Clinical indications and radiation doses to the conceptus associated with CT imaging in pregnancy: a retrospective study.

OBJECTIVE: To perform an internal audit at a university hospital with the aim of evaluating the number, clinical indication and operating procedure of computed tomography (CT) performed on pregnant patients and of estimating the radiation doses to the conceptus. METHODS: A retrospective review was conducted of all CT examinations performed in a single centre on pregnant patients between January 2008 and July 2013. The radiation doses to the conceptus were estimated. The results were compared with published data. RESULTS: The number of CT examinations during pregnancy increased from 3-4 per year in 2008-2011 to 11 per year in 2012. The mean estimated conceptus radiation dose was considered negligible for CT of the head and cervical spine, being less than 0.01 mGy, and for CT of the chest, less than 0.1 mGy. The estimated conceptus radiation dose from abdominopelvic CT was on average 28.7 mGy (range 6.7-60.5 mGy). CONCLUSIONS: The number of CT scans of pregnant patients increased threefold during the last few years. Most clinical indications and doses were in line with good clinical practice and literature; only in two cases the dose to the conceptus was higher than 50 mGy. KEY POINTS: • An increase in CT imaging of pregnant patients is of concern. • Clinical indications were in line with good practice. • Estimated conceptus doses were lower or similar to published data. • Internal guidelines for appropriate use of imaging during pregnancy should be established.

Effective dose and organ doses estimation taking tube current modulation into account with a commercial software package.

PURPOSE: To evaluate the effect of including tube current modulation (TCM) versus using the average mAs in estimating organ and effective dose (E) using commercial software. METHOD: Forty adult patients (24 females, 16 males) with normal BMI underwent chest/abdomen computed tomography (CT) performed with TCM at 120 kVp, reference mAs of 110 (chest) and 200 (abdomen). Doses to fully irradiated organs (breasts, lungs, stomach, liver and ovaries) and E were calculated using two versions of a dosimetry software: v.2.0, which uses the average mAs, and v.2.2, which accounts for TCM by implementing a gender-specific mAs profile. Student's t-test was used to assess statistically significant differences between organ doses calculated with the two versions. RESULTS: A statistically significant difference (p < 0.001) was found for E on chest and abdomen CT, with E being lower by 4.2% when TCM is considered. Similarly, organ doses were also significantly lower (p < 0.001): 13.7% for breasts, 7.3% for lungs, 9.1% for the liver and 8.5% for the stomach. Only the dose to the ovaries was higher with TCM (11.5%). CONCLUSION: When TCM is used, for the stylized phantom, the doses to lungs, breasts, stomach and liver decreased while the dose to the ovaries increased. KEY POINTS: • Estimated dose to the ovaries increased with TCM. • Estimated dose to lungs, breasts, stomach and liver decreased with TCM. • A unique but gender-specific mAs profile resulted in a radiation dose shift. • Even for normal size patients there is a variety in mAs profiles.

Does 11C-choline PET-CT contribute to multiparametric MRI for prostate cancer localisation?

BACKGROUND AND PURPOSE: The aim of this work was to determine whether 11C-choline positron emission tomography (PET)-computed tomography (CT) makes a positive contribution to multiparametric magnetic resonance imaging (MRI) for localisation of intraprostatic tumour nodules. PATIENTS AND METHODS: A total of 73 patients with biopsy-proven intermediate- and high-risk prostate cancer were enrolled in a prospective imaging study consisting of T2-weighted (T2w), dynamic contrast-enhanced (DCE) and diffusion-weighted (DW) MRI and 11C-choline PET-CT before radical prostatectomy. Cancerous regions were delineated on the whole-mount prostatectomy sections and on the different MRI modalities and analysed in 24 segments per patient (3 sections, 8 segments each). To analyse PET-CT images, standardized uptake values (SUV) were calculated per segment. RESULTS: In total, 1,752 segments were analyzed of which 708 (40.4%) were found to be malignant. A high specificity (94.7, 93.6 and 92.2%) but relatively low sensitivity (31.2, 24.9 and 44.1%) for tumour localisation was obtained with T2w, DCE and DW MRI, respectively. Sensitivity values significantly increased when combining all MRI modalities (57.2%). For PET-CT, mean SUVmax of malignant octants was significantly higher than mean SUVmax of benign octants (3.68±1.30 vs. 3.12±1.02, p<0.0001). In terms of accuracy, the benefit of adding PET-CT to (multiparametric) MRI was less than 1%. CONCLUSION: The additional value of 11C-choline PET-CT to MRI in localising intraprostatic tumour nodules is limited, especially when multiparametric MRI is used.

