Effect of normal ageing on the sites of aortic bifurcation and inferior vena cava confluence: a CT study.

The object of this retrospective study was to determine the sites of abdominal aortic bifurcation and inferior vena cava confluence in relation to age and sex. The study group comprised 180 subjects (90 males and 90 females) divided into 9 groups by age (in decades). The positions of the aortic bifurcation and the inferior vena cava confluence were evaluated by CT, and linear regression models were fitted to the data. The positions of the aortic bifurcation and venous confluence showed a highly significant downward shift with increasing age (p = 0.0001). The shift was more pronounced in women. The mean site of the aortic bifurcation for the whole group was at lower L4 (range, upper L3 to upper S1); in males, it was at upper L4 (range, upper L3 to upper L5), and in females at lower L4 (range, upper L3 to upper S1). The mean site of the venous confluence for the whole group was at disc L4-L5 (range, lower L3 to upper S1); in males, it was at disc L4-L5 (range, upper L4 to disc L5-S1), and in females at disc L4-L5 (range, lower L3 to upper S1). Thus, the aorta and the inferior vena cava can extend as low as the level of S1. These data are of relevance in laparoscopic procedures, especially in laparoscopic lumbar discectomy.

Severe myelotoxicity of oral etoposide in heavily pretreated patients with non-Hodgkin's lymphoma or chronic lymphatic leukemia.

BACKGROUND: Promising results have been reported for patients with non-Hodgkin's lymphoma (NHL) receiving chronic oral etoposide. Due to the small number of patients reported, information regarding side effects is limited, and therefore warrants further evaluation. METHODS: Twenty eligible patients with NHL and chronic lymphatic leukemia (CLL), resistant to or relapsed after previous protocols of polychemotherapy were treated with oral etoposide at a dosage of 50 mg/m2/day for 21 days in a 28-day cycle. Response and toxicity were evaluated according to standard criteria. RESULTS: Total response was noted in 13 patients, complete response in 2 patients, and partial response in 11 patients. Two patients had stable disease and five patients had progression of disease during treatment. Seventy-five percent of patients experienced neutropenia below 1500/microL. Half acquired infection and required hospitalization. Fifty-five percent required blood transfusions. All patients needed course shortening and dosage reduction. CONCLUSIONS: Chronic daily administration of oral etoposide is effective in patients with NHL and CLL. In heavily pretreated patients, myelotoxicity is severe. Therefore, modification of the schedule plan is mandatory in this group of patients.

Muscle computed tomography features of motor neuron disease in late-onset GM2 gangliosidosis.

Late-onset GM2 gangliosidosis, a rare inherited neuronal storage disease, is characterized by a variety of clinical manifestations. The common clinical picture comprises neuromuscular, spinocerebellar, extrapyramidal, cognitive, and psychiatric abnormalities. Details of the extent of muscle involvement have never been reported. Eight patients with this syndrome were evaluated for the existence and extent of motor neuron disease using routine electrodiagnosis and systematic evaluation of skeletal musculature by computed tomography. Motor neuron disease was present in each and every patient regardless of the clinical manifestations and to a degree beyond that suspected on neurological examination. Muscle imaging disclosed a diffuse wasting and fatty replacement of muscles with predilection of pelvic and thigh muscles, and especially the quadriceps group. It seems that progressive motor disability in this syndrome is mainly due to motor neuron disease, as manifested by muscle atrophy, which can be easily demonstrated by muscle computed tomography.

Primary bone tumor resectability: the value of serial MRI studies in the determination of the feasibility, timing, and extent of tumor resection.

We report the prospective analysis of 119 magnetic resonance imaging (MRI) studies in 41 patients with primary bone tumors performed from January 1984 to December 1990 to evaluate the contribution of serial MRI studies in the determination of feasibility, timing, and extent of tumor resection. Long repetition time (TR)-long echo time (TE) T2-weighted (T2, second echo) imaging was the most useful in assessing soft-tissue involvement, and short TR-short TE T1-weighted (T1) imaging for documenting the bone marrow changes. The feasibility, timing, and extent of resection was determined with the help of MRI in 20 cases with only two local recurrences. One study falsely suggested active tumor. In four other cases, a treatment decision was made based on the MRI. The MRI added significantly to the evaluation by computed tomography, radiographs, and bone scans.

