Clinical utility of computed tomography-guided core needle biopsy in the diagnostic re-evaluation of patients with lymphoproliferative disorders and suspected disease progression.

BACKGROUND: Histological transformation is a common clinical event in patients with lymphoproliferative diseases, often requiring a modification in therapy. Minimally invasive biopsy techniques have been used for initial diagnosis of these disorders but their role has not been systematically evaluated in disease progression. The purpose of this study was to evaluate the yield of computed tomography (CT)-guided core needle biopsy in patients with lymphoproliferative disorders and suspected disease progression. PATIENTS AND METHODS: We performed a retrospective analysis of the records of patients with known lymphoproliferative disorders who underwent CT-guided core needle biopsy during the course of their disease, between 1990 and 2002. RESULTS: A total of 130 patients with lymphoproliferative disorders (91 patients with non-Hodgkin's lymphoma, 21 with Hodgkin's disease, 10 with chronic lymphocytic leukemia, six with combined malignancies and two with Castleman's disease) underwent CT-guided core needle biopsy 4.7 +/- 5.1 (standard deviation) (range 0-40) years after initial diagnosis. The procedure was diagnostic in 98 cases (75.4%). In 22 patients (17%) a subsequent open biopsy was performed, and in 10 (7.6%) the final diagnosis remained unconfirmed. Histological transformation was found in 20 cases (15.4%), of which 19 were suspected clinically. A new diagnosis (malignant and non-malignant) was apparent in 18 cases (13.9%) and relapsed or ongoing evidence of the original disease was found in 82 (63%). CONCLUSIONS: CT-guided core needle biopsy is a reliable procedure in patients with suspected histological transformation of lymphoproliferative disorders, and should be used as the initial tool for pathological re-evaluation.

CT-guided biopsy with cutting-edge needle for the diagnosis of malignant lymphoma: experience of 267 biopsies.

AIM: We performed a retrospective study of 267 core needle aspiration biopsies in order to estimate the accuracy of CT-guided aspiration core needle biopsies for the diagnosis and subsequent treatment of malignant lymphoma. MATERIALS AND METHODS: Between 1989 and 1999, 267 CT-guided core needle biopsies were performed in 241 patients with either primary or recurrent malignant lymphoma. Patients age ranged from 4--88 years. One hundred and sixty-six (62.2%) nodal and 101 (37.8%) extranodal aspiration biopsies were performed using either 18G or 20G Turner needles. Statistical method used was Chi-square analysis. RESULTS: An accurate histological diagnosis was made in 199 (82.5%) patients, the remaining 42 (17.4%) patients had non-diagnostic CT biopsies. Thirty-seven of them were diagnosed by a surgical biopsy, four by bone marrow biopsy and in one patient by paracentesis. One hundred and seventy-nine patients had non-Hodgkin's lymphoma (NHL) and 62 had Hodgkin's disease (HD); 23 (9.54%) patients underwent repeated CT biopsy which was diagnostic in 17 (73.9%) and non-diagnostic in six (26%). CONCLUSION: CT-guided aspiration core biopsies were sufficient to establish a diagnosis in lymphoproliferative disorders in 82.5% of cases. In the light of this experience we suggest that imaging-guided core needle biopsy be used as the first step in the work up of many patients with lymphoma.

Is chest CT sufficient for follow-up of primary mediastinal B-cell lymphoma in remission?

OBJECTIVE: We aimed to evaluate whether chest CT alone is sufficient for follow-up assessment of patients with primary mediastinal B-cell lymphoma that is in remission. MATERIALS AND METHODS: A retrospective review of medical records and CT examinations of patients who received a diagnosis of primary mediastinal B-cell lymphoma between January 1989 and January 2000 was performed. The first-year follow-up comprised examinations at 3-month intervals of the neck, chest, abdomen, and pelvis, with the examination modality alternating between CT and gallium scintigraphy. Patients who achieved complete remission underwent the same CT protocol twice the following year and then once a year during sequential follow-up. RESULTS: Fifty-three patients with primary mediastinal B-cell lymphoma at presentation--31 females and 22 males, ranging in age from 17 to 61 years (average age at diagnosis, 34 years)--were studied. The follow-up time ranged from 6 to 143 months (average follow-up time, 42.4 months). Although 11 of the patients had only a partial remission, 42 patients (79%) achieved complete remission, with one patient lost to follow-up and thus excluded from study. Recurrence was diagnosed in six of these 42 patients. All six had mediastinal recurrence with additional involvement of the lungs, chest wall, pericardium, and pleura. One patient also had bone marrow involvement at recurrence. CONCLUSION: Recurrence of primary mediastinal B-cell lymphoma in patients who achieve complete remission appears to be confined to the chest. Consequently, chest CT alone is sufficient for routine follow-up of these patients.

