Are bilateral decubitus views necessary in assessing for vertebral compression fractures using DXA vertebral fracture assessment?

The purpose of this study is to assess the differences in VFA diagnostic accuracy when using bilateral decubitus views and whether diagnostic accuracy is affected by scoliosis. Our findings show that the current practice of performing only one side is valid; however, bilateral views can improve specificity in scoliosis. INTRODUCTION: The diagnostic accuracy of vertebral fracture assessment (VFA) can be influenced by poor patient position and scoliosis. This study aims to assess the differences in VFA diagnostic accuracy for right and left lateral decubitus views and the effect of scoliosis. METHODS: One hundred fourteen postmenopausal women received right and left lateral thoracolumbar spine dual-energy VFA and radiography. Cobb angles were measured from the posteroanterior absorptiometry image, and lumbar spine radiography was the standard reference for vertebral fracture and also provides the levels investigated. McNemar's test was used to compare accuracy between the two decubitus position and Fisher's exact test was used for patients with and without scoliosis. RESULTS: Forty-two vertebral fractures (VFs) were identified. There was no significant difference in sensitivity (p = 0.125) or specificity (p = 0.866) between the left lateral decubitus (64.3, 97.2%) and right lateral decubitus (76.2, 91.1%), respectively, views. Scoliotic patients had a significantly worse specificity (92.7 vs 98.1%, p = 0.003) than patients without scoliosis; however, a combination of both decubitus positions significantly improved specificity (p < 0.001). CONCLUSION: Right and left side lateral decubitus views have excellent agreement with radiography and similar diagnostic accuracy in the detection of VFs. Thus, the current practice of performing only one side is valid. With scoliosis, bilateral decubitus views can improve the specificity of detecting VF; however, this would increase radiation dose.

Pain following double-bundle anterior cruciate ligament reconstruction: correlation with morphological graft findings and dynamic contrast-enhanced MRI.

AIM: To determine the relationship between knee pain following anterior cruciate ligament (ACL) graft placement with morphological graft findings and dynamic contrast enhancement as assessed at MRI. MATERIAL AND METHODS: Following institutional review board approval, 37 consecutive patients with double-bundle ACL reconstruction were enrolled. Thirteen patients had pain and 24 were asymptomatic. Imaging was performed using a 1.5 T MRI machine an average of 7.6 months after surgery. Graft-related (increase signal intensity, abnormal orientation, discontinuity, cystic degeneration, anterior translation of lateral tibia, arthrofibrosis), and non-graft related causes of knee pain (meniscal tear, cartilage injury, loose bodies, and synovitis) were evaluated. During dynamic contrast enhancement analysis, peak enhancement (ePeak) was calculated by placing a region of interest at the osteoligamentous interface of each bundle. Student's t-test was used for continuous variables analysis and chi-square or Fisher's exact test was used for categorical variables analysis. RESULTS: There was no difference between symptomatic and asymptomatic patients regarding morphological graft-related or non-graft-related causes of knee pain. For dynamic contrast enhancement analysis, symptomatic patients had significantly lower ePeak values than asymptomatic patients in the anteromedial (p = 0.008) and posterolateral (p = 0.001) bundles or when using the higher ePeak value in either bundle (p = 0.003). CONCLUSION: Morphological ACL graft findings as assessed at MRI could not be used to distinguish between symptomatic and asymptomatic patients. However, lower ePeak values had a significant association with knee pain. This may indicate poor neovascularization of the graft, potentially leading to graft failure.

Computed tomography-guided core-needle biopsy specimens demonstrate epidermal growth factor receptor mutations in patients with non-small-cell lung cancer.

BACKGROUND: Target therapy with a new class of epidermal growth factor receptor (EGFR) inhibitors shows improved clinical response in EGFR gene-mutated lung cancers. PURPOSE: To evaluate the use of computed tomography (CT)-guided core-needle biopsy specimens for the assessment of EGFR gene mutation in non-small-cell lung cancer (NSCLC). MATERIAL AND METHODS: Seventeen (nine males, eight females) patients with advanced NSCLC were enrolled in this study. All patients underwent CT-guided core-needle biopsy of the lung tumor prior to treatment with the EGFR inhibitor gefitinib. There were no life-threatening complications of biopsy. The specimens were sent fresh-frozen for EGFR mutation analysis and histopathological study. RESULTS: There were 12 (70.6%) EGFR gene mutants and five (29.4%) nonmutants. The objective response rate to gefitinib therapy was 73.3% (11 of 15 patients), with 91.7% (11 of 12 mutants) for the mutant group and 0% for the nonmutant group. CONCLUSION: CT-guided core-needle biopsy of advanced NSCLC enables the acquisition of sufficient tissue for EGFR gene mutation analysis.

