Serial Changes of Tendon Histomorphology and Strain Elastography After Induced Achilles Tendinopathy in Rabbits: An In Vivo Study.

OBJECTIVES: The purpose of this study was to investigate and compare the serial changes of morphology and strain in the early process of Achilles tendinopathy in a rabbit model. METHODS: A total of 10 New Zealand white rabbits underwent ligation of one of their Achilles tendons to induce ischemic injury. Both inflamed and contralateral Achilles tendons were serially evaluated with 3 follow-ups: the first on days 3 to 5, the second on days 9 to 13, and the third and last follow-up on days 15 to 20 after surgery. During each examination, tendon thickness was measured and red, green, and blue pixel intensities of the elastogram were analyzed using color histogram analysis software. Differences between the inflamed and control group were compared. RESULTS: The mean thickness of the inflamed tendons increased during consecutive follow-ups and was significantly larger than that of control tendons (P < .01). The mean red pixel intensity ratio of the inflamed tendons was also serially increased and was higher than that in the control tendons, indicating softening. However, the difference was significant only in the second and third follow-ups (P < .01). CONCLUSIONS: Tendon thickening and softening developed during the early process of Achilles tendinopathy in a rabbit model. Tendon softening may present later than thickening.

Quantitative analysis of tumor volume reduction after three-dimensional conformal radiation therapy for intracranial meningiomas.

To provide radiobiological information on the inherent response of intracranial meningiomas after three-dimensional conformal radiation therapy. Quantitative tumor volume measurements were generated from 120 magnetic resonance images of a total of 24 patients. Gross tumor volumes were delineated on a series of contrast-enhanced T1-weighted magnetic resonance images by using commercial software. The percentage of tumor volume reduction at each follow-up was determined and compared to the baseline tumor volume. The median follow-up time was 103.5 months (range 30-137 months). The mean pre-radiation therapy tumor volume was 30.0 cm(3) (range 1.3-167.4 cm(3)). Tumor volume reduction was observed in 96 % of the study population. The mean absolute and relative tumor volume reduction were 14.0 cm(3) (range -0.6-84.5 cm(3)) and 40.8 % (range -6.8-82.9 %), respectively. The mean relative tumor volume reduction was 15.9, 28.9, 40.5, 50.3, and 52.6 % at 2, 4, 6, 8, and 10 years after irradiation. The quantitative volumetric analysis of the pattern of tumor volume reduction in response to irradiation gives an insight into the radiobiological nature of intracranial meningiomas after conventionally fractionated radiation therapy.

Effective mechanical thrombectomy in a patient with hyperacute ischemic stroke associated with cardiac myxoma.

Ischemic stroke is the most common neurologic manifestation of cardiac myxoma. However, there has been no current guideline on the treatment of hyperacute ischemic stroke due to cardiac myxoma. We describe a patient with hyperacute stroke caused by cardiac myxoma who had a good outcome with rapid recanalization through mechanical thrombectomy. A 46-year-old man was admitted with acute symptoms of right side hemiplegia and global aphasia. Brain computed tomography (CT) angiography showed a T occlusion of the left internal carotid artery. Intravenous recombinant tissue plasminogen activator was administered. However, his clinical symptoms did not improve. Thus, we performed endovascular treatment and had a successful outcome. A pathologic examination of the retrieved clot revealed a tumor emboli from a cardiac myxoma. Transthoracic echocardiogram revealed a left atrial myxoma in which a large mass was attached to the posterior wall of the aorta. The patient's neurologic deficits recovered with the exception of left eye blindness. Reperfusion therapy with mechanical thrombectomy might be safe and effective for the rapid revascularization of large vessel occlusions in hyperacute ischemic stroke, from which the tumor thrombi can be retrieved.

Direct-puncture embolization of scalp arteriovenous fistulae.

We present our experience of flow control with the aid of a circular compression device (CCD) for embolization of scalp arteriovenous fistulae (sAVFs). A 21-year-old female presented with a pulsating scalp mass with sAVFs fed by the superficial temporal arteries. A CCD with a beveled circular handle and concentric hole was used to treat the condition. After the CCD was compressed over the area of the fistulae, the fistulae were punctured and blood regurgitation was assured. While maintaining flow stasis within the boundary of the CCD and loading heparinized dextrose-saline solution, a 50% mixture of N-butyl-2-cyanoacrylate and Lipiodol was applied during the compression, which was sustained for 1-2 minutes. Finally, the sAVFs were almost completely occluded without complications. Our designed CCD was effective for flow control, and direct-puncture embolization of N-butyl-2-cyanoacrylate during flow control using the CCD was safe and effective for the treatment of sAVFs.

