The value of immunoscintigraphy in the detection of recurrent colorectal cancer.

The aim of this prospective study was to determine whether anti-carcinoembryonic antigen (anti-CEA) scintigraphy is a useful additional technique in the diagnosis recurrence of colorectal cancer. Forty patients with suspected recurrence of colorectal cancer, underwent immunoscintigraphy (IS) and helical computed tomography (CT) in the 2 weeks before surgery. Surgical findings were used to evaluate the performance of the imaging techniques. Suspected areas on IS and CT were systematically explored. Helical CT was found to be superior to IS for the liver, the sensitivity and specificity of CT being 100% and 90%, respectively, vs 53% and 100% for IS. However, IS was better than CT for the detection of extra-hepatic abdominal recurrence: sensitivity and specificity of IS were 100 and 82% respectively vs 33 and 82% for CT. Seven cases of peritoneal carcinomatosis were overlooked by helical CT. Our results indicate that IS improves detection of extra-hepatic abdominal recurrence of colorectal cancer. Immunoscintigraphy is valuable as a guide to the treatment strategy and operative procedures.

Technetium-99m ECD single photon emission computed tomography in brain trauma: comparison of early scintigraphic findings with long-term neuropsychological outcome.

OBJECTIVE: The aim of this study was to assess the prognostic value of early brain scintigraphy in head injury in relation to long-term neuropsychological behavior. Twenty-four patients underwent technetium-99m (Tc-99m) ethyl cysteinate dimer single photon emission computed tomography (SPECT) within 1 month of the trauma. Scintigraphic abnormalities were evaluated both visually and semiquantitatively using the brain-to-cerebellum ratio method. The clinical neuropsychological investigation was conducted to evaluate abnormalities related to motor deficit, frontal behavior, and memory and language disorders. All patients had abnormalities on SPECT scan. One year after trauma, 14 patients (58%) had neuropsychological sequelae. The brain-to-cerebellum ratios in the left basal ganglia and brain stem were significantly decreased in patients with memory disorders (P = .03 and P = .02, respectively). Moreover, SPECT visual analysis indicated that low uptake in the basal ganglia, thalamus, and brain stem was associated with subsequent motor deficit, frontal behavior, and language and memory disorders. The authors conclude that brain SPECT can be valuable in predicting the neuropsychological behavior of survivors of severe head injury.

[Evolution of ventricular septal defects. Relation to echocardiographic anatomy]. / Evolution des communications interventriculaires membraneuses. Relation avec l'anatomie échocardiographique.

The aim of this study was to analyse the outcome of membranous ventricular septal defects (VSD) with respect to the echocardiographic data obtained during the first year of life. This retrospective series included patients born between January 1st 1986 and December 31st 1995, in the Indre et Loire department, with membranous ventricular septal defects alone or associated with minor abnormalities. The initial echocardiography, an echocardiography performed 2 to 6 months later, one a year later and the final echocardiography were compared. Three groups of VSD were constituted according to their diameter: group I (< or = 3 mm), group II (3-6 mm), and group III (> 6 mm). Depending on the outcome, the patients were classified as spontaneous closure (group A), surgical closure (group B) or persistent VSD (group C). The population comprised 84 children. There were 6 spontaneous deaths, three of which were unexplained, and 7 children were lost to follow-up. After the initial echocardiography, the VSD were classified as group I (38%), group II (26.2%) and group III (35.7%). After the second echocardiogram, 24 VSD changed group (31.5%), by increase (N = 10) or decrease (N = 14) in diameter. Aneurysms of the membranous septum were observed during the first two echocardiographies in 31.2% and 79.3% of VSDs of group I, 31.8% and 70% of VSDs of group II and 6.6% and 3.3% of VSDs of group III (p < 0.01). The average follow-up was 3.1 years (range 1 month-10 years). In group A (N = 22), the mean age of closure of the VSD was 26 months (3 months-7 years). In group B (N = 28), surgery was undertaken at an average age of 10 months (range 3 months-5 years). In group C (N = 21), the VSDs were classified as group I (N = 19) or group II (N = 2) at the last echocardiography. The frequency of aneurysms of the membranous septum in groups A, B and C were respectively 100%, 7.1% and 66.6% (p < 0.01). At the second echocardiographic examination, a significant relationship (p < 0.001) was observed between the diameter of the VSDs and their outcome. The VSDs of group A were associated with aneurysms of the membranous septum more often than those of group C (p < 0.005). The authors conclude that surgery is required in about one third of membranous VSD. At medium term, the others either close spontaneously or become smaller in comparable numbers. The outcome is directly related to the diameter of the VSD and the development of an aneurysm of the membranous septum. During the first 6 months, the dimensions of membranous VSDs change in about 30% of cases with an increase in frequency of aneurysms of the membranous septum.

