Neurologic, neuropsychologic, and computed cranial tomography scan abnormalities in 2- to 10-year survivors of small-cell lung cancer.

In order to evaluate the relationship between neurologic function and cranial irradiation, 20 patients treated on National Cancer Institute (NCI) small-cell lung cancer (SCLC) trials who were alive and free of cancer 2.4 to 10.6 years (median, 6.2) from the start of therapy were studied. All were tested with a neurologic history and examination, mental status examination, neuropsychologic testing, and review of serial computed cranial tomography (CCT) scans. Fifteen patients had been treated with prophylactic cranial irradiation (PCI), two patients with therapeutic cranial irradiation, and three received no cranial irradiation. All patients but one were ambulatory and none were institutionalized. Fifteen patients (75%) had neurologic complaints, 13 (65%) had abnormal neurologic examinations, 12 (60%) had abnormal mental status examinations, 13 (65%) had abnormal neuropsychologic testing, and 15 (75%) had abnormal CCT scans. Compared with those given low-dose maintenance chemotherapy during PCI using 200 to 300 rad per fraction, patients who were given high-dose induction chemotherapy during the time of cranial irradiation or large radiotherapy fractions (400 rad) were more likely to have abnormal mental status examinations (6/6 v 4/9) and abnormal neuropsychologic tests (6/6 v 4/9), but no major difference in CCT findings was present. CCT scans in the majority of cases (11/18) showed progressive ventricular dilatation or cerebral atrophy up to 8 years after stopping therapy. We conclude neurologic abnormalities are common in long-term survivors of SCLC, and may be more prominent in patients given high-dose chemotherapy during cranial irradiation or treated with large radiotherapy fractions. The CCT scan abnormalities are common and progressive years after prophylactic cranial irradiation and chemotherapy are stopped.

Accuracy of ultrasound in the diagnosis of acute appendicitis compared with the surgeon's clinical impression.

OBJECTIVE: To compare the accuracy of the surgeon's clinical diagnosis of acute appendicitis with that of an ultrasonographic examination of the abdomen. DESIGN: Prospective trial. SETTING: US Navel Hospital, San Diego, Calif. PATIENTS: One hundred ten patients admitted to the hospital with suspected appendicitis from May 1990 to June 1992. INTERVENTION: Symptoms and signs for each patient were recorded, along with the surgeon's clinical impression of immediate surgery or observation. The patient then underwent an ultrasound examination performed by a staff radiologist. On the basis of the ultrasound findings the patient was placed into one of three categories: appendicitis, normal examination results, or other conditions. Patients with an ultrasound-based diagnosis of appendicitis proceeded to the operation, regardless of the surgeon's clinical impression. Those with other conditions diagnosed with ultrasonography were treated as was appropriate for the condition. RESULTS: The ultrasound-derived diagnosis of appendicitis had a sensitivity of 85.5%, a specificity of 84.4%, a positive predictive value of 88.3%, a negative predictive value of 80.1%, and an overall accuracy of 85.0%. The surgeon's clinical impression at the time of admission had a sensitivity of 62.9%, a specificity of 82.2%, a positive predictive value of 82.9%, a negative predictive value of 61.7%, and an overall accuracy of 71.2%. CONCLUSION: The overall accuracy of ultrasonography in the diagnosis of appendicitis was statistically superior to that of the surgeon's clinical impression (P < .0001). However, 24% of the patients with normal ultrasound findings were ultimately found to have appendicitis at operation, emphasizing the point that ultrasonography cannot be relied on to the exclusion of the surgeon's careful and repeated evaluation.

Prospective comparison of unenhanced spiral computed tomography and intravenous urogram in the evaluation of acute flank pain.

