Paraumbilical venous collateral circulations: color Doppler ultrasound features.

Using Color Doppler ultrasonography to trace the dilated paraumbilical vein to its connection with systemic veins in 27 patients, we have found four major pathways: In type 1 (63%), the vein connected with the external iliac vein via the inferior epigastric vein. In type 2 (3.7%), the vein connected with the saphenous vein via the superficial epigastric vein. In type 3 (22.2%), the vein connected with the internal thoracic vein via the superior epigastric vein. Type 4 (11.1%) is a combination of types 1 and 2. A frank caput medusa was not seen, but occult caput medusa were seen in two patients. Turbulent flow was seen at the junction between inferior epigastric and external iliac veins, paraumbilical and superficial epigastric veins, and superficial epigastric and saphenous veins in some patients. Color Doppler ultrasonography is a convenient, noninvasive method for determining the course and associated hemodynamic changes in the paraumbilical collateral circulation.

Interval changes in nonpalpable breast lesions as an indication of malignancy.

OBJECTIVE: To determine whether the patterns of interval changes in nonpalpable breast lesions can be used to determine malignancy. PATIENTS AND METHODS: The authors reviewed the records for 128 nonpalpable breast lesions detected by mammography between March 1990 and May 1992 for which previous imaging studies were available. Changes in size, density and contour of the 59 masses and changes in size, number, configuration and pattern for the 69 cases involving microcalcifications were determined from comparison of the current mammograms with the earlier imaging studies, obtained 6 to 42 months previously. These findings were correlated with the pathological diagnosis based on needle localization and excisional biopsy. RESULTS: Twelve (55%) of the 22 new masses and 15 (48%) of the 31 masses that changed were malignant, but none of the 6 masses that did not change were malignant (chi 2 test, p < 0.01). All of the 31 masses that changed increased in size (and of these, 15 [48%] were malignant). In addition, 14 (45%) of the masses that changed exhibited increased density (and of these 9 [64%] were malignant), and 11 (35%) became irregular (and all of these were malignant). Eight (47%) of the 17 cases of new calcifications, 18 (43%) of the 42 cases of calcifications that changed and none of the 10 cases of unchanged calcifications were malignant (chi 2 test, p < 0.01). Twelve (44%) of the 27 calcifications that changed in area and 14 (40%) of the 35 that changed in number were malignant. Fifteen (60%) of the 25 calcifications that changed from scattered to grouped and 8 (53%) of the 15 that changed from punctate to linear were malignant. CONCLUSION: A change in the density or contour of a mass is a fairly definite sign of malignancy. The authors conclude that interval observation is a good method of detecting malignancy in breast masses but is less reliable for detecting malignancy in calcifications.

Long-term follow-up of two sibs with Larsen syndrome possibly due to parental germ-line mosaicism.

Larsen syndrome is a heterogeneous (autosomal dominant or recessive) disorder of characteristic facial changes, multiple joint dislocations, and bone deformities. Few data on the adult presentation of the recessive form of this disorder have been reported; thus, we set out to describe two sibs thought to be affected with autosomal recessive Larsen syndrome who were evaluated as infants and later as adults. Aside from secondary joint changes and the presence of cataracts, changes described in children with autosomal recessive Larsen syndrome were noted. Three years after evaluation, the sister gave birth to a daughter with Larsen syndrome. This occurrence raises the possibility of germ-line mosaicism as the mode of inheritance in this family. Thus, germ-line mosaicism must be considered in the genetic counseling of families with Larsen syndrome in which neither parent appears affected. These patients also illustrate that despite the severe skeletal and joint deformities, the prognosis can be good with careful orthopedic management.

Junctional parenchyma: revised definition of hypertrophic column of Bertin.

The so-called hypertrophic column of Bertin is a normal variation and simply represents unresorbed polar parenchyma of one or both of the two subkidneys that fuse to form a normal kidney. It contains renal cortex, pyramids, and columns (septa) of Bertin. (Since all elements of the tissue are normal, that is, neither hypertrophic nor a displaced or embryonic rest, it is referred to as "junctional parenchyma.") When a masslike lesion is suspected at sonography or excretory urography, diagnosis of junctional parenchyma can be made with a high degree of certainty when sonography shows that the structure (a) is located between the overlapping portion of two renal sinus systems, (b) is bordered by a junctional parenchymal line and defect, (c) contains renal cortex, pyramids, and columns of Bertin, and (d) contains renal cortex that is continuous with the adjacent renal cortex of the same subkidney.

Milk of calcium in renal cysts: new sonographic features.