Preoperative mapping for haemodialysis access surgery with CO(2) venography of the upper limb.

OBJECTIVE: This study aims to evaluate the impact of CO(2) venography on the planning and outcome of native arteriovenous fistula (AVF) creation. METHODS: Records of patients who underwent CO(2) venography prior to access surgery between January 2000 and December 2008 were reviewed. CO(2) venography was performed selectively in chronic kidney disease (CKD) in stage IV-V patients without suitable veins on clinical examination. Findings at surgery were compared to CO(2) venography images. Patency of AVFs was analysed by the Kaplan-Meier method. Differences in outcome of maturation were compared using a chi(2) test. RESULTS: A total of 209 CO(2) venograms were obtained in 116 patients. In 89 patients (77%), 101 AVFs (21 forearm AVF (21%) and 80 elbow AVF (79%) were created. Surgical findings corresponded with CO(2) venography findings in 90% of patients. In 10 cases (10%), access was created at the elbow despite a patent forearm cephalic vein on CO(2) venography (n = 2) or access was attempted with a vein which was thought to be unsuitable on CO(2) venography (n = 8). Maturation rate of the latter was 50% (4/8) vs. 88% (80/91) for AVFs created with veins considered usable (P = 0.004). The overall maturation rate was 84% with 1-year primary, assisted primary and secondary patency rates of 63%, 70% and 71%, respectively. CONCLUSION: CO(2) venography is a useful tool for venous mapping prior to vascular access surgery, resulting in an overall maturation rate of 84% and good patency rates.

Pseudoaneurysm complicating protocol renal transplant biopsies: case reports.

Pseudoaneurysm is a rare complication of a renal biopsy procedure. We describe two cases of kidney transplant recipients who were diagnosed with a pseudoaneurysm more than 48 hours after protocol renal allograft biopsy and were successfully treated by selective embolization of the afferent artery.

Transrectal ultrasound in the staging of clinical T3a prostate cancer.

INTRODUCTION: The clinical staging of T3a prostate cancer is usually based on digital rectal examination (DRE). Overstaging of clinical T3a prostate cancer is present in 13-27% of the cases presented and understaging is in the range of 30%. The value of transrectal ultrasound (TRUS) as a staging tool is not generally accepted. The purpose of this study is to determine whether TRUS can refine the local staging in unilateral clinical T3a (cT3a) prostate cancer. PATIENTS AND METHODS: Between 1987 and 2004, 200 patients were staged as unilateral cT3a prostate cancer by DRE. All patients underwent radical prostatectomy and bilateral pelvic lymphadenectomy. Preoperative TRUS staging was performed for all patients. Final histopathological staging was compared with DRE and TRUS staging. The operable group (OG) was defined as T2 to unilateral T3a, and the advanced group (AG) was defined as bilateral T3a to T4. RESULTS: All DRE patients were assumed operable. However, in this group histopathology showed 27.0% of the patients had advanced disease. TRUS confirmed 184 patients to be operable (140 having unilateral cT3a, 44 patients having cT1c to cT2). Sixteen patients were considered to have advanced disease by TRUS. Importantly, in this group, 68.7% of the cases were indeed confirmed to have advanced disease by histopathology. CONCLUSION: TRUS can be used to refine clinical staging in unilateral cT3a prostate cancer. In cases where TRUS indicates advanced disease, it might be wise to trust the TRUS staging, rather than the DRE.

Lactating Adenoma in the Presence of Galactoceles.

BACKGROUND: A 22-year-old woman was referred to our department with a painless, fast growing breast mass. She noticed this mass during lactation, after giving birth to her first child. Her gynecologist palpated a large mass in the left breast, two smaller nodules in the left breast, and one small nodule in the right breast. Ultrasonography of the breasts, mammography and MRI were performed, and a tentative diagnosis of phyllodes tumor was proposed. She was subsequently referred to our centre.

Summary of the clinical significance of blood group alloantibodies.

The knowledge of the potential clinical significance of alloantibodies to blood group antigens is essential for selecting appropriate red blood cell (RBC) products for transfusion. This article provides a summary of clinical and technical aspects of many alloantibodies.

Cell kinetic measurements in prostate cancer.

