Incidental Detection of Femoral Pseudoaneurysm at 18F-FDG PET/CT.

A 72-year-old man with history of lung cancer and melanoma was referred for routine follow-up with 18F-FDG PET/CT. CT images showed a new mass in the right groin associated with mild FDG activity on 18F-FDG PET images. Subsequent ultrasound obtained the same day demonstrated flow within the lesion to be a pseudoaneurysm of the right femoral artery.

SERIAL NECK ULTRASOUND IS MORE LIKELY TO IDENTIFY FALSE-POSITIVE ABNORMALITIES THAN CLINICALLY SIGNIFICANT DISEASE IN LOW-RISK PAPILLARY THYROID CANCER PATIENTS.

OBJECTIVE: American Thyroid Association (ATA) low-risk papillary thyroid cancer (PTC) patients without structural evidence of disease on initial posttreatment evaluation have a low risk of recurrence. Despite this, most patients undergo frequent surveillance neck ultrasound (US). The objective of the study was to evaluate the clinical utility of routine neck US in ATA low-risk PTC patients with no structural evidence of disease after their initial thyroid surgery. METHODS: We performed a retrospective review of 171 ATA low-risk PTC patients after total thyroidectomy, with or without radioactive iodine (RAI) ablation, who had a neck US without suspicious findings after therapy. The main outcome measure was a comparison of the frequency of finding false-positive US abnormalities and the frequency of identifying structural disease recurrence. RESULTS: Over a median follow-up of 8 years, 171 patients underwent a median of 5 neck US (range 2-17). Structural recurrence with low-volume disease (≤1 cm) was identified in 1.2% (2/171) of patients at a median of 2.8 years (range 1.6-4.1 years) after their initial diagnosis. Recurrence was associated with rising serum thyroglobulin (Tg) level in 1 of the 2 patients and was detected without signs of biochemical recurrence in the other patient. Conversely, false-positive US abnormalities were identified in 67% (114/171) of patients after therapy, leading to additional testing without identifying clinically significant disease. CONCLUSION: In ATA low-risk patients without structural evidence of disease on initial surveillance evaluation, routine screening US is substantially more likely to identify false-positive results than clinically significant structural disease recurrence.

Frequent screening with serial neck ultrasound is more likely to identify false-positive abnormalities than clinically significant disease in the surveillance of intermediate risk papillary thyroid cancer patients without suspicious findings on follow-up ultrasound evaluation.

CONTEXT: American Thyroid Association (ATA) intermediate-risk thyroid cancer patients who achieve an excellent treatment response demonstrate a low risk of structural disease recurrence. Despite this fact, most patients undergo frequent surveillance neck ultrasound (US) during follow-up. OBJECTIVE: The objective of the study was to evaluate the clinical utility of routine screening neck US in ATA intermediate-risk patients documented to have a nonstimulated thyroglobulin less than 1.0 ng/mL and a neck US without suspicious findings after therapy. PATIENTS AND DESIGN: Retrospective review of 90 ATA intermediate-risk papillary thyroid carcinoma patients treated with total thyroidectomy and radioactive iodine ablation in a tertiary referral center. MAIN OUTCOME MEASURES: A comparison between the frequency of finding false-positive US abnormalities and the frequency of identifying structural disease recurrence in the study cohort was measured. RESULTS: Over a median of 10 years, 90 patients had a median of six US (range 2-16). Structural disease recurrence was identified in 10% (9 of 90) at a median of 6.3 years. Recurrence was associated with other clinical indicators of disease in 5 of the 90 patients (5.6%, 5 of 90) and was detected without other signs of recurrence in four patients (4.8%, 4 of 84). False-positive US abnormalities were identified in 57% (51 of 90), leading to additional testing, which failed to identify clinically significant disease. CONCLUSIONS: In ATA intermediate-risk patients who have a nonstimulated thyroglobulin less than 1.0 ng/mL and a neck US without suspicious findings after therapy, frequent US screening during follow-up is more likely to identify false-positive abnormalities than clinically significant structural disease recurrence.

Metanephric adenoma of the kidney: clinical and radiological study of nine cases.