Milk of calcium (MOC) in a small renal cyst or calyceal diverticulum is quite common. Ninety-one small renal cysts with MOC in 61 patients were found within a period of 4 years and 7 months. The main sonographic features are echogenic material layering in the dependent portion of a cyst, associated with reverberation echoes without shadowing. Shadowing was seen when MOC was present in larger amounts. Because MOC is usually asymptomatic and requires no treatment, differentiation from other lesions such as calculi or angiomyolipomas is important for proper patient management. MOC is detected more readily by ultrasonography than by radiography or CT.

Sonographic demonstration of annular pancreas and a distal duodenal diaphragm in a newborn.

A case of duodenal obstruction in a newborn is presented where sonographic examination demonstrated duodenal obstruction by both an annular pancreas and a duodenal diaphragm.

Epiphyseal involvement in osteosarcoma.

Plain radiography and magnetic resonance (MR) imaging were used to assess the extent of transphyseal involvement in 15 consecutive patients with long bone osteosarcoma and nonfused epiphyses. The findings were correlated with those from surgical and microscopic pathologic examinations. There were no cases of false-positive findings with either MR imaging or plain radiography. Conventional radiography accurately helped predict transphyseal spread in only nine of 15 cases (60%). Spread to the epiphysis was present in 12 of the 15 cases (80%) and was accurately predicted with MR imaging in all 12 cases. This finding contradicts the common misconception that the physis acts as a "barrier" to tumor spread.

Nonpalpable ductal carcinoma in situ versus infiltrating carcinoma of the breast--can they be differentiated by mammography?

The radiologic patterns of 193 consecutive women with nonpalpable breast carcinoma were evaluated. The results were correlated with patient age and with the histopathologic diagnosis. Of the 193 women in the study, 135 (70%) were older than 50 years; 102 women had ductal carcinoma in situ, and 67 (62%) of them were over age 50; the remaining 91 women had infiltrating carcinoma, and 73 (80%) of these patients were older than 50 years. Of the 58% of women who presented with microcalcifications, 75% had ductal carcinoma in situ and 25% infiltrating carcinoma. Of the 36% of patients who presented with a mass, 87% had infiltrating carcinoma and 90% were over age 50. Six percent presented with a mass with microcalcifications; 75% of these masses were found to be infiltrating carcinoma. Most of the masses were infiltrating carcinoma, and of these 90% were high-density masses. The small number of masses representing ductal carcinoma in situ were proportionately of low density.

Mesomelic dysplasia with absence of fibulae and hexadactyly: Nievergelt syndrome or new syndrome?

Mesomelic dysplasia is a form of short-limb dwarfism characterized by disproportionate shortness of the middle segment of all limbs. Included in this category of skeletal disorders is the Nievergelt syndrome, which typically manifests a rhomboidal shape of the tibiae and fibulae, an unusual foot deformity, radioulnar synostosis, and dysplasia of the elbow and knee joints. We describe a patient with mesomelic dysplasia with findings suggestive of the Nievergelt syndrome and with absence of fibulae and hexadactyly.

Nonpalpable breast masses: radiologic predictability of malignancy.

Of 568 nonpalpable breast lesions detected by screening mammography 242 proved to be noncalcified masses; biopsy showed 165 to be benign and 77 malignant. The lesions were evaluated with respect to contour, radiographic density and size. Of the malignant lesions 90% were infiltrating carcinomas, 88% of which had an indistinct contour and were of moderate to high density. Of the benign lesions 40% of those with an indistinct contour demonstrated high radiographic density. Low-density, distinct masses were all benign. There was no correlation between the size of the lesion and whether it was malignant.

Central pontine myelinolysis with clinical recovery: MR documentation.

Magnetic resonance (MR) features of a patient with profound hyponatremia and clinical findings of central pontine myelinolysis are presented. Resolution of the MR findings paralleled the clinical recovery.

Congenital rickets associated with magnesium sulfate infusion for tocolysis.

The records of five neonates born to mothers treated with intravenously administered magnesium sulfate for tocolysis were retrospectively reviewed to assess the presence of radiographic, clinical, and biochemical abnormalities. Two infants had radiographic bony abnormalities; one had frank rachitic changes and dental enamel hypoplasia. One of these patients, as well as an additional infant, had transient hypocalcemia. We hypothesize that prolonged infusion of magnesium sulfate, especially when initiated during the second trimester, may lead to fetal parathyroid gland suppression with consequent abnormalities resembling rickets.

Occult malignant breast lesions in 114 patients: relationship to age and the presence of microcalcifications.

