Diagnostic performance of MDCT, PET/CT and gadoxetic acid (Primovist(®))-enhanced MRI in patients with colorectal liver metastases being considered for hepatic resection: initial experience in a single centre.

PURPOSE: To compare the relative diagnostic performance of MDCT, PET/CT and Primovist-enhanced MRI (P-MRI) in the pre-resection work-up of colorectal cancer (CRC) liver metastases. METHOD AND MATERIALS: This was a retrospective study of consecutive referrals for CRC liver metastases. All patients had MDCT, PET/CT and P-MRI examinations within 3 months of each other. They were divided into 2 groups: resected and unresected. Patients in the resected group underwent liver resection within 3 months of the imaging studies. In the unresected group, patients were unresectable by imaging criteria or are awaiting surgery. Standard of reference (SOR) was intra-operative ultrasound findings and pathology for the resected group. Intermodality comparison was the SOR for the unresected group. Number of lesions identified by each imaging modality for each patient was recorded. Sensitivity (95% CI) and PPV were calculated for each imaging modality in the resected group. RESULTS: There were 19 patients in the resected group and 11 patients in the unresected group. The sensitivity (96%) and PPV (0.91) of P-MRI were both superior to that of MDCT (P = 0.0009) and PET/CT (P = 0.0003). Intermodality comparison showed that P-MRI detected more lesions than MDCT and PET/CT. CONCLUSION: The sensitivity and PPV of P-MRI was superior to that of MDCT and PET/CT. P-MRI probably has the most added value if used after MDCT and PET/CT in patients still considered eligible for liver resection.

Hepatocellular carcinoma complicating cystic fibrosis related liver disease.

Early diagnosis and treatment of the respiratory and gastrointestinal complications of cystic fibrosis (CF) have led to improved survival with many patients living beyond the fourth decade. Along with this increased life expectancy is the risk of further disease associated with the chronic manifestations of their condition. We report a patient with documented CF related liver disease for which he was under routine surveillance that presented with histologically proven hepatocellular carcinoma (HCC). It is important that physicians are aware of this association as increased vigilance may lead to earlier diagnosis and perhaps, a better outcome.

A clinical test to avoid sural nerve injuries in percutaneous Achilles tendon repairs.

Percutaneous repairs of Achilles tendon ruptures has gained popularity due the reduced incidence of wound complications, however its use is still limited by the high incidence of sural nerve injuries associated with these repairs. The only technique described to avoid this adverse event is to surgically expose the nerve peri-operatively. In our study, we describe and validate a clinical technique to identify the sural nerve. The sural nerve was mapped using this technique both clinically and by Ultrasound (US) in a cohort of male subjects with intact Achilles tendons. We demonstrated an excellent correlation between the clinical and US mapping. This study demonstrates an accurate and repeatable clinical technique for mapping the sural nerve in conjunction with percutaneous Achilles tendon repairs.

Minimal preparation computed tomography instead of barium enema/colonoscopy for suspected colon cancer in frail elderly patients: an outcome analysis study.

AIM: To evaluate the efficacy of minimal preparation computed tomography (MPCT) in diagnosing clinically significant colonic tumours in frail, elderly patients. MATERIALS AND METHODS: A prospective study was performed in a group of consecutively referred, frail, elderly patients with symptoms or signs of anaemia, pain, rectal bleeding or weight loss. The MPCT protocol consisted of 1.5 l Gastrografin 1% diluted with sterile water administered during the 48 h before the procedure with no bowel preparation or administration of intravenous contrast medium. Eight millimetre contiguous scans through the abdomen and pelvis were performed. The scans were double-reported by two gastrointestinal radiologists as showing definite (>90% certain), probable (50-90% certain), possible (<50% certain) neoplasm or normal. Where observers disagreed the more pessimistic of the two reports was accepted. The gold standard was clinical outcome at 1 year with positive end-points defined as (1) histological confirmation of CRC, (2) clinical presentation consistent with CRC without histological confirmation if the patient was too unwell for biopsy/surgery, and (3) death directly attributable to colorectal carcinoma (CRC) with/without post-mortem confirmation. Negative end-points were defined as patients with no clinical, radiological or post-mortem findings of CRC. Patients were followed for 1 year or until one of the above end-points were met. RESULTS: Seventy-two patients were included (mean age 81; range 62-93). One-year follow-up was completed in 94.4% (n=68). Mortality from all causes was 33% (n=24). Five histologically proven tumours were diagnosed with CT and there were two probable false-negatives. Results were analysed twice: assuming all CT lesions test positive and considering "possible" lesions test negative [brackets] (95% confidence intervals): sensitivity 0.88 (0.47-1.0) [0.75 (0.35-0.97)], specificity 0.47 (0.34-0.6) [0.87 (0.75-0.94)], positive predictive value 0.18 [0.43], negative predictive value 0.97 [0.96], positive likelihood ratio result 1.6 [5.63], negative likelihood ratio result 0.27 [0.29], kappa 0.31 [0.43]. Tumour prevalence was 12%. A graph of conditional probabilities was generated and analysed. A variety of unsuspected pathology was also found in this series of patients. CONCLUSIONS: MPCT should be double-reported, at least initially. "Possible" lesions should be ignored. Analysis of the graph of conditional probability applied to a group of frail, elderly patients with a high mortality from all causes (33% in our study) suggests: (1) if MPCT suggests definite or probable carcinoma, regardless of the pre-test probability, the post-test probability is high enough to warrant further action, (2) frail, elderly patients with a low pre-test probability for CRC and a negative MPCT should not have further investigation, (3) frail, elderly patients with a higher pre-test probability of CRC (such as those presenting with rectal bleeding) and a negative MPCT should have either double contrast barium enema (DCBE) or colonoscopy as further investigations or be followed clinically for 3-6 months. MPCT was acceptable to patients and clinicians and may reveal significant extra-colonic pathology.