Percutaneous image-guided needle biopsy in children--summary of our experience with 57 children.

BACKGROUND: Percutaneous image-guided needle biopsy in children has been slower to gain acceptance than in adults where it is regarded as the standard clinical practice in screening suspicious masses. OBJECTIVES: To report our experience with percutaneous image-guided needle biopsy in the pediatric population and assess its clinical use, efficacy and limitations. MATERIAL AND METHODS: Sixty-nine percutaneous image-guided needle biopsies were performed in 57 children. The age of the children ranged from 4 days to 14 years (mean 5.6 years). We used 16- to-20-gauge cutting-edge needles. Sixty-two biopsies were core-needle biopsies and 7 fine-needle aspiration biopsies. RESULTS: There were 50 malignant lesions, 10 benign lesions and 2 infectious lesions. In 55 (88.7 %) lesions the needle biopsy was diagnostic. In 7 (11.3 %) the biopsy was non-diagnostic and the diagnosis was made by surgery. Core-needle biopsy was diagnostic in 47 of 50 (94 %) of the malignant solid tumors. In 3 out of 5 children with lymphoma, an accurate diagnosis was obtained with needle aspiration. Seven children underwent a repeated core-needle biopsy, (5 for Wilms' tumor and 2 for neuroblastoma) that was diagnostic in all cases. All the biopsies were performed without complications. CONCLUSION: Percutaneous image-guided needle biopsy is a simple, minimally invasive, safe and accurate method for the evaluation of children with suspicious masses. These data suggest that image-guided needle biopsy is an excellent tool for diagnosing solid tumors in the pediatric population. Negative studies should be considered nondiagnostic and followed by excisional surgical biopsies when clinical suspicion of malignancy is high.

Value of chest CT scans in routine ovarian carcinoma follow-up.

OBJECTIVE: The purpose of our study was to examine the role of chest CT scans in routine follow-up of patients who had been treated for ovarian carcinoma. MATERIALS AND METHODS: The radiologic follow-up of 127 women with metatastic ovarian carcinoma who had undergone surgery and chemotherapy between 1985 and 1996 was reviewed. In reviewing each patient's medical record, we determined whether a chest CT scan had been obtained, and if so, how many had been obtained during the patient's follow-up period. For patients with a chest CT scan, an analysis of the presence of disease in the thorax and its relation to disease in the abdomen and pelvis, as revealed on CT images, was performed. RESULTS: Of the patients whose cases were examined, 82 (65%) had had at least one chest CT scan obtained, with more than 50% having had three or more scans. Thirty-two (39%) patients had no radiologic evidence of disease. Twenty-eight (34%) showed disease in the abdomen or pelvis but no disease in the chest. Eighteen (22%) had both chest and abdominal or pelvic CT scans that indicated disease. In all of these patients, abdominal or pelvic disease had appeared on scans before spreading to the chest. Four (5%) of the patients had isolated chest disease. The rate of lung metastases from ovarian carcinoma in our series was 6%. In all of these patients, pulmonary metastases were preceded either by abdominal or pelvic disease or by a rise in tumor markers. CONCLUSION: Pulmonary metastases in ovarian carcinoma are rare and usually preceded by recurrence of carcinoma in the abdomen or pelvis. We suggest that chest CT scanning could be eliminated in the routine follow-up of patients who have been treated for ovarian carcinoma; yet it should be performed for those patients with elevated serum tumor markers but without evidence of abdominal or pelvic disease.

[Transarterial oil chemoembolization for hepatocellular carcinoma, in 100 cases].