Soft-tissue sarcomas of the hand: oncological outcome and prognostic factors.

We have investigated the oncological outcome of 63 patients with soft-tissue sarcomas of the hand managed at three major centres in the United Kingdom. There were 44 males and 19 females with a mean age of 45 years (11 to 92). The three most common diagnoses were synovial sarcoma, clear cell sarcoma and epithelioid sarcoma. Local excision was carried out in 45 patients (71%) and amputation in 18 (29%). All those treated by amputation had a wide margin of excision but this was only achieved in 58% of those treated by local excision. The risk of local recurrence was 6% in those treated by amputation compared with 42% for those who underwent attempted limb salvage. An inadequate margin of excision resulted in a 12 times greater risk of local recurrence when compared with those in whom a wide margin of excision had been achieved. We were unable to demonstrate any role for radiotherapy in decreasing the risk of local recurrence when there was an inadequate margin of excision. Patients with an inadequate margin of excision had a much higher risk of both local recurrence and metastasis than those with wide margins. The overall survival rate at five years was 87% and was related to the grade and size of the tumour and to the surgical margin. We have shown that a clear margin of excision is essential to achieve local control of a soft-tissue sarcoma in the hand and that failure to achieve this results in a high risk of both local recurrence and metastatic disease.

Does the method of treatment affect the outcome in soft-tissue sarcomas of the adductor compartment?

We have investigated the significance of the method of treatment on the oncological and functional outcomes and on the complications in 184 patients with soft-tissue sarcomas of the adductor compartment managed at three international centres. The overall survival at five years was 65% and was related to the grade at diagnosis and the size of the tumour. There was no difference in overall survival between the three centres. There was, however, a significant difference in local control with a rate of 28% in Centre 1 compared with 10% in Centre 2 and 5% in Centre 3. The overall mean functional score using the Toronto Extremity Salvage Score in 70 patients was 77% but was significantly worse in patients with wound complications or high-grade tumours. The scores were not affected by the timing of radiotherapy or the use of muscle flaps. This large series of soft-tissue sarcomas of the adductor compartment has shown that factors influencing survival do not vary across the international boundaries studied, but that methods of treatment affect complications, local recurrence and function.

Molecular and cytogenetic changes involved in the immortalization of nasopharyngeal epithelial cells by telomerase.

Nasopharyngeal carcinoma (NPC) is a common disease in Hong Kong and southern provinces of China. EBV infection is believed to play a critical role in the development of NPC. Previous studies on the transformation mechanism of EBV genes were mostly performed in either NPC or nonnasopharyngeal epithelial cells which may not be representative of premalignant nasopharyngeal epithelial cells. Establishment of a representative cell system would greatly facilitate the elucidation of the role of EBV infection in the development of NPC. Using telomerase alone, we were able to establish an immortalized nasopharyngeal epithelial cell line from primary nonmalignant nasopharyngeal biopsies. The telomerase-immortalized nasopharyngeal epithelial cells are largely diploid in karyotype. Interestingly, this newly immortalized nasopharyngeal epithelial cell line, referred as NP460hTert, harbors genetic alterations previously identified in premalignant and malignant nasopharyngeal epithelial cells. These include inactivation of p16 by homozygous deletion of the p16(INK4A) locus and downregulation of RASSF1A expression. The deletion of the p16(INK4A) locus appears to be the most crucial event for the immortalization of nasopharyngeal epithelial cells by telomerase and precedes RASSF1A downregulation. In addition, detailed analysis of the cytogenetic changes by conventional cytogenetics, spectral karyotyping (SKY) and array-based CGH revealed a gain of a 17q21-q25 fragment on 11p15 chromosome in all NP460hTert cells which occurred before deletion of the p16(INK4A) locus. Gain of 17q has been previously reported in NPC. In addition, activation of NF-kappaB was observed in immortalized NP460hTert cells at the later population doublings, and may play a role in the survival of immortalized NP epithelial cells. Id1 which is commonly expressed in various human cancers, including NPC, was also upregulated in the immortalized NP460hTert cells. Thus, the establishment of an immortalized nasopharyngeal epithelial cell line harboring common genetic alterations present in premalignant and cancerous nasopharyngeal epithelial cells may provide a valuable cell system to examine for early events involved in NPC carcinogenesis, particularly in elucidating the role of EBV infection in NPC development.

