Prospective evaluation of internal adenopathy in a cohort of 43 patients with hairy cell leukemia.

PURPOSE: To determine the role of computed tomography (CT) in patients with hairy cell leukemia (HCL), we report a series of 43 patients prospectively evaluated for internal adenopathy by CT before and after treatment with 2-chlorodeoxyadenosine (2-CdA). PATIENTS AND METHODS: CT was performed on 43 consecutive patients with HCL before and 3 months after a single cycle of 2-CdA. Twenty-four patients were previously diagnosed and 19 were newly diagnosed. Adenopathy was considered bulky if the greatest dimension of any confluent mass was between 5 and 10 cm and massive if greater than 10 cm. RESULTS: Internal adenopathy was present in six of 43 patients (14%). Three of the six patients had massive abdominal adenopathy and one had bulky abdominal adenopathy. All six patients with adenopathy were previously diagnosed, while none of the 19 newly diagnosed patients had internal adenopathy. In those patients previously diagnosed, the six with adenopathy had a median disease duration of 68 months, while the 18 patients without adenopathy had a median disease duration of 24 months (P = .01). Adenopathy was more common in splenectomized patients. In previously diagnosed patients, adenopathy occurred in five of 10 (50%) splenectomized patients and one of 14 (7%) nonsplenectomized patients (P = .05). However, the 10 splenectomized patients had a median disease duration of 56 months, while the 14 nonsplenectomized patients had a median disease duration of 16 months (P = .004). All six patients had significant reduction in adenopathy 3 months after 2-CdA and were without residual HCL in the bone marrow. CONCLUSION: Significant internal adenopathy in patients with HCL is more frequent than previously recognized. Adenopathy is rare at diagnosis and appears to be related to disease duration. As patients treated with 2-CdA have long disease-free survival durations, detection of significant adenopathy by CT scan may be important; however, routine CT scans are not recommended at the time of diagnosis.

In vivo estimation of perfluorooctylbromide concentration in tissues.

Currently, the only available method to measure perfluorooctylbromide (PFOB) in tissues requires its extraction with a solvent followed by gas chromatography. Not only is this method invasive, but it cannot be validated because the amount of unextracted PFOB is unknown. Using a cylindrical CT phantom with eight wells in the wall filled with bromine (Br) standards, an in vivo method to measure PFOB tissue concentration was developed. Neutron activation analysis (NAA) was used to calibrate and validate the phantom since NAA allows the quantification of Br by making Br radioactive without the need for extraction. Once NAA was validated for PFOB, the phantom was calibrated using 80 rats and tested using 20 rats relative NAA. The phantom produced linear correlation between CT number and known PFOB concentrations with r = 0.998. After its calibration with NAA, the CT method produced a linear correlation between tissue PFOB concentration determined by CT and NAA near the line of identity with an r = 0.984, thus allowing the determination of PFOB tissue content in vivo noninvasively.

The low yield of routine radiographic screening of tuberculin-positive hospital employees.

On the basis of limited benefit in relation to cost, mass radiographic screening for tuberculosis was challenged and abandoned in the 1970s. In the 1980s the value of such periodic screening of hospital employees with known positive tuberculin reactions was queried on the same grounds but without comparable data. We report here the results of 11 years of radiographic screening of tuberculin-positive employees of a university hospital. Although 3900 chest films were obtained at considerable cost, only one proved and six suspect cases of tuberculosis were detected, all of which were symptomatic. Even in the absence of symptoms all could have been identified by other screening criteria, five on the basis of recent tuberculin conversion and two as tuberculin-positive new employees. These data support the recent statement that periodic chest roentgenograms of hospital employees with known positive reactions to tuberculin skin testing are not justified.

Current management of visceral artery aneurysms.

BACKGROUND: Visceral artery aneurysms are an uncommon but important form of abdominal vascular disease. This study reviews a contemporary experience with special emphasis on newer methods of diagnosis and treatment. METHODS: From 1980 to 1994, 37 patients were diagnosed with 46 visceral artery aneurysms. These consisted of 22 splenic, 10 hepatic, 4 superior mesenteric, 2 gastroduodenal, 3 celiac, 2 left gastric, 1 pancreatoduodenal, 1 jejunal-ileal, and 1 inferior mesenteric artery aneurysms. Follow-up was complete for 28 patients, average of 37.7 months. There were 17 asymptomatic and 29 symptomatic aneurysms, including 11 presenting with rupture. RESULTS: Seventeen patients were treated surgically, with no surgical deaths. Surgical complications included splenic abscess (two) and failure to thrombose (one). Transcatheter embolization was used in 12 patients. Complications included splenic infarction (one) and recurrence (two), successfully treated with repeat embolization. Nine patients were treated with observation. Eight experienced no complications during follow-up; one died of a ruptured splenic artery aneurysm before treatment was initiated. CONCLUSIONS: The widespread use of computed tomography has led to increased detection of asymptomatic visceral artery aneurysms. Although surgery remains necessary in many patients, transcatheter embolization is effective in the treatment of selected visceral artery aneurysms with few complications and low recurrence.