PURPOSE: Two approaches have been suggested for escalating the total dose in radiotherapy treatment of prostate cancer. One is conformal radiotherapy; the other is hyperfractionation using many small fractions. Both imply some possible prolongation in overall treatment time. To judge whether prolonged treatment schedules would be detrimental, it is necessary to know the proliferation rates in human prostate tumors, specifically, the potential doubling time (Tpot). There is a lack of data on this parameter in the literature. METHODS AND MATERIALS: Seven patients with adenocarcinoma of the prostate were studied. A tracer dose of 100 mg/m2 of IUdR was infused intravenously 4-12 h before biopies were taken. Biopsies were fixed in 70% ethanol, stored at 4 degrees C, and later prepared and stained by standard methods for flow cytometry, using the red fluorescence signal for DNA and the green fluorescence signal (fluorescein isothiocyanate) for 5-iodo-2'-deoxyuridine. The duration of DNA synthesis (Ts) was determined by the relative movement (RM) method, knowing the interval between tracer administration and biopsy. Tpot was calculated as the quotient of Ts by labeling index (LI). RESULTS: In two of the seven tumors the LI was too low (<0.6%) for a reliable estimate of RM to be made, so no determination of Tpot was possible for these tumors. The mean LI values in the other five tumors were 2.4%, 1.4%, 1.0%, 3.0%, and 0.9%. The durations of Ts were 13.2, 9.5, 10.0, 11.7, and 12.7 h, respectively. The resulting values of Tpot were 23, 28, 42, 16, and 61 days, respectively. CONCLUSION: The low labeling indices in prostate tumors, also reported by others, made estimation of Ts by RM impossible in about a third of these tumors. However, five tumors yielded long estimates for Tpot, implying that prolongation from 6 to about 8 weeks should not be detrimental.

The contribution of magnetic resonance imaging to the three-dimensional treatment planning of localized prostate cancer.

PURPOSE: To investigate whether the use of transaxial and coronal MR imaging improves the ability to localize the apex of the prostate and the anterior part of the rectum compared to the use of transaxial CT alone, and whether the incorporation of MR could improve the coverage of the prostate by the radiotherapy field and change the volume of rectum irradiated. METHODS AND MATERIALS: Ten consecutive patients with localized prostate carcinoma underwent a CT and an axial and coronal MR scan in treatment position. The CT and MR images were mathematically aligned, and three observers were asked to contour independently the prostate and the rectum on CT and on MR. The interobserver variability of the prostatic apex location and of the delineation of the anterior rectal wall were assessed for each image modality. A dosimetry study was performed to evaluate the dose to the rectum when MR was used in addition to CT to localize the pelvic organs. RESULTS: The interobserver variation of the prostatic apex location was largest on CT ranging from 0.54 to 1.07 cm, and smallest on coronal MR ranging from 0.17 to 0.25 cm. The interobserver variation of the delineation of the anterior rectum on MR was small and constant along the whole length of the prostate (0.09+/-0.02 cm), while for CT it was comparable to that for the MR delineation at the base of the prostate, but it increased gradually towards the apex, where the variation reached 0.39 cm. The volume of MR rectum receiving more than 80% of the prescribed dose was on average reduced by 23.8+/-11.2% from the CT to the MR treatment plan. CONCLUSION: It can be concluded that the additional use of axial and coronal MR scans, in designing the treatment plan for localized prostate carcinoma, improves substantially the localization accuracy of the prostatic apex and the anterior aspect of the rectum, resulting in a better coverage of the prostate and a potential to reduce the volume of the rectum irradiated to a high dose.

Chronic granulomatous disease and McLeod syndrome in a black child.

A 3-year-old black male child with X-linked chronic granulomatous disease and red cells of the rare McLeod phenotype is presented. The red cells showed acanthocytosis and did not react with anti-KL. Similarly the leukocytes were nonreactive with anti-Kx. The Xk and Xg linkage could not be investigated since all members of his family were Xg (a+).

Correlation of sonographic patterns in liver metastases with histology and microangiography.

Thirty-three livers with microscopic metastatic involvement were studied at autopsy by high resolution real time ultrasound at 7.5 and 10 MHz. Eighteen lesions with different sonographic appearances were selected for further microangiographic and histologic analysis. Tumor vascularity was assessed on microangiography. The anatomic pathologic study included both the evaluation of the microscopic and histologic appearances.