Multidetector computed tomography assessment on tumor size and nodal status in patients with locally advanced breast cancer before and after neoadjuvant chemotherapy.

AIMS: To evaluate the utility of multidetector computed tomography (MCT) in assessing tumor size and nodal status in patients with advanced breast cancers before and after the neoadjuvant chemotherapy. METHODS: Twenty-eight proven locally advanced breast cancer patients with 30 tumors were enrolled in this study. MCT was used to assess tumor size and axillary lymph nodes before and after the neoadjuvant chemotherapy. The correlation between tumor size on MCT and gross tumor size was tested. RESULTS: The MCT measurements documented complete response in 3, partial response in 18, non-response in 8 and progressed in 1. The mean tumor diameters on pathology and post-chemotherapy MCT were 3.6cm (S.D.=+/-2.9cm) and 3.1cm (S.D.=+/-2.6cm), respectively. The Pearson correlation coefficient was 0.76 (p<0.001). The sensitivity, specificity, positive predictive valve, negative predictive valve and accuracy of MCT in diagnosing the axillary lymph node metastases after pre-operative neoadjuvant chemotherapy were counted, respectively, to 72%, 40%, 85.7%, 22.2% and 66.7%. All the 5 downstaged axillary nodal statuses from node-positive to node-negative on MCT had micrometastases. CONCLUSION: MCT can be used to evaluate tumor size and nodal status in patients with advanced breast cancer. As there is a baseline MCT before chemotherapy for comparison, we are potentially aware of the possibility of false negative nodal micrometastases on the post-chemotherapy MCT.

The clinical significance of gas-containing liver abscesses converting from total gas content to gas and fluid content: a case report.

The first case of gas-containing liver abscesses converting from total gas content to gas and fluid content is reported, and the clinical significance of such a conversion is emphasised. A 58-year-old diabetic woman suffered from fever and chill due to totally gas-containing liver abscesses shown by computerised tomography (CT). The patient did not recover despite ultrasound-guided aspiration of the abscess. CT carried out 2 weeks later revealed that the initial totally gas-containing liver abscesses converted to ones with gas and fluid content. The patient recovered after CT-guided drainage of the abscesses.

Extraskeletal Ewing's sarcoma of the parapharyngeal space.

Extraskeletal Ewing's sarcoma (EES) is rarely found in the head and neck region. We report here a case of EES of the parapharyngeal space in a 53-year-old man who presented with blurred vision, dysphagia, hoarseness and right facial numbness. CT examination showed a large, seemingly well-defined soft tissue mass in the right parapharyngeal space with skull base destruction and intracranial extension. The patient showed poor response to chemotherapy and radiotherapy and died 6 months after initial presentation. A review of the literature revealed no previous reports of EES occurring in the parapharyngeal space.

Role of CT-guided core needle biopsy in the diagnosis of a gossypiboma: case report.

A 66-year-old woman with previous hysterectomy had dysuria and vaginal spotting for 1 month. Computed tomography showed a heterogeneous presacral mass with eccentric calcification. Biopsies of the bladder and vagina and transrectal biopsy of the pelvic mass yielded only inflammation. T2-weighted magnetic resonance images revealed a heterogeneous mass with wavy hypointensities. Computed tomographically guided biopsy targeting at the calcified area disclosed thread-like materials, thus confirming the diagnosis of gossypiboma.

Fluoroscopically guided percutaneous gastrostomy with modified gastropexy and a large-bore balloon-retained catheter in patients with head and neck tumors.

