Gastric stump lymphoma.

Lymphoma occurring in the post-operative stomach would appear to be very rare with only five previously recorded cases. In three of these, focal lymphoid hyperplasia or pseudolymphoma had been found at the time of the original ulcer surgery, or at subsequent biopsies of the gastric stump or anastomotic sites. These latter three cases developed lymphoma within 11 years of the ulcer surgery as against the 20 years or longer generally found in cases of gastric stump carcinoma. Two cases presenting with gastric stump lymphoma approximately 20 years after Billroth 2 partial gastrectomy are reported. In neither of these two cases, nor in the other two patients previously recorded with post-operative gastric lymphoma 20 or more years following gastric surgery, was luminal focal lymphoid hyperplasia reported at the time of the original gastric surgery. It is postulated that these two small groups may have developed lymphoma due to differing malignant stimuli.

Occupationally induced neoplasms of the lung and pleura.

The relationship between asbestos and mesothelioma has been well delineated in the past. The epidemiologic, clinical, radiologic, and pathologic features of mesothelioma are discussed with reference to the diagnostic evaluation of asbestos-exposed patients. The extensive epidemiologic data correlating asbestos, tobacco smoke, and induction of lung carcinoma are also reviewed. These data provide a model for evaluation of other occupationally induced lung carcinogens such as organic and metallic industrial inhalants.

US, CT, and MR evaluation of accessory renal arteries and proximal renal arterial branches.

RATIONALE AND OBJECTIVES: The purpose of this study was to compare color Doppler ultrasound (US), computed tomographic (CT) angiography, and magnetic resonance (MR) angiography for the evaluation of accessory renal arteries and proximal branches of the main renal artery. MATERIALS AND METHODS: Fifty-six subjects who had undergone conventional arteriography of the renal arteries participated in a prospective comparison of Doppler US (45 patients), CT angiography (52 patients), and nonenhanced MR angiography (28 patients). Conventional arteriography depicted 28 accessory renal arteries and 21 proximal branches of the main renal artery within 2 cm of the aorta. RESULTS: US depicted five of 24 accessory renal arteries seen at arteriography but no proximal arterial branches. CT angiography depicted 24 of 26 accessory renal arteries and 13 of 17 proximal arterial branches, as well as 15 additional accessory renal arteries not seen at conventional arteriography. MR demonstrated 11 of 15 accessory arteries, as well as four additional accessory arteries not seen at conventional arteriography. MR did not depict any of nine proximal arterial branches seen at conventional arteriography. CONCLUSION: When compared with US or nonenhanced MR angiography, CT is the preferred method for evaluation of accessory renal arteries and proximal branches of the renal artery.

Comparison of unenhanced and contrast-enhanced spiral CT for assessing interval change in patients with colorectal liver metastases.

RATIONALE AND OBJECTIVES: The purpose of this study was to determine whether the interval change in hepatic colorectal metastases as assessed with serial computed tomographic (CT) scans without contrast material enhancement differs from that as assessed using serial, portal dominant phase, contrast-enhanced CT scans. MATERIALS AND METHODS: Unenhanced and contrast-enhanced abdominal CT scans were obtained in 28 patients. Three radiologists separately reviewed serial unenhanced and contrast-enhanced studies to assess the interval change in liver metastases. These radiologists recorded total number of lesions, bidimensional measurements of the largest lesions (as many as three), and overall impressions regarding the interval change (none, worse, or better). RESULTS: Among the 84 judgments (28 patients x 3 radiologists), comparisons of unenhanced and contrast-enhanced CT studies were concordant in 60 assessments (71%). Nineteen (23%) showed mild disagreement. Of these, contrast-enhanced CT studies demonstrated disease stability when unenhanced CT studies demonstrated otherwise in 11 judgments, whereas unenhanced CT studies demonstrated stability when contrast-enhanced CT studies demonstrated otherwise in eight assessments. Furthermore, of the five marked disagreements, two resulted from a conclusion of interval improvement on unenhanced CT studies and a conclusion of interval worsening on contrast-enhanced CT studies, whereas three demonstrated the opposite. Neither set of serial CT studies systematically resulted in under- or overestimation of disease progression (McNemar Q test, P < .25). CONCLUSION: The authors found no consistent pattern to demonstrate that serial unenhanced or contrast-enhanced CT studies resulted in over- or underestimation of disease progression.

Comparison of Doppler US and CT angiography for evaluation of renal artery stenosis.

