Neurocutaneous melanosis with malignant leptomeningeal melanoma. A case with metastases outside the nervous system.

A case of neurocutaneous melanosis with malignant leptomeningeal melanoma was seen in a black man. The presence of extracranial metastases was noted, and evidence is presented favoring the central nervous system as the primary source.

Localization of abnormal parathyroid glands using thallium-201.

Ectopically located parathyroid adenomas may be difficult to find during initial neck exploration. They account for over 70 percent of missed adenomas found at reexploration. Preoperative localization of parathyroid adenomas would reduce unnecessary dissection and possibly reduce the number of negative results of initial neck exploration. Before reoperative parathyroid surgery is performed, some means of localization is mandatory to detect ectopic adenomas in the neck and mediastinum. Computed tomography and ultrasonography cannot effectively evaluate the mediastinum. Angiography and venous parathyroid hormone sampling are invasive, costly, and tedious to perform. We have shown that thallium-201 will accurately localize ectopic parathyroid adenomas. All 10 adenomas found in positions not immediately adjacent to the thyroid gland were detected by thallium-201 scintigraphy. One was a mediastinal adenoma resected with a median sternotomy. Our results suggest that thallium-201 scintigraphy should be the initial localization procedure of choice before all reexplorations. Its use before initial explorations, as well, will enable the surgeon to immediately direct attention to the area of the localized adenoma. If mediastinal uptake is found to be present, then median sternotomy may be performed during initial surgery provided a thorough neck exploration is performed first.

Perioperative ischemic injury after coronary bypass graft surgery.

Two hundred twelve patients who underwent isolated coronary bypass graft surgery were prospectively evaluated for perioperative ischemic injury. All patients underwent preoperative and postoperative testing with technetium 99m pyrophosphate first-pass ventriculography combined with myocardial uptake scans, 12-lead electrocardiography, and serial creatinine phosphokinase MB determination. Fifteen percent of the patients had ischemic injury with at least two test results positive, but only 4 percent had positive results of all three tests. No single test proved adequate. Enzyme levels were highly sensitive and had value as a screening test. The electrocardiogram was specific but only moderately sensitive. The single best test was the radionuclide scan with good sensitivity and no false-positive results. All three tests are required to rigorously diagnose ischemic injury.

Functioning liver metastases on an I-131 whole-body scan: a case of malignant struma ovarii.

A 46-year-old women was examined for severe constipation. Pelvic examination revealed a large pelvic mass extending to the level of the umbilicus. Computed tomography showed a large multicystic, septated mass in the pelvis and a small amount of fluid in the cul de sac. In addition, multiple ill-defined, mixed-attenuation hepatic lesions were identified. A malignant ovarian neoplasm with liver metastases was considered, so the pelvic mass was resected. Interestingly, histopathologic analysis revealed malignant struma ovarii of the follicular type. Biopsy of the liver lesions confirmed metastatic disease with similar histopathologic findings. All thyroid laboratory values were in the normal range. The patient then had a total thyroidectomy to optimize thyroid ablation therapy with I-131. This revealed a small follicular adenoma but no evidence of cancer. An I-131 whole-body scan was performed and showed uptake in multiple functioning liver metastases.

Occult malignant tumors in dermatologic disease. The futility of radiological search.

Analysis of 102 patients with dermatomyositis, polymyositis, bullous pemphigoid, and dermatitis herpetiformis was undertaken to determine: (a) the incidence of occult malignant tumors in these diseases, and (b) the value of radiological screening to detect unsuspected malignant neoplasms. The incidence of internal malignant disease was no higher than that encountered in a control population. Radiological screening procedures routinely performed for patients with these disorders failed to disclose any occult neoplasms. A radiological tumor search has no place in the evaluation of these patients unless specific clinical findings suggest carcinoma in a particular organ system.

[Radiologic approaches to gastric cancer (author's transl)]. / Radiologische Diagnostik des Magenkarzinoms

Radiologic study of patients continues to be of major importance in the detection of gastric malignant neoplasms and often provides the stimulus for further diagnostic procedures. The conventional roentgenographic procedure for this disease comprises a careful fluoroscopic examination of gastric peristalsis and distensibility, and views obtained with graded compression, mucosal relief, double-contrast technique, and barium filling. No single method has the ability to disclose all pathognomonic signs of a gastric tumor. Pharmacologic motor inhibitors or stimulators may be used to aid study of peristalsis. The usefulness of peritoneography, parietography and arteriography in the diagnosis of gastric carcinoma is also examined. Diagnosis of early gastric carcinoma remains a radiologic challenge and the Japanese classification system is recommended. Perhaps the disease could be detected earlier, in countries with low or moderate incidence and without the benefit of regional screeing centers, if subtile roentgenographic techniques were applied to patients with conditions known to be associated with high risk of gastric carcinoma. The differential diagnosis of lesions which simulate gastric carcinoma is extensive and is briefly reviewed.