Hepatocellular carcinoma (HCC) is a common malignancy with a grave prognosis. Most patients have both the malignant tumor as well as hepatic cirrhosis. Liver transplantation or hepatectomy are considered the only curative procedures, but can be applied in fewer than 10% of patients. In recent decades the most common treatments of HCC are transarterial chemoembolization with oil (TOCE) and percutaneous ethanol injection (PEI). We summarize our retrospective study of 100 patients (mean age 64 +/- 3) treated by TOCE. In 271 procedures between 1989-1998, in 16 patients hepatectomy was combined with TOCE and in 8 PEI was combined with TOCE, while the rest were treated by TOCE alone. Tumor mass was reduced in 36% of those treated by TOCE (tumor volume reduced 24-75%). Alpha-feto protein (AFP) was reduced 25-90% in 20/32 of those with elevated AFP levels. Median survival for the 100 in the entire group was 19 months (10.9 months in those with conservative treatment). Median survival in the 57 in Okuda stage 1 and the 43 in stages 2 or 3 was 30.1 months and 10.9 months, respectively (p < 0.0001). Of the 57 in stage 1, 16 underwent hepatectomy in addition to TOCE and 41 were treated only by TOCE (median survival 15 and 26 months, respectively, p not significant). Comparing Okuda 1 patients treated by TOCE only with the natural history of the disease and historical controls (Okuda 1 patients treated conservatively in 1984) median survival was 26 and 10 months respectively (p < 0.001). The side effects of TOCE were relatively mild. There was 1 fatality (3 days after treatment), and quality of life was maintained. Despite progress in the treatment of HCC by TOCE, PEI, and liver transplantation, long-term survival has remained unsatisfactory.

CT-guided core-needle biopsy in the diagnosis of mediastinal lymphoma.

The advent of radiologic guidance techniques for percutaneous biopsy has changed the approach to the routine diagnosis of mediastinal lymphoma. The aim of the present study was to evaluate the diagnostic accuracy of CT-guided percutaneous core-needle biopsy (PCNB) in the clinical management of patients with mediastinal lymphoma. The results of 49 CT-guided PCNB of mediastinal lymphoma performed under local anesthesia in 42 ambulatory patients were analyzed. A positive diagnosis of lymphoma was obtained in 30 of 42 patients, with an overall success rate of 71.5%. The technique was equally successful in the diagnosis of Hodgkin's and non-Hodgkin's lymphoma. There were no major complications. Percutaneous CT-guided CNB of mediastinal lymphoma is a quick, safe, accurate, and efficient alternative to open biopsy in the evaluation of mediastinal lymphoma, mainly at presentation. It should become the preferred initial diagnostic procedure for obtaining histologic samples in patients with suspected mediastinal lymphoma.

Sonographic features of horseshoe kidney: review of 34 patients.

Horseshoe kidney is a difficult sonographic diagnosis, especially if the isthmus is not seen. The purposes of this report are to review the sonographic images in 34 patients with proven horseshoe kidney, to discuss the limitations of ultrasonography in demonstrating the anomaly, and to identify features that would alert the examiner to the possibility of a horseshoe kidney. Among 34 patients, the isthmus was noted in 27. Of the 67 kidneys studied, 52 (78%) were judged to be low-lying, and in 24 (36%) the sonographic images suggested malrotation with anteriorly pointing pelvis. Additional sonographic features seen in the 67 kidneys included a bent or curved configuration of the kidney in the long axis (58%), tapering and elongation of the lower pole (60%), and a poorly defined inferior border of the kidney (84%). These features should suggest the presence of a horseshoe kidney and direct the examiner to search for the isthmus.

CT-guided aspiration core needle biopsy of gastrointestinal wall lesions.

PURPOSE: The purpose of this work was to examine the accuracy and safety of CT-guided core biopsy of gastrointestinal wall lesions. METHOD: We reviewed over 1,200 CT-guided abdominal core biopsy results from 1989 through 1998. Forty-five were from gastrointestinal wall lesions (16 gastric, 3 duodenal, 7 small intestine, and 19 colon). RESULTS: A definitive histologic diagnosis was obtained from the core biopsy in 41 patients (91%) without complication. The gastric lesion diagnoses were mesenchymal tumor of smooth muscle origin (eight), lymphoma (one), adenocarcinoma (three), and normal (one). Duodenal core biopsy diagnoses were inflammation (one) and normal (one). Small intestinal core biopsy diagnoses were non-Hodgkin lymphoma (four), metastatic leiomyosarcoma (one), carcinoma (one), and tuberculosis (one). Colon core biopsy diagnoses were carcinoma (11), lymphoma (2), actinomycosis (2), granulomatous inflammation (1), metastatic squamous cell carcinoma (1), chronic abscess (1), and mesenchymal tumor of smooth muscle origin (1). CONCLUSION: Percutaneous CT-guided core needle biopsy from gastrointestinal wall lesions is safe and accurate, especially in submucosal lesions, and should be considered in selected cases with negative endoscopic biopsy or in which endoscopic biopsy is not possible.

