Current staging of hepatocellular carcinoma: imaging implications.

The incidence of hepatocellular carcinoma has been rising in the USA in the past two decades. Hepatocellular carcinoma primarily affects older people and reaches its highest prevalence among those aged between 50 and 70 years. Chronic infection by the hepatitis B virus is the most common cause of this disease. Since hepatocellular carcinoma is an indolent tumor, it has a low life expectancy. In patients with suspected hepatocellular carcinoma, CT, MRI, and ultrasound techniques are useful for formulating the diagnosis based on vascularity and specific enhancement features. In this paper we will discuss the multimodal approach for diagnosis and surveillance of hepatocellular carcinoma. We will also furnish the latest staging and treatment, epidemiology, clinical presentation, pathology and laboratory findings in hepatocellular carcinoma.

Interaction between the F plasmid TraA (F-pilin) and TraQ proteins.

Elaboration of conjugative (F) pili by F+ strains of Escherichia coli requires the activities of over a dozen F-encoded DNA transfer (Tra) proteins. The organization and functions of these proteins are largely unknown. Using the yeast two-hybrid assay, we have begun to analyse binary interactions among the Tra proteins required for F-pilus formation. We focus here on interactions involving F-pilin, the only known F-pilus subunit. Using a library of F tra DNA fragments that contained all the F genes required for F pilus formation in a yeast GAL4 activation domain vector (pACTII), we transformed yeast containing a plasmid (pAS1CYH2traA) encoding a GAL4 DNA-binding domain-F-pilin fusion. Doubly transformed cells were screened for GAL4-dependent gene expression. This screen repeatedly identified only a single Tra protein, TraQ, previously identified as a likely F-pilin chaperone. The F-pilin-TraQ interaction appeared to be specific, as no transcriptional activation was detected in yeast transformants containing pACTIItraQ plasmids and the Salmonella typhi pED208 traA gene cloned in pAS1CYH2. Two traQ segments isolated in the screen against F-pilin were tested for complementation of a traQ null allele in E. coli. One, lacking the first 11 (of 94) TraQ amino acids, restored DNA donor activity, donor-specific bacteriophage sensitivity and membrane F-pilin accumulation to wild-type levels. The second, lacking the first 21 amino acids, was much less effective in these assays. Both TraQ polypeptides accumulated in E. coli as transmembrane proteins. The longer, biologically active segment was fused to the GAL4 DNA-binding domain gene of pAS1CYH2 and used to screen the tra fragment library. The only positives from this screen identified traA segments. The fusion sites between the traA and GAL4 segments identified the hydrophobic, C-terminal domain IV of F-pilin as sufficient for the interaction. As TraQ is the only Tra protein required for the accumulation of inner membrane F-pilin, the interaction probably reflects a specific, chaperone-like function for TraQ in E. coli. Attempts to isolate an F-pilin-TraQ complex from E. coli were unsuccessful, suggesting that the interaction between the two is normally transient, as expected from previous studies of the kinetics of TraA membrane insertion and processing to F-pilin.

Tuberculosis versus lymphomas in the abdominal lymph nodes: evaluation with contrast-enhanced CT.

OBJECTIVE: Tuberculosis in the abdominal lymph nodes may be difficult to distinguish from lymphomas. This study evaluated specific CT imaging criteria for differentiating these entities. MATERIALS AND METHODS: We retrospectively reviewed the anatomic distribution and CT enhancement patterns of disease in 69 patients, 26 (38%) with tuberculosis and 43 (62%) with untreated lymphomas involving abdominal lymph nodes. Of the patients with tuberculosis, five (19%) had disseminated disease and 21 (81%) had nondisseminated disease. Of the patients with lymphomas, 16 (37%) had Hodgkin's disease and 27 (63%) had non-Hodgkin's lymphoma. RESULTS: Disseminated and nondisseminated tuberculosis involved predominantly lesser omental, mesenteric, anterior pararenal, and upper paraaortic lymph nodes. Lower paraaortic lymph nodes were involved more often in Hodgkin's disease (15 patients [94%]), non-Hodgkin's lymphoma (24 patients [89%]), and disseminated tuberculosis (five patients [100%]) than in nondisseminated tuberculosis (one patient [5%]). Mesenteric lymph nodes were involved more often in disseminated tuberculosis (four patients [80%]) and nondisseminated tuberculosis (11 patients [52%]) than in Hodgkin's disease (one patient [6%]) (p < .01). Anatomic distribution was not different between disseminated tuberculosis and non-Hodgkin's lymphoma. Tuberculous lymphadenopathy commonly showed peripheral enhancement, frequently with a multilocular appearance, whereas lymphomatous adenopathy characteristically showed homogeneous attenuation (14 patients [87.5%] with Hodgkin's disease and 19 patients [70%] with non-Hodgkin's lymphoma [p < .01]). CONCLUSION: Our findings indicate that the anatomic distribution and specific enhancement patterns of lymphadenopathy seen on contrast-enhanced CT can be useful in differentiating between tuberculosis and untreated lymphomas of the abdominal lymph nodes.