OBJECTIVE To analyse the clinical and radiological features of metanephric adenoma (MA, a rare benign renal tumour) in nine patients, and to review previous reports. PATIENTS AND METHODS From 1992 to 2007, we identified nine patients (eight women and one man) with MA at our institution. Four patients had a radical nephrectomy and five a partial nephrectomy. Preoperative imaging was reviewed by a senior radiologist. Renal colour Doppler ultrasonography (US), abdominal computed tomography and abdominal magnetic resonance imaging were used in seven, eight and four patients, respectively. RESULTS The mean (range) age of the patients was 46.8 (19-79) years. Six tumours were discovered incidentally. Three patients were symptomatic (two with haematuria and one with polycythaemia). There was no vascular flow on colour Doppler US within the tumours. There were peripheral and/or central calcifications in six of the tumours. All the tumours were well-circumscribed with minimal enhancement after injection with non-ionic intravenous contrast or gadolinium. CONCLUSIONS Renal MA is a benign tumour occurring mainly in young and middle-aged women. Polycythaemia is associated in approximately 10%. Generally, MA is solid, well-circumscribed and hypovascular, often with calcifications. Based on a combination of clinical and imaging features, it might be possible to suspect the diagnosis of MA and propose a preoperative diagnostic biopsy, a partial nephrectomy or active surveillance.

Contemporary radiologic imaging of renal cortical tumors.

Contemporary radiologic imaging has resulted in an increasing number of smaller renal cortical tumors being identified. The ability of imaging to classify these tumors is limited, although certain features may help classify the renal cortical neoplasm. The important role of radiologic imaging in tumor detection, characterization, staging, and follow-up of patients who have renal cortical tumors is reviewed in this article.

Tumor location does not affect long-term renal function after partial nephrectomy.

OBJECTIVES: To study the effect of central tumor location on the glomerular filtration rate (GFR) after partial nephrectomy for renal cortical tumor. METHODS: We reviewed our institutional database to identify patients who had undergone partial nephrectomy from January 1995 to July 2005. Central tumors were defined as those encroaching on the collecting system or renal sinus or that did not distort the renal contour; all others were categorized as peripheral on preoperative abdominal imaging. We calculated the GFR preoperatively, during the hospital stay, and at 1 and 12 months after surgery. Linear regression models were fit to determine the association of tumor location with the changes in GFR at each period, after controlling for age, sex, operative and ischemic times, comorbidities, and blood loss. RESULTS: A total of 248 central and 333 peripheral tumors were available for analysis. Patients with central tumors were younger than those with peripheral tumors (62 versus 59 years, P = 0.014) and experienced longer intraoperative renal ischemia times (40 versus 29 minutes, P <0.001) and longer operations (195 versus 179 minutes, P = 0.004). On multivariate analysis, tumor location was not significantly associated with the change in GFR at any of the intervals, after adjusting for the covariates. CONCLUSIONS: The results of our study have indicated that tumor location does not appear to affect long-term renal function. Thus, partial nephrectomy should not be withheld from this subset of patients.

Predicting the histology of renal masses using preoperative Doppler ultrasonography.

PURPOSE: Traditional imaging techniques cannot differentiate among benign, indolent and malignant renal neoplasms. Since conventional clear cell carcinomas are highly vascular, we used preoperative color and/or power Doppler ultrasonography to evaluate the association between vascular flow in a renal mass and surgical pathology. MATERIALS AND METHODS: Nephrectomies performed at our institution between January 2001 and December 2004 were retrospectively evaluated. Any detection of flow in the renal mass on color Doppler ultrasonography was defined as vascular flow. A prospective validation study was then performed from January 2005 to October 2005 and a nomogram was constructed to predict clear cell histology. RESULTS: Of 299 renal lesions in the retrospective cohort 210 (70%) had evidence of vascular flow, including 156 of 169 conventional clear cell carcinomas (92%) (p <0.0001). On logistic regression analysis vascular flow was associated with conventional clear cell histology (OR 16.9, 95% CI 8.7-32.8; p <0.0001). This finding was validated prospectively in 97 patients. Vascular flow was detected in 54 of 65 renal masses (83%) with conventional clear cell histology (p <0.0001), which was associated with an OR of 10.8 (95% CI 4.0-29.0; p <0.0001). A nomogram incorporating vascular flow along with clinical variables (clinical size, patient sex and age) to predict conventional clear cell histology was constructed on the retrospective cohort and validated on the prospective data set (concordance index 0.82 and 0.76, respectively). CONCLUSIONS: Vascular flow detected by color Doppler ultrasonography is strongly associated with conventional clear cell histology. A nomogram incorporating vascular flow on color Doppler ultrasonography and clinical parameters may aid in the preoperative characterization of renal lesions.