Parasitic ovarian dermoid tumor of the omentum-A review of the literature and report of two new cases.

Two cases of a parasitic omental teratoma which originated from an ovarian dermoid that underwent torsion, autoamputation and omental reimplantation are presented. A review of the literature revealed 23 additional cases of omental teratoma which occurred mostly in females. In some cases, the mature teratoma of the omentum showed histological evidence of ovarian stroma, and was associated with a dermoid tumor of the remaining contralateral ovary. It is generally believed that autoamputation and reimplantation of an ovarian dermoid cyst is the most common etiology of omental teratomas. Abdominal pain is the main presenting symptom of these tumors, and on physical examination a mobile abdominal or pelvic mass is often found. Both ultrasonography with colour flow Doppler and CT-scan are helpful in the diagnosis of dermoid tumors, but the correct diagnosis of omental localisation is extremely difficult. Mature omental teratomas may be treated by simple resection. The immature teratomas of the greater omentum, however, are potentially malignant tumors requiring postoperative chemotherapy and radiotherapy.

Legionella feeleii pneumonia and pericarditis.

Legionella feeleii pneumonia has been described in seven cases, three of them being immunocompromised. We describe a case of L. feeleii pneumonia and pericarditis in a healthy man. Epidemiological survey was not conclusive. To the best of our knowledge, there have been no previous descriptions of pericarditis caused by this organism.

CT-guided biopsy of peripheral lung lesions associated with BOOP.

Diagnosis of Bronchitis Obliterans with Organizing Pneumonia (BOOP), has been carried out thus far by open lung biopsy, or by transbronchial biopsy. We report a patient who presented with fever, cough and dyspnea. A transthoracic CT-guided biopsy of a peripheral lesion resulted in the diagnosis of BOOP. The histological findings were also confirmed by a transbronchial biopsy. It is suggested that transthoracic CT-guided biopsy should be considered for the evaluation of peripheral lung lesion compatible with BOOP.

Image-guided core-needle biopsy in malignant lymphoma: experience with 100 patients that suggests the technique is reliable.

PURPOSE: In an initial evaluation of 1,500 computed tomography (CT)-guided core-needle biopsies performed at our institute during the period from 1989 to 1994, we encountered 100 patients with the diagnosis of lymphoma. Here, we review the clinical impact of 109 image-guided needle biopsies in these 100 patients with non-Hodgkin's lymphoma (NHL) and Hodgkin's disease (HD). PATIENTS AND METHODS: NHL was diagnosed in 71 patients, and 29 had HD. Among the NHL patients, 17 (24%) had proven lymphoma diagnosed before the biopsy was performed; in 54 (76%) core-needle biopsy was performed as the first diagnostic procedure. Of 29 HD patients, nine (31%) were already established cases of HD, and in 20 (69%) core-needle biopsy was the first diagnostic procedure attempted. Most of the biopsies were performed under CT control using a 20- or 18-gauge Turner biopsy needle. RESULTS: Eighty-six patients received therapy based on the results of the needle biopsy alone. Fourteen patients received therapy after undergoing surgical biopsy for a suspected diagnosis of lymphoma, which could not be established with certainty on the basis of an earlier core-needle biopsy alone. In 78% of the patients, the needle biopsy saved a further surgical procedure that may have been difficult to perform because of the primary location of the tumor. CONCLUSION: From our experience in this study, image-guided core-needle biopsies provide sufficient information for the diagnosis of and subsequent therapeutic decision to treat most cases of lymphoma.

Renal cell carcinoma metastatic to the ovary. Ultrasound and CT appearance.

Three years following nephrectomy for renal cell carcinoma, a 54-year-old woman presented with symptoms secondary to ascites, and a large left adnexal mass. A large predominantly cystic, partially solid, septated mass with thick irregular margins was found on ultrasound and computed tomography scans. Pathological examination revealed renal cell carcinoma identical to the original tumor. The etiology and appearance of metastatic disease to the ovary are discussed.

Gastric leiomyosarcoma (Review).

Gastric leiomyosarcoma is a rare malignant tumor of the stomach which has seldom been described in the literature. Three patients, aged 47, 55, and 72 at time of presentation, were treated by the authors between 1985 and 1989. Clinical and pathological findings, treatment and outcome are discussed. A literature review is provided to establish a correlation between clinical and pathological findings, surgical and oncological treatment, and rate of survival.