Diagnosis of arrhythmogenic right ventricular cardiomyopathy by fourier analysis of gated blood pool single-photon emission tomography.

To evaluate the diagnostic performance of Fourier phase analysis of gated blood pool single-photon emission computed tomography (GBP SPECT) in arrhythmogenic right ventricular (RV) cardiomyopathy, 18 patients with confirmed arrhythmogenic RV cardiomyopathy underwent GBP SPECT and x-ray cineangiography. Results were compared with data obtained with GBP SPECT in 10 control subjects. This 3-dimensional method demonstrated good correlation with cineangiography for measurements of RV enlargement and extent of the disease; RV and left ventricular segments were analyzed with the same accuracy. Tomographic abnormalities were significant decreased RV ejection fraction, RV dilatation, nonsynchronized contraction of the ventricles, increased RV contraction dispersion, presence of segmental RV wall motion disorders and/or phase delays, and occasionally regional left ventricular abnormalities. RV-delayed phase areas were always present in our population. A scoring system with RV criteria was proposed to diagnose RV disease. Because Fourier analysis of GBP SPECT provides ventricular morphologic information for the right ventricle with the same accuracy as for the left ventricle, it may replace planar radionuclide studies. Therefore, this method is helpful in patients with a strong clinical suspicion of arrhythmogenic RV cardiomyopathy, and should be used as a screening method before right ventriculography.

Free-floating thrombus and embolic risk in patients with angiographically confirmed proximal deep venous thrombosis. A prospective study.

BACKGROUND: A free-floating thrombus (FFT) is often considered to be a risk factor for pulmonary embolism (PE), despite adequate anticoagulation therapy, in patients with proximal deep venous thrombosis. METHODS: Ninety-five patients underwent prospective assessment according to the presence (FFT group [n = 62]) or absence (occlusive thrombus group [n = 28]) of an FFT. On day 1, color venous duplex scanning, venography (reference method), perfusion lung scanning, and, if results of the lung scan were abnormal, pulmonary angiography were performed. On day 10 (range, days 9-11), the lung scan was repeated, as well as pulmonary angiography if the lung scan demonstrated impairment. A 3-month clinical follow-up visit was scheduled. Five patients were retrospectively excluded from analysis for uncertain diagnosis of FFT. Patients were treated with intravenous unfractionated heparin sodium adjusted for activated partial thromboplastin time (n = 1) or subcutaneous low-molecular-weight heparin (n = 89) (nadroparin calcium, 225 Institut Choay factor Xa inhibitory units per kilogram for 12 hours). Warfarin sodium therapy was initiated on day 3 (range, days 2-4). RESULTS: Both groups were well-matched according to age, sex, risk factors, and delay from onset of symptoms to treatment. Positive and negative predictive values of color venous duplex scanning for the diagnosis of an FFT were 91% and 55%, respectively. On admission, PE prevalence was 64% in the FFT group (40 of 62 patients) and 50% in the occlusive thrombus group (14 of 28 patients) (P = .19). Two patients were excluded on follow-up analysis (range, days 9-11) for preventive vena cava filtering (due to major bleeding in 1 and cholecystectomy in the other); the recurrent rate of PE was 3.3% in the FFT group (2 of 61 patients) and 3.7% in the occlusive thrombus group (1 of 27 patients). No symptomatic recurrent PE occurred between day 10 (range, days 9-11) and 3 months. Four patients died of evolutive neoplasm after hospital discharge. CONCLUSIONS: No higher risk for PE was observed in patients with free-floating proximal deep venous thrombosis; anticoagulant therapy should prevent recurrent PE in such patients.

[Echocardiographic Doppler study of left ventricular filling in the diagnosis of minimal or moderate rejection in cardiac transplantation]. / Etude du remplissage ventriculaire gauche par écho-Doppler cardiaque pour le diagnostic de rejet aigu minime ou modéré dans les transplantations cardiaques.