TNM staging of pancreatic carcinoma using helical CT.

OBJECTIVE: The purpose of this study was to determine the accuracy of helical CT scanning in predicting the stage of carcinoma of the exocrine pancreas using TNM staging guidelines and in predicting resectability of carcinoma of the exocrine pancreas. MATERIALS AND METHODS: Twenty-six patients with proven adenocarcinoma of the pancreas underwent uniphasic or biphasic helical CT scanning. Two observers unaware of the patient's surgical stage evaluated the CT examinations using the TNM system (with specific assessment and description of disease sites). In addition, the two observers rated confidence of nonresectability using a 5-point scale (ranging from 1, definitely resectable, to 5, definitely not resectable). Observer results and preoperative interpretations were compared with surgical findings. RESULTS: Nineteen of 26 patients had nonresectable disease. The combined observer scores showed correct determination of T stage in 77% of patients, of N stage in 58%, and of M stage in 79%. The overall accuracy in determining lack of resectability was 96% and 84% for the two observers. All errors in determining resectable versus nonresectable disease occurred when the observer was not maximally confident of his or her diagnosis. CONCLUSION: Helical CT is an effective screening technique for assessing T and M stages of pancreatic carcinoma. However, helical CT is poor at detecting regional lymph node involvement. In patients with equivocal T-stage findings (such as questionable venous involvement), other studies such as endoscopic sonography may be of value.

Evaluation of an approach to choosing a left double-lumen tube size based on chest computed tomographic scan measurement of left mainstem bronchial diameter.

OBJECTIVE: Evaluation of an approach to choosing left double-lumen tube size based on chest computed tomographic (CT) scan measurement of left bronchial diameter. DESIGN: Prospective. SETTING: The operating rooms of a university hospital. PARTICIPANTS: Patients scheduled for elective thoracic surgery. INTERVENTIONS: Patients had their left bronchial diameter measured on the preoperative chest CT scan. Left double-lumen tube size for the individual patient was chosen from a protocol based on left bronchial diameter. MEASUREMENTS AND MAIN RESULTS: The double-lumen tube size was considered appropriate for the patient if some air leak was detected when the bronchial cuff was deflated and if airtight seal of the left bronchus was obtained with a bronchial cuff volume of 2 mL or less. In 17 of 20 patients, the double-lumen tube size fulfilled both criteria. In 3 women with left bronchi measuring 10 mm or less, the bronchus was sealed without any air in the bronchial cuff of size 35 Fr left double-lumen tubes. In 1 patient, who was excluded from the study, the double-lumen tube size was chosen based on measurement of the left bronchial diameter on chest radiograph because of motion artifact on the chest CT scan. CONCLUSIONS: Chest CT scan measurement of left bronchial diameter can successfully guide the choice of left double-lumen tube size for an individual patient. In individuals with a small left bronchus measuring less than 10.0 mm in diameter, currently available adult double-lumen tube sizes will tightly wedge in their bronchus.

The greater omentum.

Understanding the embryologic development, anatomic relationships, and pathologic processes of the greater omentum is critical to its complete and proper evaluation. The broad spectrum of imaging findings presented in this essay may allow readers to appreciate features that aid accurate diagnosis of omental disease.

Helical CT of renal masses: the value of delayed scans.

OBJECTIVE: Routine scanning techniques used for helical CT of the abdomen result in dense cortical opacification of the kidney, whereas the medulla and collecting system are not well opacified, which potentially compromises detection of renal masses. The purpose of this retrospective study was to determine if additional delayed views (taken approximately 2-4 min after the start of injection of contrast material) are necessary for the detection and characterization of renal masses. MATERIALS AND METHODS: Early (60-70 sec after the start of the injection of contrast material) and delayed scans of 40 patients with suspected renal masses were blindly evaluated by two observers. The patients harbored a total of 187 renal masses (including 62 solid masses). Each region of the kidney (upper, middle, and lower pole) was scored for the presence of a mass. Scoring was done as a binary decision and also as a five-point confidence score for receiver operating characteristic analysis. RESULTS: We found 97 regions that contained renal masses and 114 regions that did not. Receiver operating characteristic analysis revealed the observers to have significantly greater confidence in detection of renal masses on the delayed scans. The binary data showed the two observers to have a sensitivity of 97% for delayed scans versus 77% (p = .0002) and 89% (p = .027), respectively, for the early scans. For the first observer, early and delayed scans were of equal specificity, but for the second observer, the delayed scans yielded greater specificity (94% versus 85%, p = .024). On the early scans, both observers were significantly more likely to miss a neoplastic lesion than a nonneoplastic lesion. The less experienced of the two observers also tended to have greater difficulty in characterizing the lesions on the early scans. CONCLUSION: Because of the significant risk of missing a renal mass, especially a neoplasm, on early cortical-phase scans, additional delayed scans appear justified when a renal mass is suspected on the basis of other imaging tests or clinical history.

