Non-Hodgkin's lymphoma in bone. Pathologic and radiologic features with clinical correlates.

Thirty-seven lymphomas of bone were studied, including 33 diffuse large cell lymphomas, three undifferentiated (small noncleaved cell) lymphomas, and one well-differentiated (small) lymphocytic lymphoma. The large cell lymphomas were subclassified as large cleaved, large noncleaved, multilobated cell, and immunoblastic sarcoma (large cell lymphoma, immunoblastic type). Eleven of 26 large cell lymphoma patients with adequate follow-up were long-term survivors (free of disease for more than 5 years). Nineteen of the 33 large cell lymphomas were localized to one bone. The stage and histologic pattern significantly correlated with long-term survival among large cell lymphomas. Seventy-three percent of patients with localized lymphoma were long-term survivors, in contrast to 9% of those with disseminated disease. Sixty-seven percent of patients with large cleaved and multilobated cell lymphoma were long-term survivors, but only 21% of those with large noncleaved cell and immunoblastic sarcoma were. The tumors had a blastic, lytic, or mixed radiographic appearance and had either sclerotic, lytic, or permeative borders; none of the radiologic findings were diagnostically useful.

Computed tomography of osteosarcoma after intraarterial chemotherapy.

The response to intraarterial cis-diamminedichloroplatinum II (CDP) chemotherapy was evaluated by computed tomography (CT) in 33 patients with pathologically proved osteosarcoma of the long or flat bones. Twenty-one of the 33 patients had a CT scan before chemotherapy was started. In the other 12 patients, a CT scan was obtained after at least two courses of treatment, and additional studies were performed during the course of therapy. In those patients responding to treatment, the posttherapy scan revealed a remarkable decrease or complete disappearance of the associated soft-tissue mass and clear reestablishment of the fat planes between the muscle bundles that had been obscured. There was sharp definition of the peripheral margins of the calcified healing neoplasm, and the calcification in the healing tumor could be differentiated easily from that of the original bone neoplasm. The findings of CT were compared with those of conventional studies and pathologic results. CT was more accurate than conventional studies in detecting healing process and diagnosis of remission.

Diagnosis and treatment of lumbosacral plexopathies in patients with cancer.

Eleven patients were diagnosed as having lumbosacral plexopathy at M. D. Anderson Hospital, Houston, from August 1981 through July 1982. Four causes were documented: plexopathy secondary to metastatic disease (six cases); radiation-induced plexopathy (two cases); plexopathy secondary to intra-arterial chemotherapy (two cases); and plexopathy as the result of a second primary tumor (one case). Patients with plexopathies secondary to tumor or irradiation complained of pain in the ipsilateral lower extremity. Computed tomography of the pelvis was the most accurate method of documenting tumor in the region of the lumbosacral plexus. Radiation therapy records of patients with cervical carcinoma were reviewed with respect to positioning of intracavitary radium, which was thought to be responsible for the development of radiation-induced plexopathies. Radiation therapy and/or systemic chemotherapy provided relief of pain and improvement of neurologic deficits in three patients with metastatic involvement.

Malignant biliary obstruction: complications of percutaneous biliary drainage.

The medical records of 161 patients who underwent percutaneous biliary drainage (PBD) for malignant biliary obstruction were reviewed with attention to the complications resulting from this mode of drainage. Observed was a higher incidence of complications--particularly of cholangitis--than that generally reported in the literature. Although PBD is an effective method of biliary drainage, it carries a high risk of cholangitis in patients with cancer, who frequently receive myelosuppressive agents that predispose them to infections.

Leiomyosarcoma: computed tomographic findings.