Remote cerebral and cerebellar hemorrhage after massive cerebrospinal fluid leakage.

Dural tears can occur during spinal surgery and may lead to cerebrospinal fluid (CSF) leakage which is rarely involved in remote cerebellar hemorrhage. Only a few of cases of simultaneous cerebral and cerebellar hemorrhage have been reported in the English literature. We experienced a case of multiple remote cerebral and cerebellar hemorrhages in a 63-year-old man who exhibited no significant neurologic deficits after spinal surgery. Magnetic resonance imaging (MRI) performed 4 days after the surgery showed a large amount of CSF leakage in the lumbosacral space. The patient underwent the second surgery for primary repair of the dural defect, but complained of headache after dural repair surgery. Brain MRI taken 6 days after the dural repair surgery revealed multifocal remote intracerebral and cerebellar hemorrhages in the right temporal lobe and both cerebellar hemispheres. We recommend diagnostic imaging to secure early identification and treatment of this complication in order to prevent serious neurologic deficits.

Does a growing tumour volume induce lymphangiogenesis? A study of oral/oropharyngeal cancer.

OBJECTIVE: Tumour cell metastasis to regional lymph nodes is an early event in the spread of metastatic tumour. We postulated that an increased primary tumour volume (PTV) may modulate cervical nodal metastasis by altering lymphangiogenesis. SETTING: We investigated 48 patients who had previously been diagnosed with cancer of the oral cavity and oropharynx. METHODS: The tumour area was manually outlined from an axial magnetic resonance imaging series. The three-dimensional reconstruction software automatically calculated the PTV. Immunohistochemical staining was performed with vascular endothelial growth factor (VEGF)-C, VEGF-D, and D2-40 monoclonal antibodies on the paraffin-embedded tissues obtained from the primary tumour. MAIN OUTCOME MEASURES: The associations among the semiquantitative scores of the VEGF-C/D stained cancer cells, lymphatic vessel density (LVD), and PTV were investigated. RESULTS: PTV had a significant relationship with LVD (p  =  .037) and N+ disease (p  =  .024). VEGF-C expression was significantly associated with lymph node metastasis (p  =  .018), increased LVD (p < .001), and tumour differentiation (p  =  .015) . However, we found no significant relationship between VEGF-C expression and the PTV. Similarly, among the various clinical factors, we found that the N stage (p  =  .001) and LVD (p  =  .008) were significantly associated with VEGF-D expression. However there was no association between VEGF-D expression and the primary PTV. CONCLUSIONS: Although PTV had a significant relationship with LVD and N+ disease, we could not find any clear correlation between the expression of VEGF-C/D and the PTV.

The correlation between carotid siphon calcification and lacunar infarction.

INTRODUCTION: The aim of this study was to evaluate the correlation between carotid siphon (CS) calcification and lacunar infarction caused by small-vessel disease. METHODS: This retrospective study included 445 patients (M/F = 256:189) older than 40 years (mean age 60.0 ± 12.3 years, range 41-98 years) without large intracranial lesions who had undergone both brain CT and MRI within an interval of 6 months. The patients were classified into three groups according to the number of lacunar infarctions: group I-zero infarctions (n = 328), group II-one to three infarctions (n = 94), and group III-four or more infarctions (n = 23). The severity of CS calcification was evaluated on CT and scored on a five-point scale (0-none, 1-stippled, 2-thin continuous or thick discontinuous, 3-thick continuous, 4-double tracts), and the calcification scores on both sides were summed. An ANOVA test was used to compare calcification scores among the three groups, and a logistic regression test was used to evaluate the influence of CS calcification and known cerebrovascular risk factors on the occurrence of lacunar infarction. RESULTS: On the ANOVA test, total calcification scores were significantly different among the three groups (group I = 1.28 ± 1.99, group II = 3.31 ± 2.39, group III = 4.36 ± 2.08; P < 0.05). Higher rates of lacunar infarction were associated with higher CS calcification scores. On the logistic regression test, CS calcification, age, and hypertension were significant risk factors for lacunar infarction (P < 0.05). CONCLUSION: CS calcification was correlated with the occurrence of lacunar infarction. The degree of CS calcification may be used to predict the possibility of a future lacunar infarction.