CT of acute gastrointestinal disorders.

The evaluation of acute gastrointestinal disorders is a challenging task for both the clinician and the radiologist. Such disorders frequently are nonspecific in their presentation, often mimicking a variety of other acute abdominal disorders. No imaging test can provide a specific diagnosis in all circumstances. The choice of the initial imaging study for a particular presentation involves a compromise between various factors, including availability, safety, cost, clinical stability of the patient, the effect on other diagnostic tests and therapeutic maneuvers that may need to be performed, and the likelihood that the imaging method will provide at least some information localizing and characterizing the disorder. CT is not inexpensive, nor is it as rapidly performed as plain film radiography. Its spatial resolution limits its applicability in detection of gastrointestinal mucosal disease, fistulous tracts, and small vessel abnormalities. On the other hand, it is a powerful method to evaluate the full extraluminal extent of gastrointestinal abnormalities and to detect abnormalities of extraenteric organs and tissues. In some circumstances, such as trauma and suspected abdominal abscess, CT should probably be the initial imaging test. Also, when other imaging tests are nonrevealing, CT can provide valuable information and often suggest a clinically unsuspected gastrointestinal abnormality.

Selection of patients for gallstone lithotripsy.

Although alternatives to cholecystectomy are now available to treat patients with gallstones, the primary treatment of gallstone disease remains surgical. It is therefore important to distinguish those patients who would benefit most from nonoperative therapy of gallstones from those who require cholecystectomy while ensuring patient safety. Current criteria for selection of patients for extracorporeal shock-wave lithotripsy (ESWL) are presented herein. In addition, preliminary results from recent in vitro experiments with human gallstones obtained at cholecystectomy are outlined. The current criteria for selection of patients for treatment with ESWL are similar to those used in the initial German experience. They appear to ensure patient safety, but the actual conditions that predict successful treatment of gallstones by ESWL are not yet known, since the clinical and in vitro studies which will define the patient and stone characteristics that predict a successful treatment outcome are still in progress. Thus, current criteria should be considered guidelines for treatment which will most certainly be modified as experience is gained with ESWL.

Morphometric analysis of the popliteal artery for endovascular treatment.

This study intended to determine the precise diameter of the popliteal artery in patients at risk for popliteal aneurysms. Accurate sizing is necessary to develop devices for endovascular treatment of popliteal aneurysms. Fifty-four patients with abdominal aortic aneurysms (AAAs) had computed tomography (CT) scans of the popliteal arteries. Age- and gender-matched control subjects were measured by ultrasound. NIH Image was used to measure the minor diameter at the adductor hiatus (proximal) and femoral condyles (midpopliteal artery). There were 4 unsuspected popliteal aneurysms (7.4%). The proximal popliteal artery was ectatic in these patients: 13.4 +/- 5.2 mm. Proximal and midpopliteal arteries were significantly larger in the other patients with AAAs compared with controls: 9.6 +/- 1.8 mm vs 7.9 +/- 1.1 mm at the hiatus (p<0.001) and 10.2 +/- 2 mm vs 7.9 +/- 0.9 mm at the condyles (p<0.001). The popliteal artery was focally larger in patients with AAAs without popliteal aneurysms. The popliteal artery was larger in men compared with women; 9.8 +/- 1.8 mm vs 8.8 +/- 1.9 mm at the hiatus (p=0.024) and 10.5 +/- 1.9 mm vs 9.0 +/- 2.4 mm at the condyles (p=0.005). The proximal popliteal artery was 2 mm larger in patients at risk for popliteal aneurysms and 5 mm larger in patients with popliteal aneurysms compared to controls. Focal ectasia of the midpopliteal artery was common. Planning for endovascular treatment of popliteal aneurysms must incorporate this striking enlargement.

Mediastinal mass after coronary artery bypass surgery with internal mammary artery grafts.

The usual appearance of the postoperative chest radiograph in patients after coronary artery bypass surgery is well known. The article describes an unusual case with development of a right anterior mediastinal mass after bypass surgery with internal mammary artery grafts. This mediastinal mass, initially detected on a chest radiograph, was confirmed by contrast-enhanced chest CT to be intrathoracic fat from the right internal mammary artery pedicle.

Percutaneous cholecystostomy: diagnostic and therapeutic efficacy.