Metachronous bladder tumors in patients with upper urinary tract transitional cell carcinoma.

Sixty-nine patients who underwent nephroureterectomy for upper urinary tract transitional cell carcinoma were included in the study. The following data were collected for each patient: grade and stage of renal/ureteral tumor, tumor location, timing of tumor appearance and recurrence in the bladder, grade and stage of each of the recurrent tumors, and number of recurrences. Follow-up ranged between 2 and 15 years. Thirty-three patients (47.8%) developed metachronous bladder tumors. The appearance of the bladder tumors was related to tumor grade and multifocality of the upper urinary tract TCC. Of the 33 patients, 19 had 1 tumor appearance in the bladder, 6 had 2 recurrences, and 8 had 3 recurrences. The 5-year survival rate for patients with no subsequent bladder tumors was 57% compared to 22% for those who had subsequent tumors. It is concluded that the appearance of bladder tumors following nephroureterectomy characterizes a group of patients with biologically more active disease with unfavorable prognosis.

Effect of improved diagnosis of renal cell carcinoma on the course of the disease.

The impact of the improved diagnosis of renal cell carcinoma (RCC) on the course of the disease was evaluated in 188 patients who were diagnosed and treated at a single medical center. Sixty-seven patients (group A) who had undergone nephrectomy between 1979 and 1983 for RCC initially diagnosed by intravenous pyelography (IVP) were compared with 121 patients (group B) who had undergone nephrectomy between 1983 and 1989, diagnosed by ultrasound and/or computed tomography (CT) scan. Incidental asymptomatic tumors were found in 18 of 67 (26.9%) group A patients and in 57 of 121 (47.1%) group B patients (P < 0.001). The incidence of small tumors of < 5 cm in diameter was significantly lower in group A compared to group B (25.4% vs. 47.9%, respectively, P < 0.01). The disease-free 5-year survival rate for group A was 40% compared to 80% for group B. It is concluded that the introduction of modern imaging techniques has improved the survival of patients with RCC and decreased the progression rate of the disease.

An evaluation of lateral and medial transposition of the ovaries out of radiation fields.

BACKGROUND: Transposition of the ovaries is practiced in young women before possible radiation to the pelvic fields. In patients with carcinoma of the uterine cervix (Ca cervix), the ovaries are transposed laterally (LOT), whereas in patients with Hodgkin's disease (HD), they are usually transposed medially (MOT). Nevertheless, not all transposed ovaries are successfully protected. METHODS: Computed tomography was performed in 16 patients (7 Ca cervix and 9 HD) after ovarian transposition. The location of all identified ovaries was depicted on diagrams of the respective radiation fields for evaluation of the efficacy of LOT or MOT in relocating the ovaries out of these fields. RESULTS: All 13 ovaries transposed laterally were easily identified by CT, as compared with only 13 of 18 ovaries transposed medially (P = 0.2). Eleven of the 13 ovaries that underwent lateral transposition (6 of 7 patients) were located outside the radiation field. In contrast, only 3 of 13 identified ovaries in the medially transposed group were completely outside the radiation field (P = 0.005). Of the remainder, six were completely within the radiation field, and four were at least partially within the radiation field. CONCLUSIONS: Although LOT achieves its purpose in patients with Ca cervix, the use of MOT in patients with HD should be revised to achieve better protection of the ovaries from the effects of radiation. The authors suggest that LOT is preferred over MOT also in patients with HD if radiation of the pelvic lymph nodes is planned.

Orbital and adnexal involvement in systemic non-Hodgkin's lymphoma.

BACKGROUND: The orbit is rarely a secondary site of lymphoma dissemination, and only few reports exist on the course and characteristics of involvement in these sites. METHODS: The authors retrospectively reviewed the records of 187 consecutive patients with systemic non-Hodgkin's lymphoma (NHL) diagnosed and treated at Beilinson Medical Center between 1986 and 1992. RESULTS: Ten patients (5.3% of those with NHL) had orbital or adnexal involvement or both. Histologically, six had intermediate-grade lymphoma, three had diffuse small cleaved cell lymphoma, and one had nodular small cleaved cell lymphoma. In all 10 patients, the lymphoma was widespread, and in 6, there were two or more other extranodal sites of involvement, mainly, bone marrow (six) and skin (three). The orbital involvement was found either at presentation or as late as 53 months after primary diagnosis. Various therapeutic approaches were chosen, from local orbital irradiation to different mild to aggressive chemotherapeutic protocols. Complete regression of the orbital or adnexal involvement or both was observed in 9 of 10 patients, but in 6 the systemic disease either persisted or recurred at other sites. CONCLUSIONS: Orbital or adnexal involvement or both by NHL may appear at any time during the course of the disease. It responds well to either chemotherapy or radiation therapy with prolonged local remission. The results of this study strongly suggest that every patient with NHL in whom any periorbital or orbital mass, ptosis, proptosis or lid edema develops should be suspected of having orbital lymphoma involvement until proven otherwise.