Cut-off value for needle washout thyroglobulin in athyrotropic patients.

OBJECTIVES/HYPOTHESIS: The purpose of this study was to determine the appropriate cut-off value for fine needle aspiration-thyroglobulin (FNA-Tg) associated with postoperative recurrences and validate the diagnostic efficacy of FNA-Tg in patients after total thyroidectomy compared with concomitant cytology (C). STUDY DESIGN: Retrospective. METHODS: We retrospectively evaluated the results of ultrasound-guided FNAs performed for suspicious cervical lesions of 40 patients (male:female = 10:30; mean age, 44.0 years) after total thyroidectomy (mean duration, 89.1 months), to acquire the material for Tg and C analysis. After collection of the cytologic sample, we rinsed the same needle with 1 mL of normal saline for Tg radioimmunoassay. RESULTS: Of 40 lesions (mean size, 0.89 cm; range, 0.3-3.5 cm), 21 were confirmed as recurrences and 19 were nonrecurrences. The rates of nondiagnostic sampling and sensitivity and specificity of FNA-C when diagnostic sampling was obtained were 40% (16/40), 100% (14/14), and 90.0% (9/10), respectively. According to receiver operating characteristic analysis, the optimal cut-off value of FNA-Tg was 4.1 ng/mL (sensitivity, 100% [21/21]; specificity, 100% [19/19], P < .05). Furthermore, in 16 inconclusive lesions due to nondiagnostic cytologic results, the FNA-Tg results coincided with a final diagnosis (seven recurrences and nine nonrecurrences). The cases with maximum diameters <1 cm showed a significantly increased rate of nondiagnostic cytologic results, and the FNA-Tg results were more helpful than lesions > or =1 cm in diagnosing a recurrence (P < .05). CONCLUSIONS: Measurement of FNA-Tg is helpful for distinguishing recurrent from nonrecurrent lesions in the majority of patients who were previously treated for well-differentiated papillary thyroid carcinoma.

Concurrent chemoradiation followed by adjuvant chemotherapy in patients with locoregionally advanced nasopharyngeal carcinoma in Korea.

PURPOSE: Concomitant approach using cisplatin and 5-fluorouracil (5-FU) has shown an excellent local control rate and significantly reduced distant metastasis in patients with locally advanced nasopharyngeal carcinoma (NPC). However, optimal schedule and dosing of chemotherapy still need to be developed to reduce distant metastasis. This retrospective study was conducted to evaluate the efficacy, toxicity, and tolerability of a concurrent chemoradiation therapy (CCRT) regimen using cisplatin and 5-FU followed by adjuvant chemotherapy (AC) in patients with locoregionally advanced NPC. METHODS: Forty-three NPC patients who had AJCC stage T3/T4 or N2/N3 and M0 disease were evaluated. The chemotherapy during CCRT consisted of cisplatin (75 mg/m(2) on day 1) plus 5-FU (750 mg/m(2)/day on day 1-5), delivered every 4 weeks for two cycles. Three cycles of AC were given with cisplatin (75 mg/m(2)), epirubicin (37.5 mg/m(2)) on day 1, and bleomycin (7.5 mg/m(2) bolus iv. on day 1 followed by 9 mg/m(2) on day 1-5 by continuous infusion) every 3 weeks. RESULTS: The overall response rate after CCRT was 95% (22 CRs and 19 PRs in 43) and 100% (16 CRs and 8 PRs in 24) after AC. Grade 3/4 neutropenia, mucositis, and weight loss were observed during CCRT phase in 18, 44, and 26% of patients, respectively. AC caused grade 3/4 neutropenia and emesis in 12.5 and 20.8% of patients, respectively. CONCLUSIONS: CCRT regimen using cisplatin and 5-FU followed by three cycles of BEC chemotherapy was effective in locally advanced NPC patients, with acceptable and reversible acute toxicities.

Clinical efficacy of primary tumor volume measurements: comparison of different primary sites.