Effects of F-encoded components and F-pilin domains on the synthesis and membrane insertion of TraA'-'PhoA fusion proteins.

F-pilin, the 70-amino-acid F-pilus subunit, accumulates in the cell envelope of F+ strains in a process that requires interactions between its precursor (the traA gene product) and other host and F-encoded proteins. Here, we have used a set of phi(traA-phoA) genes to explore the effects of different TraA domains on the synthesis and membrane insertion of TraA-PhoA fusion proteins, particularly in relation to other F-encoded gene products. The 51-amino-acid TraA leader peptide fused directly to alkaline phosphatase was synthesized at comparable rates and incorporated rapidly and efficiently into the inner membrane in F' and F- cells. A second fusion gene encoded the TraA leader peptide and the first 51 amino acids of F-pilin itself fused to PhoA (TraA'-'PhoA-102 polypeptide). Alkaline phosphatase activities and patterns of pulse-labelled polypeptides indicated that TraA'-'PhoA-102 was synthesized at comparable rates in F' and F- cells, but in neither was the TraA'-'PhoA-102 polypeptide efficiently processed as a membrane protein. A third gene encoded the entire 121-amino-acid TraA polypeptide fused to PhoA (TraA-'PhoA-121 polypeptide). About 70% of the pulse-labelled TraA-'PhoA-121 polypeptide was rapidly processed in F' cells, where it accumulated in the cell envelope as active alkaline phosphatase, whereas in F- cells, < 5% of the pulse-labelled polypeptide was processed. Additionally, the apparent rate of TraA-'PhoA-121 polypeptide synthesis was threefold higher in F' cells. The traQ gene alone could not substitute for F in restoring TraA-'PhoA-121 (or wild-type F-pilin) accumulation.

Pneumatosis intestinalis in adults with AIDS: clinical significance and imaging findings.

OBJECTIVE: The significance of pneumatosis intestinalis in adults with AIDS is unknown. Adults with AIDS are predisposed to pneumatosis intestinalis. The purpose of this study is to determine the clinical significance and to characterize the imaging appearance of this finding in patients with AIDS. MATERIALS AND METHODS: In just over 3 years at our institution, pneumatosis intestinalis in adults with AIDS was detected in six cases. Medical records of those cases were retrospectively analyzed for clinical history, laboratory data, and surgical and pathologic findings. CT scans and abdominal radiographs were analyzed for location and severity of pneumatosis, presence of portal venous gas, pneumoperitoneum, and cystic versus linear gas. RESULTS: Five of the six patients with AIDS-associated pneumatosis intestinalis were managed conservatively or medically without surgical procedures and were discharged from the hospital with resolved or decreasing gastrointestinal complaints. The other patient underwent an exploratory laparotomy because of free intraperitoneal and retroperitoneal air; however, no bowel perforation was found at surgery. CONCLUSION: Pneumatosis intestinalis is a late-stage phenomenon in adult patients with AIDS that characteristically involves the cecum or right colon. Pneumatosis in patients with AIDS may be an indolent abnormality and does not necessarily constitute a surgical emergency or a sign of impending bowel necrosis.

Helical (spiral) CT of the pancreas and biliary tract.

Helical scanning offers many advantages for the evaluation of benign and malignant pancreatobiliary disease. This article presents these advantages, recommended screening protocols, and guidelines for the use of three-dimensional rendering of the peripancreatic vessels and bile ducts.

Biliary tract: three-dimensional helical CT without cholangiographic contrast material.

Bile duct anatomy depicted with a three-dimensional (3D) model developed with helical computed tomography (CT) data was compared with cholangiographic depiction. The ductal system was completely displayed from all angles in four of six patients, as well as the stricture and length of bile duct between strictures and the bifurcation in five of six cases. 3D rendering can depict preoperative ductal anatomy.

Diagnosis of aortic dissection: value of helical CT with multiplanar reformation and three-dimensional rendering.