Brain imaging in late-onset GM2 gangliosidosis.

We describe brain CT and MRI characteristics of 10 patients with late-onset GM2 gangliosidosis. Cerebellar atrophy, particularly of the vermis, was a prominent feature in all patients with normal-appearing cerebral hemispheres. The severity of these findings did not correlate with the age of onset, disease duration, severity of neurologic impairment, or mode and distribution of the various clinical presentations. In particular, no cerebral abnormality was found by neuroimaging in seven patients with intellectual decline and in six patients with recurrent psychosis, while prominent cerebellar atrophy was present in the only patient who was free of cerebellar signs.

Suture granuloma simulating lung neoplasm occurring after segmentectomy.

A suture granuloma was resected which developed after segmentectomy of a squamous cell carcinoma of the lung and radiologically mimicked a neoplasm. This report emphasises that although the appearance of the lesion may be typical for malignancy, the possibility of a benign suture granuloma should be considered, especially if the lesion appears shortly after surgery.

Vacuolar myopathy sparing the quadriceps.

Twenty-two Jewish patients, belonging to 15 families, 11 of them from Iran and three possibly of Iranian stock, suffered from progressive muscle weakness and wasting. The initial symptom was usually distal leg muscle weakness, appearing in the third or fourth decade and insidiously involving the proximal muscles and to a lesser extent the upper limbs. The quadriceps muscle was consistently spared even in advanced cases. Computerized tomography (CT) scans of muscles demonstrated variable wasting and fatty replacement of limb and axial muscles, while the vastus lateralis muscle retained its normal CT appearance. The typical light microscopy features of the affected muscles were: presence of vacuoles within muscle fibres, internal nuclei, longitudinal fibre splitting and, in severely affected muscles, endomysial fibrosis without, inflammation or fibre necrosis. Electron microscopy suggested that the vacuoles were autophagic. Cytoplasmic and intranuclear inclusions were rare. While electromyography (EMG) revealed presence of spontaneous activity, however, analysis of muscle action potentials, turns-amplitude ratio, macro-EMG and single fibre EMG suggested a primary myopathic disorder. Consanguinity in seven families, the parents being first cousins, and the presence of additional affected siblings of both sexes may suggest an autosomal recessive trait. The presence of this disorder in Iranian Jews may indicate that this is a distinct myopathic entity.

[Immunotherapy for metastatic renal cell carcinoma: treatment with PLAK cells and low-dose interleukin-2].

During the past 5 years publications from the NIH (Rosenberg et al.) and other centers have reported encouraging results in the treatment of metastatic renal cell carcinoma. Adoptive immunotherapy was applied, using lymphocytes activated by interleukin-2 (LAK cells) plus high doses of interleukin (IL-2) systemically. The mean clinical response rate was 20-35%. Severe lifethreatening adverse reactions to high doses of IL-2 were noted, although they were all of short duration. Laboratory findings of Novogrodsky et al. from Beilinson Medical Center, Israel showed that oxidizing mitogens can induce lymphocyte activation (PLAK cells). Further studies suggested that a combination of such activated cells with low doses of IL-2 could produce effective toxicity to tumor cells without the need for high doses of IL-2 which could be very toxic for the patient. In the past year we treated 7 patients with PLAK cells and IL-2. 4 completed the treatment, of whom 1 responded partially (regression of more than 50% of lung metastases), 1 is stable and in 1 liver metastases regressed but metastases in lumbar vertebrae and in the pelvis progressed. 1 patient died a month after discharge from hospital, probably due to rapid progression of the disease. Our protocol follows that of the Phase II clinical study of 40 patients treated at the Rogosin Institute, New York Hospital--Cornell Medical Center. The mean clinical response rate was 23.6%. Toxicity of IL-2 is dose-dependent. In this protocol, the low doses of IL-2 gave significantly fewer adverse reactions.