Technical report. Intra-operative ultrasound-guided needle localization for impalpable testicular lesions.

AIMS: To describe a new technique of intra-operative ultrasound-guided needle localization of impalpable intratesticular lesions. MATERIALS AND METHODS: Three patients with impalpable testicular lesions identified on ultrasound underwent needle localization under ultrasound guidance. The procedure was performed in the operating theatre under general anaesthetic using a 7.5-8 MHz linear array probe and a portable ultrasound machine. Under direct guidance, a 21 G needle was placed through the centre of the lesion allowing resection and immediate frozen section analysis. RESULTS: In two patients malignancy was confirmed and an orchidectomy was performed. In one patient a benign lesion was detected obviating the need for orchidectomy. CONCLUSION: Patients presenting with impalpable testicular lesions can pose a diagnostic dilemma and orchidectomy is often performed. We describe an ultrasound-guided intra-operative localization technique enabling direct pathological examination so surgical approach can be re-evaluated in the presence of a benign lesion. This is particularly important in the case of a solitary testicle in order to preserve testicular function.

Post-partum ovarian vein thrombosis.

Post-partum ovarian vein thrombosis (POVT) is uncommon, but the true incidence is not known. Ninety per cent of cases present as right iliac fossa pain within 10 days of delivery. Anti-coagulation and intravenous antibiotics are the mainstay of treatment. We report three cases that were referred to our unit. These cases illustrate the difficulty in the clinical diagnosis of POVT and highlight the importance of its inclusion in the differential diagnoses of an acute abdomen in post-partum patients. POVT can be accurately diagnosed by appropriate noninvasive investigations and a laparotomy avoided.

Portal venous gas: detection by gray-scale and Doppler sonography in the absence of correlative findings on computed tomography.

Two cases are described in which portal venous gas (PVG) was detectable by ultrasound, but the liver appeared normal on computed tomography (CT). The finding of PVG was associated with ischemic bowel in one case but was a benign finding in the other case. The gray-scale and Doppler ultrasound findings associated with PVG are described. This case report illustrates two key points. First, ultrasound may detect gas within the portal venous system when CT is negative. Second, when PVG is detected on ultrasound, urgent clinical assessment followed by contrast-enhanced CT is indicated to assess for associated intestinal ischemia.

The role of hepatic arterial Doppler ultrasound after liver transplantation: an 'audit cycle' evaluation.

AIMS: To compare the diagnostic performance of hepatic arterial (HA) Doppler ultrasound post-liver transplantation for hepatic artery thrombosis and stenosis in our unit with the literature. To evaluate the role of the technique in clinical practice. MATERIALS AND METHODS: In a two-phase 'audit cycle' study, adult OLT patients had Doppler studies comprising detection of HA flow and measurements of peak systolic velocity, resistive index and systolic acceleration time. In phase I, patients had Doppler examinations 'routinely' and for any hepatic biochemical abnormality. In phase II, Doppler ultrasound was performed early post-OLT and later only if a senior transplant clinician suspected graft ischaemia. In addition to HA measurements the waveform was visually assessed. Clinical outcome was the 'gold standard'. RESULTS: Phase 1: 38 patients, 40 OLT operations, 125 Doppler studies; 14 arteriograms. Phase 2: 35 patients, 42 OLT operations, two HA angioplasties, one HA revision, one non-occlusive thrombus, 140 studies; 17 arteriograms. Results; Phase 1 [Phase 2]: sensitivity 80% [100%]; specificity 71% [81%]; PPV 28% [56%]; NPV 96% [100%]; incidence of HA abnormality 12.5% [19. 5%]; likelihood ratio of negative result 0.28 [0]; of positive result 2.8 [5.3]. CONCLUSION: Previously reported results are reproducible. Normal HA waveform should also be a criterion of normality. The technique is very sensitive but relatively non-specific. Predictive values improve with discriminate use. MacEneaney, P. M. (2000). Clinical Radiology55, 517-524.

