) has proved useful in diagnosing mucinous lesions. PURPOSE: To assess mammographic, US, and CNB findings of mucinous breast tumors and to correlate them with final histology obtained in therapeutic surgery. MATERIAL AND METHODS: From 2000-2006, 25 mucinous carcinomas detected with CNB were surgically removed. The mammography, US, and CNB results were analyzed and correlated with final histology. RESULTS: Ninety-six percent of the mucinous carcinomas (24/25) were visible with US. All except two of the 24 tumors were solid masses. All the mixed-type lesions (group 2) were hypoechoic and had irregular or lobulated margins and heterogeous internal echotexture. The US features were more variable among the 14 pure mucinous carcinomas (group 1) and the six US visible mucinous carcinomas with cancerous cells outside the tumor (group 3). Fifty-seven percent of group 1 and 50% of group 3 tumors had clearly lobulated or irregular margins. Fifty-seven percent of group 1 and 67% of group 3 cancers were hypoechoic. A vast majority of these tumors had heterogenous echotexture. Seventy-one percent (17/24) of the lesions visible with US had posterior acoustic enhancement. Eighty percent (20/25) of the mucinous carcinomas were classified as BI-RADS 4 lesions in US. All the lesions with images available were visible on mammograms, where most of the tumors were seen as a high-density circumscribed lesion and classified as BI-RADS 4 lesions, while none were classified as BI-RADS 1, 2 or 5. The sensitivity and positive predictive value of CNB regarding mucinous carcinoma was 100%. CONCLUSION: CNB was found to be a highly reliable diagnostic tool for diagnosing mucinous carcinoma in this selected material. US findings of pure mucinous carcinoma were variable, however, all reached BI-RADS 4 category. The presence of posterior acoustic enhancement beneath a solid breast lesion should raise suspicion of mucinous carcinoma. Most of the tumors appeared as BI-RADS 4 lesions in US and in mammography thus making both a useful tool for raising a suspicion of malignancy in mucinous cancers.

Ultrasonography-guided core needle biopsy in differential diagnosis of papillary breast tumors.

BACKGROUND: Papillary lesions of the breast are considered diagnostically challenging for various reasons. A relatively high malignancy rate in final pathological analysis has in many cases necessitated excision of these lesions, regardless of core needle biopsy (CNB). PURPOSE: To assess mammographic, sonographic, and CNB findings of papillary lesions, and to correlate them with final histology obtained by surgical excision. MATERIAL AND METHODS: From 2000-2006, 29 benign and 19 malignant papillary tumors examined with CNB were surgically removed. Mammographic, sonographic, and CNB results were analyzed and correlated with final histology. RESULTS: On ultrasonography (US), 69% (20/29) of the benign lesions were solid and 31% (9/29) were cystic, and 47% of the malignant lesions (9/19) were solid and 53% (10/19) were cystic. The mammographic findings were nonspecific, although most of the malignant tumors (67%, 12/18) were categorized as BI-RADS 4 lesions. The sensitivity, specificity, and positive predictive value of the core needle biopsy histology was 32% (6/19), 100% (29/29), and 100% (6/6), respectively, for papillary carcinoma. A negative predictive value of 91% (21/23) for malignancy and 48% (11/23) for either atypia or malignancy was shown. Of the lesions with CNB diagnosis of benign papillary lesion with atypia, 58% (11/19) turned out to be malignant and 11% (2/19) were benign on surgery. CONCLUSION: The probability of malignancy is low when the CNB result shows a benign papillary lesion with no atypia. However, the only way to reliably diagnose atypical papillary lesions is to surgically remove all papillary tumors, irrespective of the CNB result. Differentiation between benign and malignant lesions or malignant noninvasive and invasive tumors is not possible based on sonographic or mammographic appearance.

Ultrasonography and core needle biopsy in the differential diagnosis of fibroadenoma and tumor phyllodes.

BACKGROUND: The diagnosis of phyllodes tumors of the breast is challenging due to many similarities with common fibroadenomas. PURPOSE: To determine the diagnostic accuracy of core needle biopsy in diagnosing phyllodes tumors and to analyze the ultrasonographic (US) features of phyllodes tumors and fibroadenomas. MATERIAL AND METHODS: From 1999 to 2003, 1010 breast lesions underwent imaging-guided core needle biopsy. Of these, 57 fibroadenomas and 12 phyllodes tumors were removed surgically. The US and needle biopsy results of a total of 64 lesions (52 fibroadenomas and 12 phyllodes tumors) were further analyzed, compared, and correlated with surgical histological results. RESULTS: The median sonographic sizes of the phyllodes tumors and the fibroadenomas were 3.2 cm and 1.6 cm, respectively. At US, 58% of the phyllodes tumors (7/12) were classified as equivocal or suspicious of malignancy and 42% (5/12) as probably benign, while 54% of the fibroadenomas (28/52) were classified as probably benign and 46% (24/52) as equivocal. The sensitivity, specificity, and positive and negative predictive values of core needle biopsy histology regarding tumor phyllodes were 83%, 92%, 71%, and 96%, respectively. CONCLUSION: Imaging-guided core needle biopsy was accurate in differentiating between fibroadenomas and phyllodes tumors. US classification was unreliable due to considerable overlap in the findings. Combined use of US feature analysis and needle biopsy may help to avoid the misinterpretation of phyllodes as fibroadenoma.