The impact of tumour location on the histological subtype of renal cortical tumours.

OBJECTIVE: To determine whether the location of renal cortical tumours (RCTs) is a possible factor affecting tumour behaviour, by investigating whether exophytic vs a central location is associated with a difference in histological subtype distribution, as recognized prognostic factors for RCTs include size, stage, grade, and histological subtype. PATIENTS AND METHODS: Between 1 January 1996 and 1 June 2003, we evaluated 485 consecutive RCTs in 469 patients who had renal imaging studies and underwent either partial or radical nephrectomy at our institution. A radiologist and a urologist independently reviewed the imaging studies of all patients to determine exophytic vs central location. An exophytic lesion was defined as one that clearly both pushed out the renal contour and did not extend into the collecting system, hilum, or renal sinus. A lesion that did not meet these criteria was defined as a central lesion. Logistic regression analysis was used to determine if either type of lesion had a greater representation of any histological subtype. A two-tailed P < or = 0.05 was considered to indicate significance. RESULTS: Of the 485 RCTs, 171 (35%) were exophytic and 314 (65%) were central, while 308 (64%) were clear cell and 177 (36%) were non-clear cell tumour histology. Of the exophytic lesions, 52.0% were clear cell, while 69.7% of central lesions were clear cell (P < 0.001). Conversely, 71.1% of clear cell tumours were central, while 53.7% of non-clear cell tumours were central (P = 0.003). After controlling for size and stage, tumour location remained associated with histological subtype (P = 0.003). CONCLUSIONS: Exophytic lesions are significantly more likely than central lesions to be non-clear cell tumours, and clear cell tumours are significantly more likely than non-clear cell tumours to be central. As studies indicate that the clear cell histological subtype portends a worse prognosis than the non-clear cell subtype, our results imply that tumour location affects the prognosis in RCTs, with exophytic lesions having a better prognosis than central lesions. This result may have important implications for physicians and patients when planning partial vs radical nephrectomy by either open or minimally invasive techniques.

Comparison of outcomes in elective partial vs radical nephrectomy for clear cell renal cell carcinoma of 4-7 cm.

OBJECTIVE: To compare the outcomes of patients who had a elective partial nephrectomy (PN) or radical nephrectomy (RN) for clear cell renal cell carcinoma (RCC) of 4-7 cm. PATIENTS AND METHODS: From March 1998 to July 2004, 45 and 151 patients underwent PN and RN, respectively, for clear cell RCC. A multivariate Cox model was constructed for disease-free survival with adjustment for markers of disease severity, and a propensity-score approach used as a confirmatory analysis. RESULTS: In the PN and RN cohorts the treatment failed in one and 20 patients, respectively; the median follow-up was 21 months. The hazard ratio (95% confidence interval) for PN after adjusting for disease severity was 0.36 (0.05-2.82; P = 0.3). Using planned PN as a predictor (intent-to-treat analysis) the hazard ratio was 1.06 (0.32-3.53; P = 0.9). In the propensity-score model, planned PN was associated with a hazard ratio of 1.75 (0.50-6.14; P = 0.4). The serum creatinine level 3 months after surgery was significantly lower in patients who had PN, with a difference between the means of 0.36 (0.23-0.48; P < 0.001). CONCLUSIONS: Renal function was preserved after PN for 4-7 cm clear cell RCC tumours. When comparing the outcomes of PN and RN it is important to consider the intended operation as an independent variable. There was no clear evidence that PN was associated with worse cancer control, although a continued follow-up of this and other cohorts is warranted.