RATIONALE AND OBJECTIVES: The authors compared Doppler ultrasound (US) with computed tomographic (CT) angiography in the evaluation of stenosis of the main renal artery. MATERIALS AND METHODS: Fifty-six patients who had undergone conventional angiography of the renal arteries participated in a prospective comparison of Doppler US (45 patients) and CT angiography (52 patients). US evaluation included both the main renal artery and segmental renal arteries. RESULTS: There were 27 main renal arteries with at least 50% stenosis in 20 patients. In 36 patients, there was no significant stenosis. All cases of main renal artery stenosis detected with Doppler US of the segmental arteries were also identified with Doppler US of the main renal artery. The by-artery sensitivity (63%) of US of the main renal artery was greater than that (33%) of US of the segmental arteries. CT angiography was more sensitive (96%) than Doppler US (63%) in the detection of stenosis, but the specificity of CT (88%) was similar to that of US (89%). The difference in the area under the receiver operating characteristic curve (AUC) between CT (AUC = 0.94) and US (AUC = 0.82) was statistically significant (P = .038). CONCLUSION: Doppler US of the main renal artery is more sensitive than Doppler US of segmental arteries in the detection of stenosis. CT angiography is more accurate than Doppler US in the evaluation of renal artery stenosis.

Bronchial atresia with relapsing pulmonary infection in a middle-aged man.

Congenital bronchial atresia (CBA) is a rare disorder, first reported in 1953. Less than 100 cases are reported in the literature, mostly in young, asymptomatic male patients with involvement of the apical-posterior segment of the left upper lobe. Patients may complain of fever, cough, or shortness of breath, symptoms that result from post-obstructive, sometimes recurrent, infections. Chest radiography and computed tomography reveal a tubular branching density representing mucus impaction or mucocele with surrounding focal hyperinflation. Surgical excision is reserved for symptomatic cases. We report an unusual case of CBA in a middle-aged man with a history of relapsing infections, who was found to have an atretic superior segment of the left lower lobe, with surrounding areas of organizing pneumonia.

Actinomycosis and nocardiosis of the lung.

Actinomyces and Nocardia species are frequently overlooked pulmonary pathogens until their presence is histologically proved. These infections often are not considered in the differential diagnosis of lung disease because of the spectrum of their presentation, the similarity of their appearance to other granulomatous or neoplastic diseases, and coexistence of these infections with other pulmonary conditions. Pulmonary actinomycosis is characterized by pulmonary consolidation, frequently with cavitation and spread to contiguous tissues without regard for normal anatomic barriers. The appearance often is confused with that of bronchogenic carcinoma or other granulomatous infections, especially tuberculosis. Pulmonary nocardiosis most frequently develops in immunocompromised patients, and the incidence of this infection is increasing. The radiographic manifestations of nocardiosis are pleomorphic, but early recognition is essential to initiate appropriate therapy.

Diaphragmatic and paradiaphragmatic tumors and pseudotumors.

Primary lesions of the diaphragm are rare and are often difficult to distinguish from a host of other entities. Primary tumors include lipomas, cysts, and sarcomas, while secondary lesions, which can mimic them, include direct extensions from neighboring organs or metastatic implants and adenopathy. In addition, one must exclude a variety of pseudotumors, such as eventrations, diaphragmatic invaginations, and crural thickening. Examples of such primary and nonprimary diaphragmatic lesions are discussed.

Cross-sectional imaging of the chest wall.

Computed tomography and magnetic resonance imaging are now commonly performed for a variety of pulmonary and mediastinal lesions. However, some of the lesions that affect these areas also involve the chest wall. These include tumors, infections, trauma, and congenital processes. In such cases, a knowledge of chest wall anatomy combined with careful analysis of cross-sectional images is necessary to make the diagnosis. This article describes the basic cross-sectional anatomy of the chest wall and the principal pathologic chest wall lesions.

Pulmonary calcinosis following orthotopic liver transplantation.

Pulmonary opacities following orthotopic liver transplantation (OLT) are frequent due to pneumonia, infarction, or pulmonary edema. Metastatic pulmonary calcifications are present as persistent opacities that may mimic these conditions. In a series of 91 patients who underwent OLT, chest radiographs of 77 were reviewed and pulmonary calcinosis was seen in 4 (5.2%). Pulmonary calcinosis may be due to a variety of conditions, including dystrophic calcification in damaged lung and primary or secondary hyperparathyroidism. In this series, patients with pulmonary calcinosis had significantly higher levels of serum phosphate and calcium postoperatively and had received more intraoperative platelets and other blood products containing exogenous calcium than other patients. Pulmonary calcinosis should be considered in patients following OLT when stable, nonspecific pulmonary opacities are present. CT or radionuclide studies will aid in confirming this diagnosis.

Vertebral vein migration of a long-term central venous access catheter: a cause of brachial plexopathy.

We report a patient whose central venous catheter tip had migrated into the vertebral vein. Infusion of chemotherapy agents for cancer through this catheter resulted in brachial plexopathy.