The computed tomographic (CT) findings in 118 patients with the diagnosis of leiomyosarcoma were reviewed. The tumor masses visualized in these patients were often quite large; extensive necrotic or cystic change was a frequent finding. Calcification was not observed in these tumors. The liver was the most common site of metastasis in these patients, with marked necrosis of the liver lesions a common finding. Other manifestations of tumor spread included pulmonary metastases, mesenteric or omental metastases, retroperitoneal lymphadenopathy, soft-tissue metastases, bone metastases, splenic metastases, and ascites. The metastatic lesions were often centrally necrotic. Although the CT appearance of leiomyosarcoma is not specific, these findings, when present, suggest consideration of this diagnosis.

Fine needle aspiration cytology of the adrenal gland.

The cytologic appearance of fine needle aspiration (FNA) specimens emanating from both symptomatic and incidental masses of the adrenal glands in 22 patients who attended a large cancer institution from 1976 to 1981 is described. Eligibility for the study required thorough clinical and radiologic follow-up for at least two years following the initial cytologic diagnosis. Histologic and ultrastructural correlations were performed when possible. Nine patients were found to have benign lesions, including five adrenal cysts, two adenomas, one nodular hyperplasia and one adrenal myelolipoma. Thirteen patients had malignant lesions, of which six were primary adrenal tumors, either neuroblastoma (two) or adrenocortical carcinoma (four). The overall sensitivity of FNA in detecting the presence of malignancy was 85%, while the number of patients correctly classified for all adrenal masses was 90%. The test was 100% specific for malignant lesions. It is concluded that FNA of adrenal masses is a safe and simple procedure with a high degree of accuracy. Its use appears to be especially justified in those patients with primary neoplasms of nonadrenal sites, in whom silent adrenal lesions are detected during radiologic surveys for metastatic disease. Fifteen of the patients fell into this category, yet over half (53%) of them were shown to have benign adrenal lesions, treatable with a conservative approach.

Clinical features and results of management of superior vena cava syndrome secondary to lymphoma.

Thirty-six of 915 patients with non-Hodgkin's lymphoma presented with superior vena cava syndrome (SVCS). The histologic types associated with SVCS were diffuse large cell in 23 patients, lymphoblastic in 12, and follicular large cell in one patient. Radiotherapy alone appeared equal to chemotherapy alone or in combination with radiotherapy in achieving relief of SVCS symptoms. Chemotherapy alone or in combination with radiotherapy was superior to radiotherapy alone in prolonging relapse-free survival and overall survival. No differences in relapse-free survival and survival were found between the patients treated with chemotherapy alone and those treated with chemotherapy and radiotherapy, but the addition of radiotherapy appeared to prevent local relapses in the group with large-cell lymphoma. The presence of symptoms of involvement of other mediastinal structures such as dysphagia, hoarseness, or stridor (DHS), a higher grade of intensity, and a shorter duration of symptoms (less than or equal to 2 weeks) appeared to adversely influence relapse-free survival and survival. The following conclusions were made: (1) a histologic diagnosis before the onset of treatment is desirable and feasible in patients presenting with SVCS except in those with severe respiratory distress, (2) both chemotherapy and radiotherapy are equally effective in alleviating the symptoms of SVCS, and (3) combined modality treatment with chemotherapy and radiotherapy results in a lower frequency of local relapses compared to chemotherapy alone but survival was similar in both groups.

Intraosseous pneumatocysts of the ilium. Findings on radiographs and CT scans.

CT scans demonstrated a localized collection of gas adjacent to a normal sacroiliac joint in 5 patients. In each case the lesion was sharply demarcated by a thin sclerotic rim. A benign bone cyst was confirmed histologically in 2 cases. The radiologist should be aware of this appearance so as to avoid invasive procedures based on a misdiagnosis of infection or neoplasm.

Soft-tissue desmoid tumors: radiographic bone changes.

A retrospective study was done of 132 patients with desmoid fibromatosis (fibrosarcoma grade I desmoid type [FIDT]). Eight patients with tumor in the extremities demonstrated abnormalities in the adjacent bones. Bone erosion and a "frondlike" periosteal reaction were the radiological patterns identified. A local recurrence occurred in 5 of the 8 patients, indicating the locally aggressive behavior of this tumor.