PURPOSE: To report on fluoroscopically guided percutaneous gastrostomy (FPG) using a modified gastropexy technique with the insertion of a large-bore balloon-retained gastrostomy catheter in patients with head and neck tumors. MATERIAL AND METHODS: Thirty-four patients with head and neck tumors underwent a modified gastropexy with two T-fasteners followed by the insertion of a 14-F ballooon-retained catheter through a peel-away introducer. The success rate and the complications of the procedures were evaluated at 14 days, 30 days, and 60 days. The complications were classified as: major complications that necessitated intensive and/or surgical treatment; minor complications that could be treated conservatively; and tube-related complications manageable by tube exchange. RESULTS: FPG was technically successful in all cases. There were no major complications, two minor complications where superficial stoma infection was controlled by antibiotics, three minor tube-related complications, all three easily managed by catheter replacement via the original tract. CONCLUSION: FPG with insertion of a large-bore balloon-retained catheter using a modified gastropexy technique is a safe and effective method that creates a feeding access for patients with head and neck tumors and esophageal obstruction. Minor complications can be managed conservatively. FPG may be a good alternative to surgical or percutaneous endoscopic gastrostomy.

Concomitant pulmonary and mediastinal sclerosing haemangiomas.

We report a case of thoracic sclerosing haemangioma with concomitant pulmonary and mediastinal involvement in a 19-year-old girl who presented with haemoptysis and dyspnoea. CT showed a large oval mass in the left lower lobe and another larger dumbbell-shaped mass in the posterior mediastinum. Both masses were well-defined and harboured punctate calcifications. They exhibited inhomogeneous contrast enhancement and contained some cystic areas. In addition, an air meniscus sign was present around the pulmonary lesion.

Analysis of sonographic features for the differentiation of benign and malignant breast tumors of different sizes.

OBJECTIVE: To analyze the value of various sonographic features in differentiating benign from malignant breast tumors of different sizes to improve the diagnostic accuracy in small lesions. METHODS: The sonographic features of 1203 histologically confirmed solid breast lesions were prospectively documented with respect to anteroposterior (AP) diameter/width ratio, shape, margin, echogenicity, echotexture, posterior echo and bilateral refraction sign. The sensitivity, specificity and accuracy of breast ultrasound were calculated for lesions grouped according to size (< or = 1, 1.1-2 and > 2 cm). Univariate and multiple logistic regression analyses including calculation of odds ratios for single sonographic features were used to analyze the significance of the different diagnostic features. RESULTS: The accuracy of breast sonography in differentiating between benign and malignant tumors < or = 1, 1.1-2 and > 2 cm in size was 75.6%, 86.4% and 88.4%, respectively. Univariate analysis demonstrated that all sonographic features were significant in tumors > or = 1.1 cm. Shape, margin, echogenicity and echotexture were the significant factors in those tumors < or = 1 cm. Multiple logistic regression analysis demonstrated that margin, shape, posterior echo and echogenicity were the significant factors for differential diagnosis in tumors > 2 cm. Echogenicity, margin, shape, bilateral refraction sign and echotexture were the significant factors for tumors 1.1-2 cm. On multiple regression analysis, margin was the only significant factor for tumors < or = 1 cm. CONCLUSION: Tumor margin is the most important sonographic feature in evaluating breast lesions in any size group. With the combination of significant factors and emphasis on specific features according to size of lesion, the diagnostic accuracy of ultrasound for the differential diagnosis of malignant and benign tumors may be improved.

Combined hepatocellular-cholangiocarcinoma: a case report.

Combined hepatocellular-cholangiocarcinoma (HCC-CC) is a rare primary liver tumour. We report a carrier of both HBV and HCV presenting with intermittent abdominal pain, fever, chillness and elevated á-fetoprotein (AFP) of 1197 ng/ml. Computed tomography showed an irregular hypodense mass in the left lateral segment of the liver with vague contrast enhancement and multiple regional lymphadenopathy. Hepatic angiogram showed that the mass was hypovascular and the left portal vein was occluded with a tapered end. Percutaneous ultrasound-guided core needle biopsy of the liver yielded HCC-CC. We suggest that HCC-CC should be considered in hypovascular liver tumours with striking elevation of serum AFP and multiple regional lymphadenopathy.

Magnetic resonance imaging of hyaline cartilage regeneration in neocartilage graft implantation.