A phase II trial of gemcitabine in patients with metastatic breast cancer previously treated with an anthracycline and taxane.

PURPOSE: This study was designed to evaluate the efficacy and safety of single-agent gemcitabine for the treatment of patients with anthracycline- and taxane-pretreated metastatic breast cancer (MBC). Eligible patients were required to have bidimensionally measurable MBC that had been treated with 2-4 prior chemotherapy regimens that included an anthracycline and a taxane. Gemcitabine was delivered at a dose of 800 mg/m2 on days 1, 8, and 15 of a 28-day cycle until evidence of disease progression. PATIENTS AND METHODS: Twenty-two patients were enrolled and included in the safety analysis; 18 patients were evaluable for response. The median age of patients was 54 years (range, 36-70 years). The mean number of prior chemotherapy regimens for metastatic disease was 2.3, and the mean dose of gemcitabine delivered was 911 mg/m2 (range, 600-1600 mg/m2). RESULTS: Overall, gemcitabine was well tolerated with minimal grade 3 toxicities; the only grade 4 toxicity was 1 case of pulmonary embolus. Three patients had evidence of partial tumor regression (17%; 95% CI, 4%-41%), and 1 patient had a 41% decrease in tumor volume, including liver metastasis. CONCLUSIONS: Gemcitabine is active and well tolerated as monotherapy given in heavily pretreated patients with MBC after anthracyclines and taxanes. The activity and safety reported in this trial are consistent with previous reports in similar patients.

Sonohysterography compared with endometrial biopsy for evaluation of the endometrium in tamoxifen-treated women.

OBJECTIVE: This study was performed to compare endometrial biopsy and sonohysterography for evaluation of the endometrium in tamoxifen-treated women. METHODS: Medical records were retrospectively reviewed to identify 51 consecutive tamoxifen-treated women who had sonohysterography and correlative endometrial biopsy for evaluation of postmenopausal bleeding or thickened endometrium of greater than 8 mm. Endometrial biopsy and sonohysterographic results were compared in all women, and for 27 (53%) women who had hysteroscopy with dilation and curettage, endometrial biopsy and sonohysterographic findings also were compared with surgical pathologic findings. RESULTS: Thirty-two (63%) of 51 sonohysterograms revealed endometrial polyps; 4 (8%) showed endometrium of greater than 5 mm; 14 (27%) showed endometrium of less than 5 mm; and 1 (2%) was inadequate. Endometrial biopsy findings were benign endometrium in 42 (82%), polyps in 4 (8%), and insufficient samples in 5 (10%). Among the adequate sonohysterograms, 64% (32 of 50) resulted in a diagnosis of polyps (95% confidence interval, 49%-77%) whereas the corresponding proportion for endometrial biopsy was 9% (4 of 46; 95% confidence interval, 2%-21%). For the group with hysteroscopy, 24 (92%) of 26 polyps were confirmed histopathologically; 1 polyp had complex hyperplasia. Polyps were present in 23 (89%) of 26 women with benign endometrium or insufficient samples by endometrial biopsy, and only 1 confirmed polyp was identified by endometrial biopsy. The sensitivity of sonohysterography for diagnosis of endometrial polyps (100%) was significantly higher than for endometrial biopsy (4%; P < .01). CONCLUSIONS: In tamoxifen-treated women, sonohysterography provides a significant improvement in sensitivity for diagnosis of endometrial polyps compared with endometrial biopsy.

Utility of sonography for small hepatic lesions found on computed tomography in patients with cancer.

