MRI combined with MR cholangiopancreatography versus helical CT in the evaluation of patients with suspected periampullary tumors: a prospective comparative study.

PURPOSE: To establish the diagnostic accuracy of MRI including MR cholangiopancreatography (MRCP) compared with helical CT in the differentiation of malignant and benign lesions in the periampullary region. MATERIAL AND METHODS: Fifty-one patients (27 M, 24 F, mean age 66 years, range 39-86 years) with obstructive jaundice and sonographic evidence of intra- and extrahepatic bile duct dilatation (n=31) or suspicion of periampullary tumor, based on previously performed ultrasound and/or CT examination (n=20), were studied. MRI with MRCP and helical CT were reviewed blindly under standardized conditions. Lesion status (differentiation of malignant versus benign) was rated on a 5-point diagnostic confidence scale. Reference standards for comparison were findings at surgery or laparoscopy and/ or the clinical outcome. The predictive value of imaging findings was determined with multivariate logistic regression analysis. RESULTS: The areas under the receiver operating characteristic curve were 0.96 for MRI with MRCP and 0.81 for CT (P <0.05). Multivariate analysis of eight imaging variables at MRI indicated that a stricture with malignant characteristics at MRCP was the best predictor of malignancy. CONCLUSION: MRI with MRCP was significantly more accurate than CT in differentiating between malignant and benign lesions in patients with suspected periampullary tumors, mainly due to the information obtained on the MRCP images of the biliary and pancreatic duct anatomy.

The assessment of endometrial pathology and tubal patency: a comparison between the use of ultrasonography and X-ray hysterosalpingography for the investigation of infertility patients.

OBJECTIVES: The aim of the present study was to examine the role of hysterosalpingocontrast sonography (HyCoSy) as a screening test for endometrial and tubal pathology at the start of the infertility investigation protocol. METHODS: HyCoSy was compared with X-ray hysterosalpingography (HSG) for the assessment of the endometrial cavity and Fallopian tube patency. A total of 103 women with a history of at least 1 year's infertility were included. Each woman underwent both HyCoSy and HSG on the same day. Laparoscopy was performed in 43 cases. For HyCoSy examinations, saline was used for evaluation of the endometrial cavity and Echovist contrast medium to assess Fallopian tube patency. RESULTS: The concordance between HyCoSy and HSG for the presence of endometrial cavity pathology was 90%, but for tubal patency the concordance was lower (72%). HyCoSy classed more examinations of tubal patency as uncertain. HSG more frequently classified tubes as occluded. In the subset of patients in whom all three techniques were used, HSG and HyCoSy demonstrated a high concordance with laparoscopy (83% and 80%, respectively). The prevalence of occluded tubes according to laparoscopy as the reference standard was 13%. The two methods had a high negative predictive value for tubal disease (HSG, 94%; HyCoSy, 88%), and the positive predictive values were 47% and 75%, respectively. The detection rate for occluded tubes was 73% and 27%, and specificity 87% and 90%, respectively. CONCLUSIONS: Our data demonstrate that HyCoSy obtains similar information about the status of the endometrial cavity and Fallopian tube patency to that of HSG. It is possible that in some cases HyCoSy may replace HSG in order to select women with patent tubes who may be suitable for further infertility treatment without more invasive investigation.

Histamine in immunotherapy of advanced melanoma: a pilot study.

Sixteen patients with advanced metastatic malignant melanoma were treated with a high-dose infusion of interleukin-2 (IL-2; 18 x 10(6) IU/m-2 day-1) together with daily subcutaneous (s.c.) injections of interferon alpha (IFN alpha; 3 x 10(6) U/m-2 day-1) in 5-day cycles. Nine of these patients were given histamine (1 mg s.c.) twice daily during treatment with IL-2 and IFN alpha. In the seven patients who did not receive histamine, one partial response (that is a reduction of more than 50% in the total tumour burden) was observed in a patient with skin and lymph node melanoma. In the eight histamine-treated patients evaluable for response, four partial responses were observed. Two other patients showed regression at one site of metastasis but tumours remained unchanged at other sites. Two histamine-treated patients showed complete resolution of extensive liver metastasis. Sites of response in histamine-treated patients also included the subcutis, lymph nodes, skeleton, spleen and muscle. Lung melanoma did not respond to histamine/IL-2/IFN alpha. Three patients with lung tumours responded with significant (more than 50%) reduction of the volume of soft-tissue tumours, suggesting that the response to histamine may be organotropic. Survival was significantly prolonged in patients receiving histamine. Our data suggest that treatment with histamine may improve the antitumour efficacy of immunotherapy in metastatic melanoma.

Radiological study of changes in the pelvis in women following proctocolectomy.

The vagina, uterus and adnexa of 21 women who had a proctocolectomy for ulcerative colitis or Crohn's colitis were examined with vaginography and hysterosalpinography. Six healthy women were used as controls. A characteristic post-operative deformation of the adnexa and the vagina was demonstrated. In 17 of 21 women the fallopian tube anatomy was pathological, in four cases with total obstruction. These abnormalities explain why vaginal discharge, dyspareunia and involuntary sterility are common complaints in women after this type of surgery.