Xanthogranulomatous pyelonephritis with emphasis on computerized tomography scan. Retrospective study of 20 cases and literature review.

The authors reviewed 20 cases of xanthogranulomatous pyelonephritis. An accurate preoperative diagnosis of this disease is difficult because of its clinical and radiologic similarities to various other renal lesions. A resistant urinary tract infection in a patient with a nonfunctioning kidney and a perinephric abscess should lead to the condition being suspected. Although xanthogranulomatous pyelonephritis is mainly a histologic diagnosis, computerized tomography opens new perspectives in the preoperative determination. This could allow less radical surgery in selected cases.

Temperature steering in prostate by simultaneous transurethral and transrectal hyperthermia.

Localized hyperthermia (HT) is presently under investigation as a treatment for benign prostatic hyperplasia and carcinoma of the prostate (CaP). One popular approach employs a transrectal (TR) device, a directional microwave (MW) applicator inserted into the rectum and aimed at the prostate. Alternatively, in the transurethral (TU) technique, a symmetrically radiating MW antenna is placed directly within the prostatic urethra. Used individually, TR applicators are capable of effectively heating (> 42 degrees C) the prostate up to 2 cm from the rectum, whereas TU applicators selectively heat the periurethral tissue with effective radial penetration of about 0.6 cm. Neither technique is of much value in heating the anterior prostate. In general, the highest temperatures are produced in the tissue immediately adjacent to the surface of intracavitary microwave devices. However, when MW antennas are used in arrays, the resulting heating pattern can differ significantly from that of the individual antennas. Heating at depth can be selectively enhanced and "steered" by adjusting the phase relationship between the devices. Prostatic temperature profiles were measured in 6 patients treated with TR alone, TU alone, and simultaneous TR and TU heating. In the combined treatments different phase relationships between the antennas were applied. We found that a higher temperature could be produced in the center of the prostate than on the surface of either applicator for certain phase relationships, and that the temperature profiles could be changed by shifting phase. The results of these measurements are in agreement with those of a computer simulation. Based on the above data we feel the combined use of TU and TR hyperthermia may be justified in Phase I-II trials for patients with locally advanced CaP.

Is low-grade prostatic intraepithelial neoplasia a risk factor for cancer?

INTRODUCTION: High-grade prostatic intraepithelial neoplasia (HGPIN) is generally accepted to be a precursor lesion of prostate cancer. The likely outcome of isolated low-grade PIN (LGPIN) lesions in prostate biopsies remains unclear. A follow-up study of 106 patients with LGPIN- and HGPIN lesions was performed. MATERIALS AND METHODS: In a 2-y period, 207 men were diagnosed with isolated PIN on standard systematic sextant biopsy of the prostate. In total, 104 patients had LGPIN and 103 had HGPIN. No patients had ever received androgen deprivation therapy, chemotherapy or radiation therapy. In all, 106 patients who underwent repeat second or third sextant biopsies were analysed in the study; 30% of these patients received a selenium-vitamin E supplement for at least 6 months. RESULTS: In total, 43 had LGPIN and 63 HGPIN on the first biopsy. The mean age was 63.5 y (range 46-77) in the LGPIN group and 64.9 y in the HGPIN group. The mean total PSA was 6.96 ng/ml (range 0.59-34.13) in the LGPIN group and 8.44 ng/ml (range 0.59-35.3) in the HGPIN group. In the LGPIN group, 30% of the patients had cancer in at least one of the repeat biopsy cores. In the HGPIN group, 27% had cancer in at least one of the repeat biopsy cores. The mean total PSA of patients who had cancer in repeat biopsies with LGPIN was 7.84 ng/ml (range 2.92-34.13). The mean total PSA of the patients who had cancer in repeat biopsy in the HGPIN was 6.73 ng/ml (range 0.56-25). There was no significant difference in PSA and pathological stage between those patients who did and those who did not receive selenium-vitamin E supplements. CONCLUSIONS: These data are intriguing since the risk of finding prostate carcinoma on repeat sextant biopsy in the LGPIN group is 30%. This is higher than commonly reported. The importance of recognising and re-biopsying HGPIN was confirmed. If chemoprevention could be shown to be effective, it might be beneficial not only in HGPIN but also in LGPIN. The possible activity of chemopreventive agents and their combination with iso-flavonoids needs further investigation.

Diagnostic fine-needle aspiration cytology and immunocytochemistry analysis of a primary thyroid lymphoma presenting as an anatomic emergency.