Potential of diffusion imaging in brain tumors: a review.

Diffusion magnetic resonance imaging (MRI) is a method for quantifying the microscopic random motion of water molecules in tissues. Diffusion imaging provides indirect structural information of a kind not available on basic MRI sequences of many pathological conditions. Lately, especially brain tumors have been under active investigation, with numerous papers already published, and their number continues to increase. This review summarizes the heterogeneous and complex research data on diffusion imaging of brain tumors.

Pneumothorax and the value of chest radiography after ultrasound-guided thoracocentesis.

PURPOSE: To determine the incidence, the operator's experience, and other variables that may influence the development of pneumothorax or re-expansion edema after ultrasound (US)-guided thoracocentesis. MATERIAL AND METHODS: The medical records of 264 procedures in 212 patients who had undergone US-guided thoracocentesis in our radiology department or intensive care unit during the period 1996-2001 were retrospectively reviewed. RESULTS: Post-thoracocentesis pneumothorax occurred in 11 cases, the incidence being 4.2% (11/264). None of the pneumothoraces occurred in the 10 mechanically ventilated patients. All but one patient with pneumothorax were asymptomatic or had only minor symptoms. Chest tube drainage was needed in one patient with a large pneumothorax. No re-expansion edema was recorded, although 1500 ml or more pleural fluid was aspirated in 29 patients. The operator's experience had no effect on the complication rate. Needle size was the only significant variable that contributed to the pneumothorax rate. CONCLUSION: US-guided thoracocentesis can be done equally as safely by residents as by senior radiologists. The safety and feasibility of the method are evident among mechanically ventilated intensive care patients. Our results do not support the routine use of post-thoracocentesis chest radiography.

Lymphoma of the cervix. Imaging and transcatheter arterial embolization.

A case of uterine cervix lymphoma with selective embolization after angiography is described. Chemotherapy and radiotherapy were carried out and surgery was avoided.

Increased amount of type III pN-collagen in AAA when compared with AOD.

OBJECTIVE: the extent of the processing of type III procollagen to type III collagen was determined in nine human abdominal aortic aneurysms (AAA), and compared with ten samples of aortoiliac occlusive disease (AOD). METHODS: the aminoterminal propeptide (PIIINP) and telopeptide (IIINTP) of type III procollagen and collagen, respectively, were immunologically measured in the soluble and insoluble fractions of the extracellular matrix. The assay for PIIINP in the insoluble matrix was further validated. RESULTS: the insoluble matrices of AAAs contained at least 12 times more incompletely processed type III pN-collagen than AOD specimens (0.74% and 0.061%, respectively). Also, the soluble extracts of AAAs tended to contain more non-processed type III pN-collagen than free, properly cleaved aminoterminal propeptide. CONCLUSIONS: the larger amount of type III pN-collagen suggests an alteration in the metabolism of type III collagen in AAAs. This may partially explain the decreased tensile strength of the aortic tissue.

Isolated neurosarcoidosis - MR findings and pathologic correlation.

Neurosarcoidosis is a diagnostic challenge, especially if systemic symptoms are absent. We present a 49-year-old woman with isolated neurosarcoidosis. The main symptom was loss of vision in the left eye. Brain MR imaging showed 6 high-signal white matter lesions frontotemporally on proton density and T2-weighted turbo spin-echo images. Coronal fat-saturated turbo FLAIR images of the orbits showed a swollen left optic nerve with increased signal intensity, which finding has not been previously published in sarcoid optic neuropathy. A control MR examination showed meningeal enhancement of the left optic nerve and leptomeningeal enhancing lesions around the brain stem. Spinal MR revealed leptomeningeal enhancement throughout the spinal cord and asymptomatic enhancing cauda equina lesions, mimicking subarachnoid tumour seeding, and an enhancing nerve root mass at Th12/L1. Biopsy of the latter lesion revealed non-caseating granulomas consistent with sarcoidosis.

Increased amount of type III pN-collagen in human abdominal aortic aneurysms: evidence for impaired type III collagen fibrillogenesis.