Comparison of non-enhanced, bolus enhanced, and delayed scanning techniques in computed tomography of hepatic tumours.

Non-enhanced, bolus contrast medium enhanced and 4 to 6 hours delayed computed tomography of the liver was performed in a prospective study of 53 patients. Forty patients had focal lesions, in 12 of these they were hypervascular. Contrast medium was administered as an initial bolus followed by a rapid injection of meglumine metrizoate (Isopaque Cerebral). The total iodine dose varied between 56 and 63 g, which gave an average increase in attenuation of 14 HU in normal parenchyma comparing delayed with non-enhanced scanning. Presence and extent of focal lesions were evaluated in a randomized and independent analysis by two radiologists. The percentage of examinations with correct tumour description was higher with bolus scanning (observer I 73%, observer II 75%) and delayed scanning (observer I 75%, observer II 78%) than with non-enhanced scanning (observers I and II 67%). An optimal bolus technique requires an exact timing of the contrast medium administration and scanning. Delayed scanning provides an excellent supplement when the bolus examination is suboptimal or shows equivocal findings.

Double contrast barium enema and flexible rectosigmoidoscopy: a reliable diagnostic combination for detection of colorectal neoplasm.

The efficiency of double contrast barium enema and flexible rectosigmoidoscopy (to 60 cm) in the assessment of patients with a positive Hemoccult II test in a randomized screening study for colorectal neoplasms was evaluated. A positive test was present in 625 patients, of whom 530 had a complete enema and rectosigmoidoscopic assessment. A carcinoma was diagnosed in 26 and an adenoma greater than or equal to 1 cm in diameter in 71. As a control, 323 patients with a negative assessment repeated the Hemoccult II test and of these 67 had a positive second test, of whom 55 underwent colonoscopy. One carcinoma (Dukes' A) and two adenomas greater than or equal to 1 cm in diameter were diagnosed. The efficiency of the assessment was also checked by rescreening the whole group 1-2 years after the first study and by continuing follow-up. It was found that two more carcinomas and one adenoma greater than or equal to 1 cm in diameter had been overlooked at the primary assessment. The sensitivity for neoplasms greater than or equal to 1 cm in diameter at the primary assessment was 72 per cent for double contrast barium enema and 86 per cent for rectosigmoidoscopy. The sensitivity for the combined methods was 94 per cent and the specificity was 99 per cent. The combination of double contrast barium enema and rectosigmoidoscopy in the primary assessment of patients with a positive Hemoccult II test gives an acceptable result and immediate retesting of those with a negative assessment is not necessary.

Gynaecological problems related to anatomical changes after conventional proctocolectomy and ileostomy.

Seventy-one women who had a proctocolectomy for ulcerative colitis (n = 41) or Crohn's disease (n = 30) were interviewed in the follow-up clinic about gynaecological problems and fertility. All women were examined by an independent gynaecologist and abnormalities of the internal genital tract were registered. Forty-nine per cent (35/71) of the women had a distressing vaginal discharge after proctocolectomy, compared with 9% (6/71) before surgery. At the gynaecological examination 45% (32/71) had a heavy vaginal secretion with- out any signs of an acute vaginal infection. In 68% (30/44) fluid retention in the vagina was associated with a caudally firmly fixed and dilated posterior vaginal fornix. Twelve per cent (8/66) of the women reported dyspareunia before surgery. After surgery, 27% (18/66) complained of this symptom. Fertility was significantly reduced after surgery since only 37% (10/27) of the women who attempted to become pregnant succeeded within 5 years follow-up. The corresponding figure before surgery was 72% (39/54). Those who conceived went through pregnancy and parturition without any incident, 6 of 21 delivered by caesarean incision. In conclusion, conventional proctocolectomy in women will result in distressing vaginal discharge, and dyspareunia in a considerable proportion of the patients. The operation also seems to decrease their chances of becoming pregnant.

In-vivo measurements of ultrasound attenuation in normal or diseased liver.

Ultrasonic attenuation coefficients of liver have been derived from echoes received by a modified commercial B-scan imaging instrument. Values have been measured from selected regions within liver scans of 59 individuals, of which 15 cases were presumed normal (based on medical histories), and the remainder were involved with diffuse liver disease such as alcoholic cirrhosis, chemotherapy toxicity, chronic hepatitis, and liver metastases. Medical histories on most individuals include the results of serum liver function enzymes, conventional B-scan examinations, and exposure to drugs and alcohol. The results of CT abdominal scans (N = 13) and/or liver biopsy (N = 12) were also available. The results show that normal attenuation values for human liver are 0.054 +/- 0.009 Np/cm-MHz (0.47 dB/cm-MHz) with a frequency dependence of fn, where n = 1.05 +/- 0.25, in agreement with in vitro studies of mammalian liver. In diffuse liver disease, no relationship was found between the attenuation coefficient and the results of CT or conventional ultrasonic examination. A trend towards higher attenuation with increased fibrosis and fat, as graded from liver biopsies, was noted, but the results were generally not statistically significant. However, a significant correlation was found between high values of attenuation and abnormal liver function tests. High attenuation is also found with ingestion of alcohol, chemotherapeutic agents, and steroids, all of which may affect liver composition.