The case of a 66-year-old woman with rapidly progressive respiratory distress caused by a massive anterior neck mass with tracheal compression is presented. Within 24 hours, fine-needle aspiration cytology (FNAC) and immunocytochemistry provided a diagnosis of high-grade B-cell lymphoma and the opportunity to institute a chemotherapeutic regimen resulting in a rapid volume reduction and airway expansion. One year after combined modality treatment the patient was in complete remission (with an estimated thyroid volume of 4 cm3). This case report illustrates the advantages of FNAC and immunocytochemistry in the diagnosis of thyroid lymphoma.

Radical prostatectomy for localized prostate cancer.

A retrospective analysis of 70 patients, undergoing a radical prostatectomy in 1989 and 1990 is reported. The value of computed tomography (CT) scanning in preoperative lymph node staging should be reconsidered. Evaluation of the resection margins is of utmost importance as is the distinction between capsular invasion, penetration and transgression. The etiology of local failure and its treatment are discussed.

Ultrasound of the normal kidney: a sonographic, anatomic and histologic correlation.

Technical progress in sonographic equipment providing routinely high resolution images makes it appropriate that some criteria of normality have to be reviewed. In this paper normal sonographic images of the kidney are correlated with anatomy and histology. The effect of aging upon normal anatomical relations and histologic findings is analysed. Special attention is focussed on particular anatomical details as far as they can explain the particular topography or sonographic appearance of some pathologies.

Management of carcinoma of the bladder.

Carcinoma of the bladder (CaB) is a common tumor of the genitourinary tract. In the United States in 1997, CaB was second in frequency of occurrence and third in mortality among genitourinary tumors. This tumor has a well-documented history of environmental and industrial causative factors. The strongest etiologic risk factors include the use of tobacco, which is thought to be responsible for half of the CaB diagnosed in men in the United States, and some arylamines. In the past 30 years, there has been major improvement in the survival of patients with this disease. Multiple factors were responsible for this accomplishment and they include: 1) better understanding of the natural history of CaB, 2) development of immunohistochemical analysis helpful in defining prognostic factors, 3) improved imaging and nonimaging diagnostic modalities helpful in making earlier diagnosis and better defining the true anatomical extent of the tumor, 4) development of more effective therapy for carcinoma in situ, 5) major improvement in surgical techniques resulting in better treatment outcomes, and 6) the wide use of adjuvant chemotherapy. Major stress has been placed on the quality of life of patients treated for CaB. Quality of life was improved by optimizing surgical, radiation, and medical treatment techniques. The two most important factors producing this quality-of-life improvement include: 1) the use of organ-preserving therapy in properly selected patients that involves the use of a multimodality therapeutic approach with transurethral resection, radiation therapy, and chemotherapy; and 2) the ability to treat selected men and women with radical cystectomy followed by orthotopic reconstruction that allows patients nearly physiologic voiding. Current research efforts are directed toward better patient selection for appropriate therapy which is expected to increase patient survival and improve quality of life. Of particular importance in the selection of this optimal therapy in patients with CaB is a wide application in the clinical practice of important recent advances in molecular genetics.

Carcinoma of the kidney, testis, and rare urologic malignancies.

The purpose of this symposium was to provide a forum for discussion on current information on the etiology and diagnosis of, and therapy for, tumors of the kidney, testis, and several uncommon malignancies of the genitourinary tract. The most recent contributions in epidemiology and molecular genetics were discussed with specific reference to their importance for clinical practice. Contemporary treatment approaches with the emphasis on multidisciplinary patient management of tumors commonly seen in the clinic as well as those that are only rarely diagnosed by urooncologists were presented. Major stress was given to the management optimization as it pertains to short- and long-term quality of life issues of patients treated for these tumors. Methods to reduce treatment toxicity including carcinogenic potential of chemotherapy, radiotherapy, or their combination were found to be of nearly equal importance to patient survival. Symposium participants reached consensus on a number of important points: 1) The management of patients with several malignancies discussed requires the presence of a multidisciplinary team of specialist who are interested in diagnosis and treatment of genitourinary tumors; 2) Patients managed in such an environment are expected to have optimal survival and the best possible quality of life; 3) Real advances in the management of patients can be best obtained through well-designed prospective clinical trials; and 4) There is a need for timely introduction of relevant advances in epidemiology and molecular genetics to clinics.