This study evaluates the mammographic findings in 352 patients, aged 30-85 years, who underwent spot localization and biopsy for evaluation of nonpalpable breast abnormalities. Malignancy was found at biopsy in 114 cases. The mammographic appearance (specifically, whether grouped microcalcifications, mass, or both were present) was correlated with patient age and histologic findings (specifically, whether the pathologic changes were infiltrating or noninfiltrating in nature). The prevalence of malignant conditions increased directly with age. The presence of grouped microcalcifications as the sole indicator of malignancy was seen in 100% (seven of seven) of the patients in the 30-39-year age group, 64% (18 of 28) in the 40-49-year age group, 37% (11 of 30) in the 50-59-year age group, 30% (seven of 23) in the 60-69-year age group, and 23% (six of 26) in the 70-85-year age group. Of the 49 tumors that were manifested solely as microcalcifications, 34 (69%) were noninfiltrating. The finding of grouped microcalcifications should be aggressively investigated, since it may indicate noninfiltrating carcinoma in an early stage, when the potential for cure is greatest.

Comparison of magnetic resonance imaging and ultrasound in evaluating follicular and endometrial development throughout the normal cycle.

A prospective study was undertaken to evaluate and compare magnetic resonance imaging (MRI) and ultrasound (U/S) in monitoring follicular and endometrial development during the normal menstrual cycle. Results of MRI, U/S, estradiol (E2), and progesterone were obtained from five ovulatory volunteers on days 4, 8, 12, 16, 20, and 24 of the cycle. On U/S, all the women had only one dominant follicle, whereas MRI was able to detect a secondary cohort of follicles in three of five volunteers. Endometrial development on U/S and MRI showed similar patterns of growth with an increase on MRI from 5.8 +/- 1.1 mm on day 4 to a mean peak of 10.3 +/- 1.7 mm on day 24. A distinct feature of MRI was the demonstration of a junctional zone (JZ), which has a pattern of growth that resembles that of the endometrium, with accelerated growth from day 8 to day 16 (5.1 +/- .7 mm to 6.7 +/- .7 mm). The JZ corresponds anatomically to the distribution of the arcuate vessels and may therefore represent changes in blood supply to the endometrium. MRI, similar to U/S, is noninvasive and does not involve any radiation exposure but provides new information on uterine changes in the normal cycle. At present, its clinical applications are limited.

Amniotic sac development: ultrasound features of early pregnancy--the double bleb sign.

The amniotic sac-embryo-yolk sac complex can be seen with ultrasonography (US) as two small blebs of almost equal size attached to the wall of the early gestational sac. We have called this the double bleb sign. Since the developing embryo and its cardiac pulsation are located between these two blebs, the size of an early embryo can be measured. The crown-rump length thus measured corresponds well to that described in embryologic textbooks, and an embryo as small as 2 mm (5 weeks 3 days) can be measured with use of this method. Three stages of development of the amniotic sac-embryo-yolk sac complex can be identified with US, and they are useful in dating the pregnancy. These three stages are 1, a simple double bleb, 2, a double bleb with a stalk, and 3, a double bleb with a separating yolk sac. As the amniotic sac enlarges, strands of echoes may be seen within the chorionic cavity and should be differentiated from amniotic bands, which may cause serious fetal abnormality. Separation of the amniotic from the chorionic membrane before the 13th week is normal but may be abnormal after the 17th week of gestation. Separation of the chorionic membrane from underlying decidua, however, is abnormal at any stage of pregnancy.

Nonpalpable breast lesions: accuracy of prebiopsy mammographic diagnosis.

Mammograms of 220 patients who underwent spot localization for removal of nonpalpable breast lesions were reviewed for accuracy of interpretation. Results of subsequent biopsy indicated malignancy in 77 cases. The interpretations of mammograms obtained before biopsy were incorrect in 71 cases (27 false-negative and 44 false-positive studies). Among the false-negative cases, 70% of the abnormalities were determined histologically to be noninfiltrative cancers. An aggressive screening program with preoperative localization and biopsy is needed in questionable cases, since mammographic signs of early or nonpalpable malignancy are often subtle and nonspecific.

Preoperative chest radiography: value as a baseline examination for comparison.

An important use of the preoperative chest radiograph is as a baseline for comparison when complications occur after surgery. Many authors have commented on the value of preoperative chest radiography as a screening examination, but no statistics have been presented regarding its impact on postoperative management. In 369 consecutive general surgical patients, the need for a baseline chest radiograph was evaluated. In 65 patients undergoing chest radiography postoperatively, a preoperative baseline was essential in making an accurate interpretation in 33 (51%). The value of preoperative chest radiography proved to be twofold. Some minimal abnormalities on postoperative radiographs were demonstrated to be clearly new, necessitating treatment or further evaluation. Second, significant abnormalities detected on postoperative radiographs that may have otherwise been subjected to expensive evaluation were often shown to have been present preoperatively. In approximately 9% of patients the preoperative chest radiograph had a significant impact on postoperative management.