Radiologic spectrum of localized Castleman's disease.

We report seven patients with the localized form of Castleman's disease, diagnosed by surgical biopsy; four had the plasma cell type and three the hyaline vascular type. A variety of nonspecific clinical and radiologic findings were identified in these patients. Precise clinical staging is important to separate the widespread from the localized form of Castleman's disease, as the localized form may be successfully treated surgically. Percutaneous core needle biopsy is not helpful in the diagnosis of Castleman's disease. Significant computerized tomography enhancement with intravenous contrast in the hyaline vascular type is indicative of increased vascularity which may cause surgical complications when resection is attempted.

Liposomal doxorubicin: antitumor activity and unique toxicities during two complementary phase I studies.

PURPOSE: The purpose of our studies was to define the maximal-tolerated dose of liposomal doxorubicin (DOX-SL; Liposome Technology Inc, Menlo Park, CA), a doxorubicin formulation of polyethyleneglycol-coated liposomes, characterize the toxicities associated with this formulation, and evaluate any indication of antitumor activity within a phase I setting. PATIENTS AND METHODS: Two separate phase I studies were conducted following the initial human pharmacokinetic testing at one of the sites (Hadassah). The starting dose of 20 mg/m2 at the University of Southern California was just below the dose without toxicity in the pharmacokinetic study. At Hadassah, the phase I starting dose was just above their earlier safe single doses, 60 mg/m2. Both studies involved cohorts of at least three patients and redosing every 3 to 4 weeks. To determine the recommended dose for phase II trials, an additional level of 50 mg/m2 every 3 weeks was explored, and the level of 60 mg/m2 every 4 weeks was expanded. RESULTS: A total of 56 patients receiving 281 courses of DOX-SL was accrued and evaluated for toxicity. Hand-foot (H-F) syndrome and stomatitis are the two main dose-limiting factors of DOX-SL. Stomatitis was dose-limiting for high single doses of DOX-SL greater than 70 mg/m2. Skin toxicity manifested primarily as H-F syndrome was dose-limiting for repetitive dosing, but acceptable at either 50 mg/m2 every 3 weeks or 60 mg/m2 every 4 weeks. Attenuation of acute subjective symptoms and lack of alopecia were generally observed. Patients with carcinomas of the breast, ovary, prostate, and head and neck were among those showing objective antitumor responses or improvement based, in part, on blood levels of tumor markers. CONCLUSION: The toxicity profile of DOX-SL differs prominently from that of the free drug administered by bolus or rapid infusion and with some differences, resembles that of prolonged continuous infusion. This finding, as well as the antitumor activity observed, supports wide phase II testing of DOX-SL in solid tumors.

Disseminated Nocardia transvalensis infection resembling pulmonary infarction in a liver transplant recipient.

Infections due to Nocardia transvalensis are extremely rare: only four disseminated infections with this pathogen have been reported, three of which ended fatally. This is the first report of a liver transplant recipient with Nocardia transvalensis infection. The patient had disseminated infection with pulmonary involvement, which presented as pulmonary infarction. Despite a ten-day delay in the administration of correct therapy, he responded rapidly to trimethoprim-sulfamethoxazole. The pitfalls of differentiating nocardial infection from pulmonary thromboembolism in solid organ transplant recipients and the diagnostic considerations unique to liver transplant recipients are discussed.

Value of lymphangiography in the staging of Hodgkin lymphoma.

PURPOSE: To evaluate the usefulness of lymphangiography in the staging of Hodgkin disease. MATERIALS AND METHODS: The authors retrospectively evaluated the lymphangiograms of 39 previously untreated patients with Hodgkin disease (clinical stage, 1-2A). The patients had no evidence of bulky mediastinal nodal disease, and results of abdominal and pelvic computed tomographic examination were negative for parenchymal organ disease and retroperitoneal and mesenteric node involvement. The studies were officially interpreted as normal or abnormal. No attempt was made to differentiate benign reactive changes from tumor infiltration. All patients underwent confirmatory staging laparotomy. RESULTS: Of the 39 patients, 29 had normal lymphangiograms. All 29 had normal lymph nodes at laparotomy. Of the 10 patients with abnormal lymphangiograms, only two had malignant infiltration of lymph nodes at laparotomy. The other eight showed benign reactive hyperplasia. CONCLUSION: Lymphangiography has no place in the management of Hodgkin lymphoma.