A comparison of a non-ionic dimer, iodixanol with a non-ionic monomer, iohexol in low dose intravenous urography.

A prospective, double-blind study of 392 patients randomized into four groups was performed to establish whether diagnostic intravenous urograms could be obtained with a lower dose of iodine when using the dimeric, non-ionic contrast medium iodixanol compared with the monomeric, non-ionic iohexol. Patients received iodixanol or iohexol containing either 9 or 12 g of iodine (gI). The primary parameter was the diagnostic quality of the 6 min film, assessed in a blinded fashion, by consensus, by four radiologists. Iodixanol at both doses was diagnostic in over 90% of cases. Iohexol was only diagnostic in 74% (9 gI) and 81.8% (12 gI). Pairwise comparisons revealed that iodixanol 9 gI was significantly better than both iohexol 9 gI (p = 0.0005) and 12 gI (p = 0.014). No significant difference was present for different doses within the same contrast medium group. Iodixanol resulted in poorer bladder distension than iohexol. Iodixanol caused significantly less discomfort than iohexol.

Evidence for the polyp-cancer sequence in gallbladder cancer.

We report a patient with symptomatic biliary disease and who was diagnosed by ultrasound to have a large polypoid gallbladder lesion. Histopathology revealed adenoma in combination with carcinoma in situ. The evidence for the adenoma-carcinoma sequence in gallbladder cancer and diagnostic and therapeutic implications are discussed.

Diagnosis and treatment of heel pain in chronic inflammatory arthritis using ultrasound.

The authors examined the role of ultrasound (US) in diagnosis and management of heel pain in chronic inflammatory arthritis. Nineteen patients underwent US examination. Eight patients (2 with previously unsuccessful nonguided injections), had 11 US-guided corticosteroid injections for treatment of retrocalcaneal bursitis (n = 6), plantar fasciitis (n = 3), and posterior tibial tenosynovitis (n = 2). US-demonstrated Achilles tendon rupture (n = 2), Achilles tendinitis (n = 8), posterior tibial tenosynovitis (n = 6), peroneus longus tenosynovitis (n = 2), retrocalcaneal bursitis (n = 13), and plantar fasciitis (n = 4). Loss of smooth bone contour (n = 13) correlated with bone erosions on plain radiographs in all but one case. Ten of 11 guided injections resulted in full resolution of heel pain. The diverse causes of heel pain are highlighted, and the ability of US to provide information with management implications is confirmed. US-guided corticosteroid injection is beneficial, especially after failure of nonguided injection.

Technical report: ultrasound guidance for injection of soft tissue lesions around the heel in chronic inflammatory arthritis.

We describe the use of ultrasound guidance for local steroid injection of the retrocalcaneal bursa and the tibialis posterior tendon sheath in patients with chronic inflammatory arthropathy. Ultrasound guidance may be the injection technique of choice but is particularly indicated for patients with lesions unresponsive to injections guided by palpation.

Magnetic resonance imaging of rectal carcinoma: a prospective study.

Accurate preoperative staging of rectal cancer is necessary to identify patients who might benefit from adjuvant therapy. Magnetic resonance imaging (MRI) was evaluated in 20 consecutive patients with rectal cancer undergoing 'curative' surgery. Detailed histopathological examination of the resected lesion was correlated with findings of MRI. MRI staging concurred with histological staging in 18 of 20 patients using the Dukes or tumour node metastasis classification but in only 14 using the modified Astler-Coller system. MRI diagnosed transmural invasion in all but one patient with microscopic mural invasion (positive predictive value, 100 per cent; negative predictive value, 80 per cent; overall accuracy, 95 per cent). MRI correctly diagnosed tumour deposits or involved lymph nodes in 12 patients. MRI overstaged one patient, in whom nodes that were enlarged on imaging studies were negative at histological examination (positive predictive value, 92 per cent; negative predictive value, 100 per cent; overall accuracy, 95 per cent). MRI has a role in selected cases for the preoperative assessment of rectal carcinoma.