OBJECTIVE: Twenty-three patients with suspected aortic dissection were evaluated in this preliminary study of helical CT to determine the usefulness of axial sections, multiplanar reformation, and three-dimensional (3D) rendering in assessing the presence of dissection and the extent of intimal flap. MATERIALS AND METHODS: Patients were referred for helical CT scanning because of chest pain or an abnormal chest radiograph. Scans were performed during bolus injection of nonionic contrast material at 2.0-2.5 ml/sec using a mean scan delay of 47 sec. Axial scans with 5-mm collimation were obtained in all patients. They extended from the great vessels to the distal thoracic aorta just above the hiatus. Delayed nonhelical sections were obtained through the upper abdomen. Multiplanar reformations and 3D models were reconstructed from the helical data in 13 patients and were compared to axial sections in 7 patients who proved to have documented dissection. The efficacy of CT was determined using surgery, angiography, or clinical outcome to establish the diagnosis. RESULTS: Of the 23 patients studied, axial sections resulted in 15 true-negative, 7 true-positive, and 1 false-positive interpretation. In three of seven patients with dissection, it was difficult to determine the extent of the intimal flap on axial sections; multiplanar reformation or 3D views clarified the relevant anatomy in all 3 cases. Among the 3D display methods, ray-sum projection views were superior to surface model or maximum-intensity-projection views. CONCLUSION: If studies of larger numbers of patients confirm our preliminary findings, multiplanar reformation and 3D rendering of helical CT scans will be a valuable addition to axial display of CT studies used to detect aortic dissection and to determine the extent of the intimal flap.

Helical (spiral) computed tomography. Implications for imaging of the abdomen.

Dramatic refinements in CT technology are resulting in improved evaluation of the liver, pancreas, and gastrointestinal tract. Further clinical trials are necessary to compare the relative merits of CT versus MR imaging and endoscopic ultrasonography in a wide variety of gastrointestinal diseases.

Three-dimensional imaging of the hypopharynx and larynx by means of helical (spiral) computed tomography. Comparison of radiological and otolaryngological evaluation.

A new computed tomography (CT) technology, helical (spiral) CT, allows the entire neck to be imaged in only 30 seconds. Although multiplanar and three-dimensional (3-D) imaging could be performed with conventional CT, the volumetric acquisition provided by helical (spiral) CT allows significantly improved quality and easier reconstruction for more applications. These 3-D models show an airway appearance similar to that obtained with laryngography. Independent review of the 3-D images in 12 patients with lesions by two radiologists and one otolaryngologist was performed to assess 1) image quality, 2) ability to judge lesion extent, and 3) assistance in understanding the lesion compared to that provided by routine axial scans. Rating scores of 1 to 5 were assigned, with 5 representing the best quality or greatest value. The results showed that both groups scored image quality equally: 4.7. Lesion extent for the radiologists was 2.6, while the otolaryngologist's ranking was 3.7 (p < .01). In assisting understanding of lesions versus axial scans, radiologists ranked 3-D images 2.1, while the otolaryngologist ranked them 3.1 (p < .01). In summary, 3-D models provide a complementary imaging technique in understanding upper airway disease.

Conspicuity of hepatic metastases on helical CT: effect of different time delays between contrast administration and scanning.

OBJECTIVE: The purpose of this study was to compare two time delays between injection of contrast material and helical CT scanning to determine relative conspicuity of hepatic metastases. SUBJECTS AND METHODS: Twenty-five patients with hepatic metastases were examined with helical CT. The first imaging phase was initiated at 50 sec and the second 75 sec after the start of contrast material injection (3 ml/sec, 150 ml). Differences in lesion and liver attenuation were measured quantitatively. Four radiologists used a 5-point scale to assess lesion conspicuity subjectively. RESULTS: Mean differences in enhancement between liver and lesion were 41 H during the first phase and 59 H for the second phase (p = .0001). Radiologists' conspicuity score averaged 2.4 for lesions in the first phase versus 3.3 for lesions in the second phase (p = .0001). In 56 (88%) of 64 lesions, objective measurements showed greater enhancement of lesions during the later phase. Radiologists found 60 (94%) of 64 lesions to be more conspicuous on these later images. CONCLUSION: Our results show that conspicuity of hepatic metastases on helical CT scans is better with a 75-sec scan delay between contrast administration and scanning than with a 50-sec scan delay. The longer delay time should be used when scanning is used to detect metastases.

Three-dimensional models of the abdominal vasculature based on helical CT: usefulness in patients with pancreatic neoplasms.