OBJECTIVES: The purpose of study was to determine the clinical efficacy of primary tumor volume measurements of different primary sites in the oropharynx compared to the oral cavity. METHODS: A retrospective analysis of 85 patients with oral cavity or oropharynx cancer. The tumor area was manually outlined from axial magnetic resonance (MR) series. The software calculated the tumor volumes, automatically. The values of the primary tumor volumes were then subdivided into separate groups (3,500 mm(3)). RESULTS: The prognostic indicators were the cT and cN (oral cavity); age, primary site, cT, cN, and primary tumor volume (oropharynx) on the univariate analysis. There was no significant prognostic factor for oral cavity cancer on the multivariate analysis. Primary site, cN, and primary tumor volume were independent prognostic indicators for oropharynx cancer by multivariate analysis. CONCLUSION: Primary tumor volume measurement is a reliable way to stratify outcome, and make up for the weak points in the American Joint Committee on Cancer staging system with oropharynx cancer.

Hemodynamic depression during carotid angioplasty with stenting: potential risk factors determined by multidetector computed tomography angiography and related clinical factors.

OBJECTIVE: To investigate potential risk factors for hemodynamic depression (HD) in elective carotid angioplasty with stenting (CAS) by using multidetector computed tomography (MDCT) angiographic findings and clinical data. METHODS: A retrospective study was conducted for 32 patients that underwent MDCT angiography before CAS in our hospital. We reviewed the MDCT angiographic findings to evaluate parameters including total plaque volume, composition and the composition ratio of plaque, degree of stenosis, and distance of the most stenotic portion from carotid bifurcation. Clinical data such as patient age, presence of neurological symptoms, underlying medical disease, smoking history, and previous stroke history were noted. The MDCT angiographic parameters and clinical data were then analyzed to determine a prediction for periprocedural HD (systolic blood pressure, <90 mm Hg; or heart rate, <40 beats/min). RESULTS: Periprocedural HD was observed in 9 patients (28.1%). Among the MDCT angiographic parameters, the hemodynamic unstable group of patients had a smaller total plaque volume than that of stable group of patients (P = 0.04). The other MDCT parameters and clinical data did not show statistically significant difference between 2 groups. CONCLUSIONS: In this study, only the total volume of plaque was a positive factor for predicting HD during CAS. Multidetector computed tomography angiography can be helpful for predicting HD during CAS.

Sonographically guided fine needle aspiration of thyroid nodule: discrepancies between cytologic and histopathologic findings.

PURPOSE: To analyze the discrepancies between the cytologic results of sonographically (US)-guided fine needle aspiration (FNA) of thyroid nodules and final histopathologic results and to discuss the limitations of US-guided FNA. MATERIALS AND METHODS: The results of US-guided FNAs performed by a single experienced radiologist in 315 thyroid nodules in 292 patients (246 women, 46 men aged 12-79 years) were retrospectively correlated with their surgical pathologic results. The FNA results were classified as nondiagnostic, indeterminate, negative, or positive, whereas final pathologic diagnoses were classified as malignant or benign. RESULTS: The FNA results were nondiagnostic in 31 cases (9.8%), indeterminate in 97 cases (30.8%), and determinate in 187 cases (59.4%). Of the 187 conclusive cases, 169 (90.4%) were concordant with the final pathologic results, whereas 18 (9.6%) were discordant with 14 false-positive and 4 false-negative results. These discrepancies were caused by atypical nuclear features. Among the 97 indeterminate and 31 nondiagnostic cases, a malignancy was found in 14 (14.4%) and 8 (25.8%) cases, respectively. In addition, 10 papillary carcinomas, which were not visualized on sonograms, were detected incidentally in thyroidectomy specimens. CONCLUSION: The diagnostic accuracy of US-guided FNA of thyroid nodule has limitations that should be minimized by careful interpretation of the cytologic findings and accurate sampling.

US diagnosis of cervical recurrence in patients operated on thyroid cancer: sonographic features and clinical significance.