Eosinophilic granuloma of bone: diagnosis and management.

Fifty patients with eosinophilic granuloma of bone were reviewed. Thirty-one lesions were in the head and neck, 24 in the extremities, seven in the pelvis, and five in the ribs. The lesions were lytic with ill-defined margins, endosteal erosion, and solid periosteal reaction. The diagnoses were obtained by surgical biopsy in 36 patients and by percutaneous biopsy in 14. Twenty-six lesions were treated with radiotherapy, 14 by surgery, and nine by surgery and radiotherapy. The last 14 cases have been treated by percutaneous injection of methylprednisolone sodium succinate into the lesion. Healing was obtained in every lesion. There were no complications.

Work in progress: hypotension and high-volume biliary excretion following external percutaneous transhepatic biliary drainage.

A review of 120 consecutive percutaneous transhepatic biliary drainage (PTBD) procedures performed for high-grade obstructive jaundice identified seven patients whose bile output exceeded normal volumes. Three patients required intense fluid therapy for intravascular volume depletion. No patient exhibited fever or bacteremia. Hypovolemia due to high-volume biliary drainage was considered responsible for severe hypotension. Hypovolemia secondary to large-volume biliary secretion may complicate PTBD. The pathophysiology of high-volume biliary drainage unrelated to initial decompression is uncertain.

Fine-needle percutaneous biopsy. A useful evaluation of lymph node metastasis from prostate cancer.

When fine-needle aspiration biopsy is combined with bipedal lymphangiography, the presence of nodal metastases can be determined histologically without an open surgical procedure. Thirty-five patients with carcinoma of the prostate who had "positive" or "suspicious" lymphangiograms underwent fine-needle aspiration biopsy of the involved node. The diagnosis of metastatic disease was confirmed cytologically in 10 of 20 patients with "definitely positive" x-ray films and 9 of 15 patients with "suspicious" x-ray films. Over-all, nodal metastases were confirmed cytologically without surgical exploration in 19 of 36 patients (54%). No complications were encountered.

Gastric leiomyosarcoma.

A retrospective study was made of 28 patients who had gastric leiomyosarcomas to identify histologic patterns and radiologic appearances. Three histologic patterns were identified: spindle cell, epithelioid, and pleomorphic. The histopathologic type of tumor did not correlate with the size, the grade of malignancy, or the location of the mass within the stomach. All but one tumor presented as a submucosal mass by barium contrast examination. Ulceration was present in 17 of 28 patients. Sonographic examination in six patients and computed tomography (CT) in one provided further information about the degree of extragastric extension. Sonographically the masses were echogenic in three patients, hypoechoic in two, and anechoic in one. Surgery remains the only curative therapy and surgical excision is recommended regardless of mass size.

Carcinoma of the cervix: percutaneous lymph node aspiration biopsy.

Percutaneous retroperitoneal lymph node biopsy was performed on 129 patients with carcinoma of the cervix, in whom a lymphangiographic study was reported as suspicious or positive for metastatic nodal disease. Of 159 total biopsies, 114 were performed on external iliac nodes and 45 on paraaortic nodes. An overall accuracy of 68% was obtained without significant complication. The sensitivity of the test was 58% and the specificity 100%. In patients with suspicious lymphangiograms for metastatic disease, percutaneous biopsy identified metastases in 32% of the cases. The predictive value of a negative test was only 42%, but the predictive value of a positive test 100%.

Percutaneous needle biopsy of soft tissue tumors guided by ultrasound and computed tomography.

Ultrasound and computed tomography (CT) guided percutaneous needle biopsy of soft tissue lesions was performed in 39 patients. A correct diagnosis was obtained in 35 of 42 biopsies, with an overall accuracy rate of 83%. No false-positive diagnoses were obtained, and no complications related to the procedure were encountered. The value of this technique in the management of selected patients with soft tissue masses is detailed.