OBJECTIVE: To assess the performance of sonography in evaluating small indeterminate liver lesions detected on computed tomography in patients with cancer. METHODS: Radiology database review from January 1, 1998, to August 4, 2000, identified 76 patients with 124 indeterminate hepatic lesions smaller than 1.5 cm on computed tomography who had abdominal sonography within 3 months. Sonographic reports and images were reviewed to assess whether lesions were referenced or specifically sought and to verify lesion correspondence, detection, and characterization. The validity of sonographic characterization was determined by histopathologic examination or follow-up imaging (mean time to follow up, 17 months; range, 6.5-38.8 months). RESULTS: Sixty (48%) of 124 indeterminate lesions were evident on sonography. Detection improved when lesions were specifically sought and lesion size was greater than 0.5 cm. Forty (66%) of 61 lesions were detected when the radiologist referenced the preceding computed tomography versus 20 (32%) of 63 lesions when the computed tomographic findings were not referenced (P = .0004). Fifty-one (67%) of 76 lesions measuring 0.6 to 1.5 cm were detected on sonography versus 9 (19%) of 48 lesions measuring 0.1 to 0.5 cm. Lesion size (P < .0001) and body habitus (P = .02) were significant factors influencing lesion detection. Sonography characterized 56 (93%) of 60 detected lesions (33 cysts, 18 solid lesions/metastases, and 5 hemangiomas). Sonographic diagnoses were supported in 42 (93%) of 45 lesions by follow-up imaging (37 of 40) or histopathologic examination (5 of 5). CONCLUSIONS: Sonography may be useful in cancer patients with average body habitus to characterize small (0.6- to 1.5-cm) indeterminate liver lesions detected on computed tomography.

Is there an increased incidence of contralateral testicular cancer in patients with intratesticular microlithiasis?

OBJECTIVE: The objective of this study was to determine if there is an association between intratesticular microlithiasis and contralateral testicular cancer. MATERIALS AND METHODS: Retrospective review of a radiology database revealed 156 men who had undergone testicular sonography and orchiectomy for testicular cancer. Sonographic abnormalities were correlated with medical records and histopathology. Statistical significance was assessed using Fisher's exact test. RESULTS: Twenty-three (15%) of 156 patients with prior orchiectomy for testicular cancer had microlithiasis, and 133 (85%) did not have microlithiasis. Four of 23 patients with microlithiasis had masses, and eight had heterogeneous changes. Sonograms of 133 patients without microlithiasis revealed masses in seven and heterogeneous changes in 15 patients. Five patients with microlithiasis and six without microlithiasis underwent a second orchiectomy. Contralateral testicular cancer was confirmed in five (22%) of 23 patients with microlithiasis versus three (2%) of 133 men without microlithiasis. Microlithiasis was present in five (63%) of eight patients with bilateral testicular cancer, and microlithiasis was highly associated with confirmed bilateral testicular cancer (5/23 vs 3/133, odds ratio [OR] = 12.0, p = 0.002). Among the 34 patients who had either testicular masses or heterogeneous changes, microlithiasis had an OR of 4.5 (p = 0.10). CONCLUSION: In our study, contralateral testicular cancer was significantly associated with intratesticular microlithiasis. Nevertheless, there was not sufficient evidence that intratesticular microlithiasis adds independent diagnostic information for bilateral testicular cancer in the absence of a mass or heterogeneous changes.

Clinical experience with upper extremity venous sonography in a high-risk cancer population.

OBJECTIVE: To determine the frequency of sonographically evident upper extremity venous thrombosis in symptomatic cancer patients with and without central venous catheters. METHODS: Retrospective review of 573 consecutive upper extremity venous sonographic reports from a 26-month period was performed. Findings including distribution of venous thrombosis, the presence of a central line, cancer type, and miscellaneous findings were recorded. RESULTS: Overall, 514 studies (90%) had satisfactory visualization of all upper extremity vessels; 53 (9%) had limited visualization of 1 or more vessels; and 6 (1%) were inconclusive. Venous thrombosis was present in 227 (40%) of 573 studies. Of the studies with positive findings, there were 186 acute, 13 chronic, 19 fibrin sheath versus nonocclusive, and 9 superficial thromboses. Central venous catheters were present in 325 (57%) of 573 studies. Sonographically evident thrombosis was present in 157 (48%) of 325 studies with central catheters versus 70 (28%) of 248 studies without central venous catheters (P = .001) CONCLUSIONS: Upper extremity venous thrombosis is common (40%) in symptomatic cancer patients and is nearly twice as frequent in cancer patients with indwelling central venous catheters.