The study of left ventricular filling by Doppler echocardiography may be a non-invasive diagnostic method of detection of acute rejection of cardiac transplants. The aim of this study was to assess the value of the method for diagnosis of minimal to moderate rejection (grades 1 to 3 of the Billingham classification). A total of 466 Doppler echocardiographic studies were performed in 23 cardiac transplantation patients (21 men, mean age 49.3 +/- 10 years) with endomyocardial biopsy as the reference method for the diagnosis of rejection. Over a follow-up period of 18.5 +/- 10 months, 22.7% of biopsies showed minimal or moderate rejection. The Doppler measurements of the isovolumic relaxation period and peak early diastolic (E) velocity with respect to the mitral velocity-time integral were no different in cases of acute rejection. The only difference observed was in the mitral half-pressure time which was much shorter in cases of rejection. However, after drawing a ROC graph, the accuracy of this parameter was insufficient for diagnosing rejection irrespective of the threshold of variation considered (23% sensitivity for a 20% shortening and 36% sensitivity for a 10% shortening). The authors conclude that Doppler echocardiographic study of left ventricular filling is of limited value for the diagnosis of acute minimal or moderate rejection in cardiac transplant patients. The half-pressure time may be a useful complement to endomyocardial biopsy or when biopsy investigations are performed less frequently.

[Scintigraphic detection of gastrointestinal hemorrhage. Value and limitations]. / Localisation scintigraphique des saignements digestifs. Intérêts et limites.

A technetium-99m labelled red blood cell scintigraphy was performed in 51 patients with an unexplained gastro intestinal bleeding. Static images were acquired on the injection day then at 24 hours. Forty one patients had a positive scintigraphy. In 13 patients with a positive scintigraphy, on the injection day (5 cases) and later (8 cases), no intestinal bleeding was identified in spite of further investigations guided by scintigraphy. In 24 patients, with a positive scintigraphy on the injection day (20 cases) and later (4 cases), an intestinal lesion was identified and treated; data were confirmed in 19 cases: there were 15 colon lesions, localized on caecum in 10 cases and 4 small bowel lesions. Clinical value and limitations of the investigation are discussed. The scintigraphic localization is usually accurate if the abnormal focus activity is noticed on the injection day. It helps to guide further investigations of the bleeding site. This non invasive method should be performed more quickly to help to localize intestinal bleeding which poses a diagnostic problem.

[Significance of isotopes in the study of pre-excitation and ventricular tachycardia]. / Intérêt des isotopes dans l'étude des préexcitations et des tachycardies ventriculaires.

In normal patients, Mac Carthy has demonstrated that there was a very close correlation between the ventricular contractile activity, evaluated by Fourier's isotopic phase analysis, and electrical depolarization, evaluated by endocardial mapping. It has therefore been possible to study asynchronisms or asymmetries of the ventricular contraction-depolarization and particularly the syndromes of ventricular pre-excitation and ventricular tachycardias. In Wolff-Parkinson-White syndromes (WPW), the mapping obtained by heart cavity tomography in addition to dual-plane gamma-angiography, provides most useful informations, due to additional section planes permitting tridimensional location of the earliest site of ventricular activation. It is quite useful to locate the bundle of Kent always difficult on surface electrocardiogram, or when the endocardial exploration does not permit to precisely locate the site of the excentric atrial activation in case of multiple bundles of Kent or without retrograde conduction. When the left bundle of Kent is barely identified, the isotopic image may be improved by oesophageal stimulation. Additional parameters (use of several harmonics, factorial analysis) will permit to improve the localization of accessory pathways, to be destroyed by fulguration or surgery. In case of ventricular tachycardias with limited functional tolerance, only gamma-angiography, lasting only 3 to 5 minutes, may be used. Combined with endocardial tomography or even gamma-angiography performed in sinus rhythm, not only the site of origin of the ventricular ectopy may be localized, but it also can be correlated with ventricular kinetics abnormalities and the cardiopathy in question may be identified. Most authors consider that there is a close relationship between isotopic site, electrocardiographic appearance and the site found by endocardial mapping or "pace-mapping". In patients with ventricular tachycardias of different morphologies, isotopic mapping permits to differentiate those originating from a same lesion (which may be treated by surgery of fulguration) from those originating in remote areas. Therefore, this technique is a non aggressive and rapid method providing accurate informations on severe rhythm disorders currently treated by eradication of their anatomical substratum.