Percutaneous cholecystostomy was performed in 32 patients for treatment of suspected cholecystitis (16 patients), decompression of biliary obstruction (six patients), or performance of diagnostic cholangiography (ten patients). The gallbladder was successfully catheterized in 32 of 32 patients (100%), and therapeutic or diagnostic benefit was achieved in 29 of 32 patients (91%). There were no major complications and no procedure-related deaths. There were four minor complications. In the 14 patients with severe cholecystitis there was substantial clinical improvement in 13. Five patients underwent catheter withdrawal after stabilization or long-term drainage. In biliary obstruction, hyperbilirubinemia was successfully treated with percutaneous cholecystostomy in five of six patients, and associated cholangitis was successfully treated in four of four. Ten patients underwent transcholecystic cholangiography; diagnostic visualization was achieved in all, including seven who underwent percutaneous cholecystostomy-assisted transhepatic biliary drainage. Percutaneous cholecystostomy is a safe and effective procedure in diagnosis and treatment of biliary tract problems.

Percutaneous cholecystostomy: does transhepatic puncture preclude a transperitoneal catheter route?

Percutaneous cholecystostomy is now commonly performed for the diagnosis and treatment of gallbladder and biliary disorders. The optimal method and route of percutaneous cholecystostomy catheter placement, however, remain controversial and may depend on the indication for the procedure. The ability to predict traversal of the extraperitoneal plane of fixation ("bare area") between the liver and gallbladder with a transhepatic approach was investigated. With sonographic guidance, 21 transhepatic catheterizations were attempted: 19 in cadavers and two in patients who subsequently underwent cholecystectomy. In all cases, 8-F or 5-F self-retaining catheters were used. At autopsy or surgery, the catheter course and gallbladder puncture site were evaluated. Of 21 punctures, 19 (90%) were transhepatic and two (10%) were transperitoneal. Among the 19 transhepatic punctures, eight catheters (42%) traversed the bare area, while 11 (58%) entered the free gallbladder wall adjacent to the serosal attachment. There were four instances of guide-wire dislodgment during catheter placement; all occurred following puncture of the free wall of the gallbladder. No guide-wire dislodgment occurred when the bare area was transversed. Transhepatic gallbladder puncture does not prevent puncture of the free gallbladder surface. However, the liver and bare area do seem to provide guide-wire stability during catheter placement.

Lymphadenopathy in chronic active hepatitis: CT observations.

CT scans were obtained in 17 patients who had biopsy-proved chronic active hepatitis in order to evaluate deteriorating liver function and clinical status. Lymphadenopathy in the porta hepatis and/or retroperitoneum was found in 11 patients (65%), and this was the only CT indication of significant hepatic disease in six patients (35%). In three of five patients who subsequently underwent immunosuppressive therapy, serial biopsy, and CT scanning, clinical and histologic improvement in the condition of the liver were accompanied by a reduction in lymph-node size on CT. These findings suggest that abdominal adenopathy is a frequent CT finding in patients who have chronic active hepatitis and might be a useful marker in monitoring immunotherapy.

Tumor thrombus in a retroaortic left renal vein and incidental right circumcaval ureter.

The authors describe computed tomographic (CT) and magnetic resonance (MR) imaging of coexistent anomalies of the inferior vena cava and renal venous system. These were particularly relevant due to the presence of a renal neoplasm which invaded an anomalous renal vein.

Malignant tumors invading chest wall: treatment with CT-directed implantation of radioactive seeds.

Computed tomography (CT) was used to direct permanent implantation of radioactive iodine-125 seeds in two patients with unresectable lung cancer and in one with recurrent breast cancer invading the chest wall. An average of 60 seeds were implanted, with a mean total radioactivity of 35.6 mCi (1,317 MBq). Tumor coverage was adequate and pain relief was good in all patients. One patient had histologically documented complete response and another had CT-documented partial response.

Spinal enostoses (bone islands).

Spinal enostoses are regarded as rare; they have been reported as present in approximately 1% of all spines. We have identified several patients with spinal enostoses in the thoracic and lumbar vertebral bodies. Therefore, we have initiated a prospective radiographic and pathologic investigation of enostoses, and we report the occurrence of these lesions in 14 of 100 cadavers (14%). The lesions varied in size from 2 X 2 mm to 6 X 10 mm. They were seen on radiographs of the whole specimen and of specimen sections, but only 29% of radiographs obtained prior to the death of the patient demonstrated such findings.

Posttraumatic intrahepatic arterial pseudoaneurysm: treatment with direct percutaneous puncture.

The authors describe a patient with a posttraumatic intrahepatic false aneurysm. In this case, transcatheter embolization was not possible because of previous right hepatic artery embolization. To avoid the morbidity associated with surgery, direct percutaneous puncture of the pseudoaneurysm was performed under fluoroscopic guidance to permit embolization with Gianturco coils. Direct percutaneous embolization of intrahepatic aneurysms and pseudoaneurysms can be a safe and effective alternative to surgery when transcatheter techniques are not feasible.