Lymphangioma of the pancreas exhibiting an unusual pattern of calcification.

A case of calcified lymphangioma of the pancreas is presented. The pattern of calcification evolved through three distinct phases over a 15-year period, suggesting at first a lymphangioma or hemangioma and later a cystadenoma.

Roentgenographic features of mushroom (Amanita) poisoning.

The clinical and roentgenographic features of six cases of Amanita mushroom poisoning were reviewed. The roentgenographic manifestations included adynamic ileus (three patients) and small, irregularly shaped kidneys secondary to the healing process of acute tubular necrosis (one patient). Intestinal pseudo-obstruction can result from many medical problems and mushroom poisoning should be considered in its differential diagnosis.

Factor analysis in left ventricular first-pass radionuclide angiography: value of the ventricular factor to measure ejection fraction.

Factor analysis theoretically generates the time-activity curves of the various physiological compartments, or factors, which are superimposed in a dynamic series of scintigraphic frames. An image of the spatial distribution of each of these factors is also displayed. We tested the ability of one of these, the ventricular factor, to measure the left ventricular ejection fraction (LVEF) in first-pass radionuclide angiography (FPRA). Forty-nine patients divided into three groups were studied. In a group of 32 patients, factor analysis was compared to a conventional scintigraphic method and to contrast angiography. The coefficient of correlation was similar for both techniques (r = 0.83). To test reproducibility, another group of 10 patients received two successive injections of Au-195m, three minutes apart. The reproducibility of LVEF was r = 0.78 with factor analysis and r = 0.81 with the conventional method. In a third group of seven patients, three successive injections of Au-195m were performed in the right and in the left anterior oblique projections. The reproducibility of LVEF was r = 0.71 with factor analysis. However LVEF was significantly lower in LAO than in RAO, 50 +/- 11% vs 58 +/- 17% respectively. It is concluded that factor analysis does not offer a more reliable means of calculating LVEF than a conventional method.

Intraosseous lipoma of the coccyx. Report of a case.

A case of benign intraosseous lipoma in the form of an expansile, non-radiolucent lesion of the distal coccyx is reported. Bony detail was completely obliterated. The anterior and posterior cortical margins were markedly thin and in places appeared eroded.

Liver scan "hot spot" in hepatic veno-occlusive disease.

A focal "hot spot" seen on liver scan in an unusual case of hepatic veno-occlusive disease bore striking similarities to scanning patterns in superior vena cava syndrome. The findings are also compared to those reported in Budd-Chiari syndrome.

Bacteremia and the barium enema.

To investigate the possible association of bacteremia with barium enema examinations, blood samples were obtained from 42 patients before and at 5, 10, and 20 min after administration of the enema. Patients with fever or symptoms suggestive of inflammatory bowel disease were not included in the study; neither were patients who had received antimicrobiotic medication during the preceding 3 months. Pour-plate blood cultures showed no bacteremia due to enteric organism in the 42 patients-a result at variance with previously published reports.

Chiba percutaneous transhepatic cholangiography. A valuable method for visualizing the nondilated biliary tract.

Percutaneous transhepatic cholangiography with the Chiba needle has had remarkable results in cannulating small bile ducts. We have roentgenographically visualized a nondilated biliary system in the first five out of seven cases attempted. Including our series, there have been 71 successful Chiba studies in 107 nondilated or presumed normal biliary tracts with only one questionable major complication. The technique is simple to learn, particularly in comparison with endoscopic retrograde cholangiography. Since the incidence of complications is low, surgical standby should seldom be necessary. The value of the Chiba percutaneous transhepatic cholangiogram is described via four unusual case reports.

Invasion of the duodenum by carcinoma of the stomach.

It has frequently been stated that extension to the duodenum occurs commonly in patients with gastric lymphoma but almost never in those with carcinoma of the stomach. We found radiographically detectable invasion of the duodenum in six of 111 consecutive patients (5%) with gastric carcinoma. The duodenum was involved microscopically in 18%. Radiographic abnormalities in the duodenum in 11 patients with proven transpyloric spread of tumor varied from irregularity of the base of the bulb narrowing and distortion extending well into the second portion of the duodenum. On the basis of these data and the reported frequency of transpyloric extension in gastric lymphoma, carcinoma appears to be the more likely diagnosis in a patient with duodenal involvement by an antral tumor.