BACKGROUND: The purpose of this study was to investigate the regenerative potential of hyaline cartilage in a neocartilage graft implant with the aid of MR cartilage imaging using a rabbit model. METHODS: Surgical osteochondral defects were created in the femoral condyles of 30 mature New Zealand rabbits. The findings of neocartilage in autologous cartilage grafts packed into osteochondral defects were compared with control group of no implant to the osteochondral defect. The outcome of the implantations was correlated with histologic and MR cartilage imaging findings over a 3-month interval. RESULTS: Neocartilage grafts packed into osteochondral defects showed regeneration of hyaline cartilage at the outer layer of the implant using MR cartilage imaging. Fibrosis of fibrocartilage developed at the outer layer of the autologous cartilage graft together with an inflammatory reaction within the osteochondral defect. CONCLUSION: This animal study provides evidence of the regenerative ability of hyaline cartilage in neocartilage transplants to repair articular cartilage.

Sonographic differentiation of invasive and intraductal carcinomas of the breast.

The purpose of this study is to evaluate the diagnostic ability of ultrasound and define the sonographic features of symptomatic intraductal and invasive breast carcinoma. To achieve this the ultrasound features of 488 invasive carcinomas and 65 non-screening detected intraductal carcinomas were compared retrospectively. The features included size, AP/W (anteroposterior diameter/width) ratio, shape, margin, internal echogenicity, internal echotexture, posterior acoustic transmission, bilateral edge shadowing sign and calcifications. The sensitivity and specificity of the detection of calcifications by ultrasound in comparison with mammography were also studied. The accuracy of ultrasound diagnosis is 92.0% for invasive carcinoma of breast and 84.8% for intraductal carcinoma. Differentiation of ultrasound features of intraductal and invasive carcinoma can be based on the internal hypoechogenicity, loss of bilateral edge shadowing, posterior acoustic transmission, irregular shape and non-uniform internal echotexture with odds ratio of 0.3, 0.3, 0.4, 0.5 and 0.5, respectively. Internal echogenicity was the only significant differentiating factor on multiple logistic regression analysis. Non-comedo type ductal carcinoma in situ can be differentiated from comedo type by irregular shape with odds ratio of 0.3. The sensitivity, specificity and accuracy rate for the detection of calcifications in invasive carcinomas by ultrasound were 65.1%, 61.9% and 63.2%; in comedo type intraductal carcinoma 62.5%, 66.7% and 63.6%, and in non-comedo type intraductal carcinoma 30.0%, 86.7% and 64.0%, respectively. The ultrasound appearance of non-screening detected intraductal carcinoma is relatively isoechoic in comparison with invasive carcinoma. More than 60% of microcalcifications in comedo type intraductal carcinoma can be accurately demonstrated by ultrasound. However, the role of ultrasound in detecting symptomatic intraductal carcinoma warrants further study.

Histopathological and CT features of pulmonary sclerosing haemangiomas.

AIM: To demonstrate the computed tomography (CT) features of pulmonary sclerosing haemangiomas. MATERIALS AND METHODS: Six pathologically proven sclerosing haemangiomas were included in this retrospective review. Patients consisted of five women and one man aged 20-54 years (mean, 34.5 years). Their CT features were recorded according to enhancement patterns and the presence of a tail sign, prominent pulmonary artery sign, air-trapping sign, presence of calcification or cystic spaces, consolidation, and interstitial infiltration. The predominant composition of an individual sclerosing haemangioma was documented by means of microscopy. RESULTS: Inhomogeneous enhancement was frequently present and depended on the various compositions of the tumours, especially those in sclerotic and predominantly papillary predominant types. The presence of a tail sign, intra-tumoural cystic areas, and a prominent artery sign were the frequent features in our cases. CONCLUSION: Sclerosing haemangioma should be considered in young or middle-aged female patients whose CT images show them having an inhomogeneous enhancing soft tissue mass with a smooth outline and with above the aforementioned features.

Submandibular Castleman's disease.

Castleman's disease is a rare benign lymphoid tumour of unknown aetiology, which usually appears as a solitary mediastinal mass. We report an unusual case of Castleman's disease, an asymptomatic submandibular mass in the lower jaw, and we discuss the computed tomography appearance.