PURPOSE: This study aimed to characterize the distribution of structural domains of type I and III collagens in the wall of abdominal aortic aneurysms (AAAs), by the use of undilated atherosclerotic aortas (aortoiliac occlusive disease [AOD]) and healthy abdominal aortas as controls. METHODS: Immunohistochemical staining was applied with antibodies for the aminoterminal propeptides of type I (PINP) and type III (PIIINP) procollagens, which represent newly synthesized type I and III pN-collagens. In addition, an antibody against the aminoterminal telopeptide of type III collagen (IIINTP) was used as a means of detecting maturely cross-linked type III collagen fibrils. RESULTS: The newly synthesized type III procollagen detected by means of PIIINP staining was concentrated in the media in aneurysmal aortas, whereas type I pN-collagen was localized in the intima in both AAAs and AODs. The healthy aortas showed no immunoreactivity for either PIIINP or PINP. The cross-linked type III collagen, detected by means of IIINTP staining, stained transmurally in all study groups, but appeared more abundant in the media in AAAs. CONCLUSION: Our results strongly suggest that the metabolism of type III collagen is enhanced in AAAs. Intensive type III pN-collagen staining was present mainly in the media layer in AAAs, suggesting a role of type III collagen in aneurysm formation, whereas type I pN-collagen was present in the intima in both AAAs and AODs, suggesting that type I collagen synthesis is a fibroproliferative response related to the atherosclerotic process. The increased type III pN-collagen in AAAs may result in impaired fibril formation and, thus, in decreased tensile strength of aneurysmal tissue.

Type I and III collagens in human colon cancer and diverticulosis.

BACKGROUND: Collagens are major proteins in the extracellular matrix, providing tissues with tensile strength. They are also important for cell adhesion and the invasion of malignant tumours. METHODS: Thirty-nine samples of human colon (24 diverticulosis, 6 malignant tumours, 9 controls) were collected during elective surgery. Immunoassays for different domains of type I and III collagens and procollagens were used in soluble tissue extracts and trypsin digests of tissue samples. RESULTS: The contents of cross-linked type I and III collagen telopeptides and total collagen were similar in diverticulosis and healthy tissue, whereas in malignant tissue maturely cross-linked type III collagen was scarce. Furthermore, some of the cross-linked type I telopeptide antigens were exceptionally small in size, indicating that the cross-linking of type I collagen in collagen fibres is impaired in cancer. The rate of type I collagen synthesis was clearly increased in malignancy, but not significantly in diverticulosis. However, type III collagen synthesis was increased in diverticulosis, but not in malignancy. CONCLUSIONS: In colon malignancy, the collagen cross-linking process was aberrant and the synthesis of type I collagen increased. In diverticulosis, the synthesis of type III collagen was increased, suggesting only moderately increased metabolic activity.

Cross-linked telopeptides of type I and III collagens in malignant ovarian tumours in vivo.

Malignant tumours often induce a fibroproliferative response in the adjacent stroma, characterized by increased expression of type I and type III procollagens. In normal tissues, fibrillar collagens normally undergo extensive intermolecular cross-linking that provides tensile strength to the tissue. Here we set out to characterize collagen cross-linking in human ovarian carcinoma tissue in vivo. Biochemical and immunochemical methods were used for cross-linked telopeptides of type I and III collagens in samples of benign and malignant serous tumours. The locations and staining patterns of these proteins were visualized immunohistochemically. The contents of both total collagen and the cross-linked type I and type III collagens in the malignant samples were only about 20% of those in the benign tumours. The cross-linked telopeptide antigens derived from the collagens were smaller and more heterogeneous in size in the malignant than in the benign tumours, indicating a defective cross-linking process scarcely leading to the formation of mature cross-links in the collagen fibres in malignancy. Immunostaining revealed disorganized type I and type III collagen bundles in carcinomas. These findings suggest that the collagen cross-linking process is aberrant in malignant tumours, possibly resulting in increased susceptibility of tumour collagens for the proteolysis often associated with tumour invasion.

Complete processing of type III collagen in atherosclerotic plaques.

The extent of processing of type III collagen is assessed, and the proportions of type I and III collagens are estimated in atherosclerotic plaques obtained from the carotid artery, common femoral artery, and aorta. The fraction of type III collagen that had retained its amino-terminal propeptide (pN-collagen) was 42% in the soluble extract but only 0.0081% in the insoluble residue. Taken together, only 0.011% of the type III collagen in whole plaques was in the form of type III pN-collagen. Together with the small amounts of the free propeptides of type I procollagen, this finding indicates a low rate of collagen turnover. The amounts of solubilized telopeptides of type I and III collagens were measured, after heat denaturation and trypsin digestion of the collagenous helix, by specific immunoassays for the corresponding trypsin-generated antigens. The mean proportion of type III collagen was 61% (95% confidence interval, 58% to 65%) in the carotid and femoral artery plaques and 56% (95% confidence interval, 44% to 68%) in the aortic specimens. The completely processed and cross-linked type III collagen seems to be the major collagen type in atherosclerotic plaques.