Three-dimensional (3D) rendering of helical (spiral) CT data is used increasingly to show abnormalities of the vascular system [1]. Abdominal applications have focused mainly on the arterial system, but the portal venous system also can be depicted effectively with this technique. In patients with pancreaticobiliary neoplasms, axial display of helical CT images generally allows accurate staging of the lesion [2, 3]. Many surgeons, however, continue to request arteriography to specifically look for evidence of vascular encasement that would preclude surgery or vascular anomalies that would alter the surgical approach [4, 5]. The purpose of this essay is to illustrate the value of 3D rendering of CT data in providing useful information for surgical planning and showing the extent of vascular involvement by tumor.

Routine helical CT of the abdomen: image quality considerations.

PURPOSE: Both helical and nonhelical abdominal computed tomographic (CT) scans were obtained to compare image quality, study the effect of patient size and collimation, and compare the frequency of visualization of normal abdominal structures. MATERIALS AND METHODS: The study group consisted of 60 consecutive patients with clinically suspected metastatic malignancy. RESULTS: Both helical and nonhelical image quality was excellent, with equal mean image quality scores of 4.1 on a 5-point scale. In patients weighing more than 175 lb (79 kg), both helical and nonhelical image quality degraded equally when 5-mm collimation was used; 10-mm collimation resulted in excellent image quality, regardless of patient size. Small in-plane structures (eg, renal arteries, renal veins, pancreatic duct) were seen best on helical scans. With the addition of retrospectively reconstructed overlapping images, improvement in visualization of these structures was statistically significant. CONCLUSION: Helical CT scanning should be the preferred means of acquiring routine abdominal CT images.

Delayed contrast enhancement of ascitic fluid on CT: frequency and significance.

OBJECTIVE: Enhancing peritoneal fluid has been described as an uncommon finding resulting from active extravasation of contrast material from the bowel, urinary tract, or blood vessels. We have noted that enhancing peritoneal fluid occurs in other clinical settings. The CT number of ascites frequently increases between initial images obtained during bolus injection of IV contrast material and delayed images obtained after completion of the routine study. The objective of this study was to define the frequency and clinical significance of this phenomenon. SUBJECTS AND METHODS: Fifty patients (32 with malignant disease and 18 with benign disease) with free intraperitoneal fluid were examined with abdominal CT with IV contrast material. Active intraperitoneal bleeding or perforation of the bowel or bladder was not clinically suspected in any patient studied. When intraperitoneal fluid was detected on review of initial dynamic scans, a limited number of delayed scans were obtained also. Significant enhancement was determined by comparing the CT numbers of fluid on dynamic and delayed images. RESULTS: Significant delayed enhancement of intraperitoneal fluid was seen in 54% of patients, with increases averaging 25 H (range, 7-54 H). Parametric analysis indicated enhancement was inversely proportional to the amount of intraperitoneal fluid but independent of the type of IV contrast material (ionic vs nonionic), time delay (range, 10-104 min), clinical history, and serum creatinine and serum albumin levels. Enhancement occurred in both malignant and benign diseases and was more likely when small amounts of ascites were present. CONCLUSION: Enhancement of intraperitoneal fluid is a common and often striking finding on delayed CT scans after administration of IV contrast material. The phenomenon is nonspecific, occurring in a wide spectrum of clinical conditions. Caution should be used in interpreting the significance of high-attenuation intraperitoneal fluid on delayed images to avoid an erroneous diagnosis of active intraperitoneal bleeding or contrast extravasation.

Improved detection of small cavernous hemangiomas of the liver with high-resolution three-headed SPECT.

The purpose of this study was to review our experience with 99mTc-red blood cell scintigraphy for diagnosis of cavernous hemangiomas of the liver using a new three-headed, high-resolution dedicated SPECT system. Of 19 patients referred with a total of 38 lesions seen on CT, US, or MRI, 14 patients had 24 lesions that were hemangioma-positive with SPECT (all true-positives). Six of these 14 patients also had 9 hemangioma-negative lesions; all were less than or equal to 1.3 cm in size and false-negative. The remaining five patients had hemangioma-negative lesions only (1 false-negative, 4 true-negatives). Two hemangiomas were seen by SPECT that were not detected by CT, US, or MR. The sensitivity for hemangiomas greater than or equal to 1.4 cm. was 100% (20/20). The sensitivity was 33% for lesions 0.9-1.3 cm, and 20% for lesions less than or equal to 0.8 cm. The smallest hemangioma detected was 0.5 cm. These results show a definite improvement in sensitivity with high-resolution triple-headed SPECT over previously reported results using single-headed SPECT. High-resolution SPECT has improved our ability to detect small cavernous hemangiomas of the liver.