Role of thoracoscopy and preoperative localization procedures in the diagnosis and management of pulmonary pathology.

Video-assisted thoracic surgery is an important component of modern thoracic surgery, providing a safe, less invasive alternative to open thoracotomy in the evaluation of pleural, mediastinal, and parenchymal pathology. Advancements in endoscopic techniques and video-optics have permitted greater visualization of the thoracic cavity and allowed limited pulmonary resections with significantly reduced postoperative morbidity. Thoracoscopy is indicated for diagnosis of intrathoracic pathology when usual methods of diagnosis, including fine-needle aspiration and transbronchial biopsy, are inconclusive. The diagnostic accuracy of video-assisted thoracic surgery approaches 100%. Increasingly, the indications for thoracoscopy include therapeutic resections of pulmonary nodules in cases of limited lung metastases and bronchogenic carcinoma when pulmonary function is poor. Successful diagnostic and therapeutic resection by thoracoscopy requires intraoperative localization of the lesion within the collapsed lung. The indications and methods of thoracoscopic surgery and preoperative localization are discussed.

Prospective comparison of computed tomography and duplex sonography in the evaluation of recently inserted Kimray-Greenfield filters into the inferior vena cava.

A prospective comparison of contrast-enhanced computed tomography (CT) and duplex sonography (DS) was performed to examine the Kimray-Greenfield filter in the inferior vena cava (IVC) in the immediate postoperative period. Fourteen patients were studied for five complications: IVC thrombosis, malpositioning, pericaval hematoma, filter angulation, and prong perforation. Our results found CT to be more efficacious because it was a) able to evaluate more patients with fewer technically inadequate scans and b) more definitive in all categories. However, when visualized, DS was as accurate as CT in the evaluation of thrombosis.

Anterior protrusion of retroperitoneal processes. A mimic of lesser sac or gastrohepatic masses.

The space between the left lobe of the liver and the lesser curvature of the stomach normally contains intraperitoneal structures. These include the gastrohepatic recess of the greater peritoneal cavity, the medial recess of the lesser sac and the interposed gastrohepatic ligament. An anterior protrusion of retroperitoneum can project into this space, dorsal to the posterior reflection of the medial compartment of the lesser sac. Tumors that extend into this fossa are anterior and medial to the fundic and upper body region of the stomach. These tumors may cause confusion regarding their origin if the radiologist is not aware of the existence of this retroperitoneal protrusion. Between 1982, and 1986, 183 patients with pancreatic cancer were hospitalized at our institution, 63 of whom had computed tomography (CT) scans of the abdomen. Four of these patients (6.3%) demonstrated direct tumor extension anterior to the stomach. During this same period, four large benign retroperitoneal tumors also exhibited this finding. Masses in the gastrohepatic interval between the liver and stomach can be extensions of retroperitoneal processes and should not be assumed to represent intraperitoneal involvement.

Thymic cyst secondary to cervical irradiation: a complication of treated laryngeal cancer.

This report demonstrates a thymic cyst arising in association with cervical irradiation for laryngeal carcinoma; a process not previously described. Thymic cysts are rare anterior mediastinal masses which have many etiologies, though an increased incidence of thymic cysts in association with Hodgkin's disease has been reported. This association was thought to be related to either mediastinal irradiation or cystic changes within a thymic focus of Hodgkin's disease. This case supports the theory that at least some thymic cysts arise secondary to irradiation.

The development of distant pulmonary infiltrates following thoracic irradiation: the role of computed tomography with dosimetric reconstruction in diagnosis.

High doses of external beam radiotherapy are required to obtain local control of many intrathoracic neoplasms. Because spinal cord tolerance limits the radiation dose that can be given through anterior and posterior fields, it is often necessary to increase the dose to the primary tumor site using oblique or lateral fields. When pulmonary infiltrates develop following treatment in these patients, it is frequently difficult to distinguish between infection, recurrent tumor, and radiation pneumonitis. In nine patients in whom acute pulmonary infiltrates occurred following a course of thoracic irradiation, computed tomography (CT) with computed dosimetric reconstruction (CDR) were studied in an attempt to correlate the treatment volumes with the location and configuration of the infiltrates and in this way establish the source for the pulmonary abnormalities. In seven of these patients, the diagnosis was changed, and the resulting post-irradiation clinical therapy was altered as a consequence of this retrospective study.

Imaging of the distal radioulnar joint.

The distal radioulnar joint can be evaluated by many different imaging techniques, including plain radiography, arthrography, tomography, nuclear medicine bone scanning, computed tomography, and magnetic resonance imaging. Each of these techniques has advantages and disadvantages that must be considered when determining the appropriate diagnostic evaluation for a particular patient.