Pitfalls in the follow-up of cervical and mediastinal goitres: role of CT imaging.

Four patients with cervical and mediastinal goitres were described. Routine investigation in these patients, including chest X-rays, oesophageal and tracheal X-rays and scintigraphy of the thyroid gland, failed to show significant changes over the years, or underestimated the true extent of the goitres. Three of the goitres caused severe mediastinal compression, evident only on computed tomography (CT) imaging, and requiring urgent surgery. The pros and cons of different diagnostic modalities for imaging cervical and mediastinal goitres are discussed, stressing the importance of CT imaging as exemplified in the cases presented.

The effect of intravesical bacillus Calmette-Guerin therapy on the upper urinary tract.

A total of 66 patients with low grade, low stage transitional cell carcinoma of the bladder who were treated with intravesical bacillus Calmette-Guerin (BCG) underwent cystourethrography to detect vesicoureteral reflux. BCG was instilled weekly for 6 weeks and monthly thereafter for up to 24 months. Whenever vesicoureteral reflux was found or morphological abnormalities were detected on excretory urography (IVP) an isotope renal scan was performed to evaluate the relative renal function. Vesicoureteral reflux was found in 13 patients (19.7%): 10 had grades 1 and 2A, and 3 had grade 2B reflux. The number of BCG instillations ranged from 8 to 22. IVPs were normal in 11 patients. In 2 patients mild unilateral dilatation was present before BCG instillations, and this remained unchanged during and after therapy. None of the 13 patients with vesicoureteral reflux had IVP features suggestive of urinary tuberculosis. In 11 patients the refluxing renal systems had normal relative renal function (50 to 55%). Two patients had a decrease to 40% of the relative renal function with normal IVPs, suggesting a nonBCG related cause. We conclude that BCG therapy is safe in patients with minimal reflux.

Short pancreas in polysplenia syndrome.

Two cases with the polysplenia syndrome also had a short pancreas. To the best of our knowledge the radiologic characteristics of this anatomic anomaly have not yet been reported. Both cases were asymptomatic with regard to their anomaly-complex. The radiologic findings of the short "pancreas" are similar to the only pathologic description of this association. The awareness of this association led to the diagnosis of the second case after a few months only. A physician performing ERCP in the polysplenia syndrome should keep in mind the possible presence of the "short pancreas" when the whole length of the pancreatic duct is not visualized.

Air in vagina. Indicator of intrapelvic pathology on CT.

Computed tomography of the normal female pelvis may show the presence of a tiny air bubble within the vagina. Among 2,800 female abdomino-pelvic CTs, 27 were found to contain large amounts of intravaginal air. Twenty-three patients suffered from pelvic malignancy while in 4, non-tumorous pelvic pathology was present. Detection of air bubbles in the vagina is abnormal and indicates, in the majority of cases, an intrapelvic malignancy.

Hemorrhage associated with "bone crisis" in Gaucher's disease identified by magnetic resonance imaging.

Children suffering from Gaucher's disease were examined by magnetic resonance imaging (MRI) during a characteristic episode of "bone crisis". An unexpectedly high intramedullary as well as subperiosteal signal was observed on both the T1- and T2-weighted sequences in 5 patients, suggesting a subacute hemorrhage or hematoma. It is conceivable that such a painful hemorrhage is an important component of the "bone crisis" phenomenon. Furthermore, in these cases this is a specific sign which may enable differentiation of bone crises from other types of bone pain associated with Gaucher's disease.

[Acute mesenteric thrombosis. Successful resection and revascularization. Report of a case]. / Thrombose mésenterique aiguë. Résection et revascularisation réussies. Rapport d'un cas.

Acute mesenteric thrombosis; resection and successful revascularization. A case report. A patient with acute mesenteric thrombosis was surgically treated with extensive bowel resection and revascularization interposing a synthetic vascular graft. A few months later on aortoduodenal fistula ensued. Critical discussion by the authors of their therapeutic approach with special emphasis on the value of dynamic CT scanning in the evaluation of a functioning synthetic vascular graft.