OBJECTIVE: To describe the sonographic features of cervical recurrence in patient with thyroid cancer and review clinical significance. MATERIALS AND METHODS: Twenty-two consecutive patients with 24 surgically confirmed recurrences undergoing preoperative ultrasonography (US) and US-guided fine needle aspiration biopsy (FNAB) were enrolled. Retrospective analysis was conducted on the sonographic features of recurrence including size, location, shape, echogenicity, multiplicity, laterality relative to initial primary tumor and presence of characteristic findings; cystic change and microcalcification. In addition, review was made on their clinical data including the time interval between the thyroidectomy and the recurrence, serum thyroglobulin (Tg), anti-thyroglobulin antibody (Tg Ab) and 131 iodine whole body scan (IWBS). RESULTS: Fifteen of 24 recurrences occurred in internal jugular lymphatic chain and 9 in the postoperative paratracheal region with mostly ipsilaterally to the initial tumor (19/24). Their mean size was 1.0 cm (range: 0.5-2.5 cm) with ovoid (n=18) or lobulated (n=6) shape. They appeared hyperechoic in nine (37.5%), hypoechoic in nine (37.5%), and mixed echoic due to cystic change in six (25.0%). Microcalcification was observed in eight (33.3%) and multiplicity in seven (29.2%). US-guided FNAB established the preoperative diagnosis of recurrence in all. The mean interval between the thyroidectomy and recurrence was 59 months (range: 15-162 months). Suspicion of recurrence was possible in 8 with Tg of 2 ng/ml or greater (8/24) during thyroxine (T4) therapy and 6 (6/8) after T4 withdrawal. All of the 8 recurrences were negative on 131 IWBS. In two patients with Tg less than 2 ng/ml after T4 withdrawal, elevated Tg Ab was observed. CONCLUSION: US and US-guided FNAB are valuable postoperative follow up modalities of thyroid cancer due to their convenience, early detection and precise localization. Therefore, it's essential to get familiar with sonographic findings of cervical recurrence.

Obliterative urethral stricture: MR urethrography versus conventional retrograde urethrography with voiding cystourethrography.

Institutional review board approval and informed consent were obtained. The purpose of the study was to prospectively evaluate magnetic resonance (MR) urethrography for the depiction of obliterative urethral stricture. Twelve patients with obliterative urethral stricture were examined preoperatively with T2-weighted, T1-weighted, and contrast material-enhanced T1-weighted MR imaging of a urethra distended with sterile lubricating jelly. Ten of the 12 patients were examined with conventional retrograde urethrography (RGU) combined with voiding cystourethrography (VCUG) prior to MR imaging. Each imaging result was compared with either a surgical specimen or a description of the surgical findings to determine which method allowed accurate estimation of stricture length. MR measurements of stricture length demonstrated significantly lower errors (P < .05) and better linear fit to surgical measurement than did conventional RGU combined with VCUG measurements (r(2) = 0.85, P < .001 and r(2) = 0.03, P > .05, respectively). MR imaging of the urethra distended with sterile lubricating jelly is an effective tool for evaluating obliterative urethral strictures.

Extraadrenal paragangliomas of the body: imaging features.

OBJECTIVE: This article illustrates the anatomic distribution of the healthy paraganglion system and the imaging and pathologic features of various extraadrenal paragangliomas occurring in the head and neck, chest, and abdomen. CONCLUSION: Although paragangliomas can occur in a variety of anatomic locations, the majority are seen in relatively predictable regions of the body. Extraadrenal paragangliomas have nearly identical imaging features, including a homogeneous or heterogeneous hyperenhancing soft-tissue mass at CT, multiple areas of signal void interspersed with hyperintense foci (salt-and-pepper appearance) within tumor mass at MRI, and an intense tumor blush with enlarged feeding arteries at angiography.

Diffusion-weighted magnetic resonance imaging in the syndrome of acute bilateral basal ganglia lesions in diabetic uremia.

In this report, we have presented a diabetic patient with uremia, in which acute Parkinsonism occurred, coupled with acute mental confusion, after a sudden increase in blood urea nitrogen and serum creatinin levels. Diffusion-weighted magnetic resonance imaging revealed a unique cytotoxic-type edema in the bilateral basal ganglia during the acute phase. Signal alterations were shown to regress in accordance with the normalized apparent diffusion coefficient (ADC) values, but irreversible cystic degeneration developed in the globus pallidus, with the very low preceding ADC values.

Inflammatory myofibroblastic tumor of the larynx.