[Limitations of two-dimensional echocardiography in infants under one month of age]. / Les limites de l'échocardiographie bidimensionnelle chez l'enfant de moins d'un mois.

One hundred and thirty-three children less than one month of age and presenting with congenital heart disease were investigated using two-dimensional echocardiography (TD echo). In these children, 234 cardiovascular abnormalities had been proven by hemodynamic and angiographic investigations (n = 103), post-mortem examinations (n = 15) or operative findings (n = 12). TD echo identified 201 cardiovascular abnormalities with 33 false negatives (sensitivity 86%) and 12 false positives (specificity 94%). Diagnosis after TD echo was correct in 100 children (75%), incomplete in 18 (13.5%), imprecise in 11 (8.3%) and false in 4 (3%). The most frequently unrecognized lesions were: anomalous systemic venous drainage (5/8), persistent ductus arteriosus (5/12), pulmonary stenosis (3/8), ventricular septal defect (5/27), coarctation (2/18). The lesions difficult to characterize concerned mostly the pulmonary valve and the aspect of the aortic arch. On the other hand, TD echo allowed to correctly identify major intracardiac abnormalities, malpositions of the great vessels and to well appreciate the dimensions of the trunk and branches of the pulmonary artery. These results allow to refrain from diagnostic endocavitary investigations in most of the heart defects revealed in the neonatal period and to perform curative or palliative closed heart surgery without preoperative catheterization. However, clinical, angiographic and hemodynamic investigations keep an important place in the preoperative evaluation of defects that may benefit from open heart surgery.

[Endocarditis of the ventricular septum. Echocardiographic diagnosis]. / Endocardite du septum interventriculaire. Diagnostic échocardiographique.

A 5 year-old child presented with prolonged fever, severe impairment of general condition and a pleuro-pericardium effusion. Echocardiography revealed a "bell-clapper-like tumor" in each ventricle, developed from the ventricular septum. Presence of a staphylococcal sepsis and early disappearance of the echocardiographic signs after antibiotic treatment allowed for diagnosis of bacterial endocarditis with abscess of the ventricular septum. Sinusitis and IgA deficiency were later found to be also present.

[Ultrasonic diagnosis and follow-up of aneurysms of the ampulla of Galen in infants]. / Diagnostic et surveillance de l'anévrysme de l'ampoule de Galien (AAG) du nourrisson par les ultrasons.

An aneurysm of the vein of Galen can have a varied sonographic appearance in infancy. The classical picture is a spherical posterior third ventricular mass with no internal echoes. With varying degrees of thrombosis of the aneurysm which may occur spontaneously or after surgery, the mass became hyper-echogenic. Our experience in two patients with this spectrum of echographic findings will be demonstrated and correlated with clinical findings CT scan, and angiography.

The contribution of nuclear medicine and ultrasounds in cardiac surgery.

The constant progress in surgical techniques during the last few years have prepared the way for important developments in the field of noninvasive cardiac exploration. Their non-traumatic character, appreciable in diagnostic and preoperative examinations, become indipensable whenever there is a need to repeat the examination in order to evaluate the effects of a treatment or to monitor progress both in the short and long term. In order that such methods be adopted in cardiac surgery it is important that not only must they be without risk but also that the results obtained be clearly presented, if possible in the form of images, and allow a quantitative interpretation. It is necessary also that the results can be justified both by clinical experience and also by comparison with other examinations. No procedure, not even radiologic, can at the same time explore the myocardium and its perfusion, the central circulation and the cardiac haemodynamics. By reason of their respective principles, radioisotopic methods and ultrasounds tackle cardiac problems in different ways and facilitate, by appropriate choice of methods, the selection of one diagnostic response from among several. This paper contains first of all, a resume of the principal nuclear and ultrasonic techniques used together with their basic principles. Next we try to show how these non-invasive techniques, most with dynamic imaging, can assist cardiac surgery. For this, we successively look at the different pathologies, working from the exterior (pericardium) towards the interior (intracardiac structures and central circulation) and covering the different aspects of the myocardial pathology. In each case the mutual contributions of physical techniques is specified as well as the preference for either isotopic or ultrasonic methods.