BACKGROUND: Inflammatory myofibroblastic tumor, composed of myofibroblastic spindle cells with acute and chronic inflammatory cells, is an unusual, benign solid mass that mimics a neoplastic process. METHODS: We report a rare case of a patient with a laryngeal inflammatory myofibroblastic tumor. Laryngoscopy demonstrated a submucosal mass involving the right false cord. The mass was a well-enhanced supraglottic lesion on CT scan. It showed medially high signal intensity and peripherally low signal intensity on T2-weighted MR images, and it displayed a high magnetization transfer ratio; before surgery, it was believed to be a malignant tumor. Laryngoscopic biopsy was performed. Pathologic features of the specimen were diagnostic for inflammatory myofibroblastic tumor. RESULTS: Steroid therapy was chosen for further treatment. No recurrence was observed for 4 years. CONCLUSION: In patients with chronic hoarseness who have a malignant-looking submucosal laryngeal mass, inflammatory myofibroblastic tumor should be considered. Conservative surgery and steroid treatment are advocated because of laryngeal preservation.

Granulocytic sarcoma (chloroma) presenting as a lateral neck mass: initial manifestation of leukemia: a case report.

We present a rare case of granulocytic sarcoma (chloroma) in the lateral neck as an initial manifestation of acute leukemia in a 37-year-old man. The lesion appeared as a solid mass with homogenous contrast enhancement on CT. Recognition of this rare entity is important, because early, aggressive induction chemotherapy can improve prognosis.

Acinic cell carcinoma of the head and neck: radiologic-pathologic correlation.

OBJECTIVE: To describe and correlate the imaging and pathologic findings of acinic cell carcinoma (ACC) in the head and neck. METHODS: We reviewed the radiologic findings of 12 patients with pathologically proven ACC in the head and neck. They were 6 males and 6 females (ages: 5-75 years, mean 36 years) who undergoing computed tomography (CT, n=9) and CT with magnetic resonance (MR) imaging (n=3). RESULTS: The lesions in the superficial lobe of the parotid gland were solid (n=7), cystic (n=1), and cystic mass with mural nodule (n=1) on CT. A parapharyngeal lesion was cystic mass with mural nodule, and a submandibular and a palate tumor were cystic lesions on CT. All solid masses in the parotid gland (n=7) included focal low-attenuating portions on CT, which were microcyst, hemorrhage, or necrosis on pathologic examination. We could not find intratumoral calcifications or metastatic lymphadenopathy on imaging and histologic studies in all 12 cases. Internal hemorrhage on the MR images was seen in a parapharyngeal and a parotid lesion. CONCLUSION: Although ACC appears to have nonspecific imaging findings, familiarity with some imaging features can be helpful for differential diagnosis of head and neck tumors.

CT findings in Kikuchi disease: analysis of 96 cases.

BACKGROUND AND PURPOSE: Although CT findings of Kikuchi disease (KD), or histiocytic necrotizing lymphadenitis, are reported in several case reports, large-scale analysis of the disease has not been undertaken. We characterized the clinical and CT findings in a large group of patients with KD. METHODS: Between 1990 and 2002, 96 patients (68 women, 28 men; mean age, 24.4 years) underwent biopsy of the cervical lymph nodes and had histologically proved KD at our institution. We reviewed their clinical and CT findings and recorded the total number of affected nodes; location and size of the lymph nodes; and characteristic findings including necrosis, perinodal infiltration, and contrast enhancement. RESULTS: We identified 1196 affected lymph nodes (12.5 nodes per patient). The affected lymph nodes were 0.5-3.5 cm (mean, 1.62 cm). Perinodal infiltration was found in 78 patients (81.3%). Eighty (83.3%) had homogeneous nodal contrast enhancement. Nine patients (9.4%) had lymph nodes with a focal low attenuation, and seven (7.3%) had ring-shaped lymph nodes. Unilateral and bilateral cervical lymph nodes were affected in 76 and 20 patients, respectively. Lymph nodes were mainly located at levels II (IIA, 174 nodes; IIB, 254 nodes), III (222 nodes), IV (160 nodes), and V (VA 126 nodes, VB 130 nodes). Follow-up CT in 32 patients showed complete resolution in 14 and partially improved lymphadenopathy in 18. CONCLUSION: Awareness of the various CT appearances of KD and follow-up CT may be helpful for more accurate diagnosis of the disease.