OBJECTIVES: To prospectively compare the diagnostic ability of unenhanced spiral computed tomography (NCCT) and intravenous urogram (IVU) in the evaluation of adults with acute flank pain. METHODS: After giving informed consent, 106 adult patients with acute flank pain suspected of having urolithiasis underwent NCCT followed by IVU. Subsequent follow-up was scheduled within 72 hours in the Urology Clinic. Each NCCT was read by a single radiologist who was unaware of clinical history and IVU results. Each IVU was read by a different radiologist who was unaware of clinical history and NCCT results. Sensitivity, specificity, and positive and negative predictive values were determined for NCCT and IVU. RESULTS: The diagnosis of ureterolithiasis was defined as unequivocal evidence of urolithiasis on either NCCT or IVP. Seventy-five of 106 patients evaluated were diagnosed with ureterolithiasis. Clinical follow-up was available in 74 (98%) stone patients and in 31 (100%) of 31 non-stone patients. In 72 of the 75 patients diagnosed with ureteral calculi, the NCCT made the diagnosis. IVU made the diagnosis in 65 of the 75 patients. Of the 31 patients without ureterolithiasis, the NCCT was negative in all cases. IVU was negative in 29 of the 31 cases. Unenhanced spiral CT was 96% sensitive and 100% specific (P <0.001). IVU was 87% sensitive and 94% specific (P <0.001). Compared with IVU, using the log odds ratio and Fisher's exact test, NCCT was significantly better able to predict the presence of urolithiasis (P=0.015). CONCLUSIONS: NCCT accurately diagnoses ureterolithiasis in patients presenting with acute flank pain. NCCT is significantly better than IVU in determining the presence of urolithiasis.

Cardiac lipoma: six-year follow-up with MRI characteristics, and a review of the literature.

A total of 63 cardiac lipomas have been reported to date. Although most of these rare tumors cause no symptoms, a few can have a detrimental effect on myocardial function as well as displacing and encasing the coronary arteries. This case of a cardiac lipoma was initially seen in 1982. The lipoma was found to be nonresectable at surgery due to involvement of the coronary arteries. This neoplasm was characterized with magnetic resonance imaging in 1989 on a follow-up visit. Magnetic resonance imaging is shown to be superior to computed tomography for identifying the relationship of the lipoma to the coronary arteries. This is a significant factor in determining resectability.

Rhabdomyosarcoma of the testicular appendage in an infant: case report.

This is a case report of embryonal rhabdomyosarcoma of the epididymal appendage in a 15-month old infant. It is a rare tumor with a good prognosis when treated promptly. The ultrasound examination showed the testicle to be enlarged but hypo-echoic in comparison to the epididymis which was infiltrated with tumor. An inflammatory mass or enlargement of a testicle demands careful diagnosis and appropriate therapy with immediate referral to a urologist if the normal clinical course deviates. Representative images are included. Rhabdomyosarcoma of the testicle or extra testicular scrotal structures is rare. A report in 1983 by Kage et al from Japan revealed two cases of the tumor, however, both were in adult males. This case report is an embryonal rhabdomyosarcoma in a fifteen month old infant which presented with a confusing clinical picture. This case is presented in an effort to alert the clinician to the possibility of a rare, non-germ cell tumor presenting as an inflammatory lesion.

Aortic dissection in acute pancreatitis.

Extrapancreatic fluid collections are frequently seen in acute pancreatitis. Vascular damage with life-threatening hemorrhage is also a known complication. In the case report presented, we include documentation by computed tomography of an apparent abdominal aortic wall dissection by fluid in a patient with acute pancreatitis. Conservative therapy resulted in complete resolution without hemorrhage or aneurysm formation.

A gastric bezoar causing a target lesion as revealed by ultrasound.

A case of a bezoar of the stomach causing a "target lesion" of the gastrointestinal tract is presented. The observance of this mass as water passed through the stomach may, in the future, differentiate the mass from a true stomach-wall lesion as more of these patterns are recognized. Other lesions that may enter into the differential diagnosis are blood clots and pedunculated polyps.

Sonographic appearance of left spermatic vein thrombosis simulating incarcerated inguinal hernia.

We report a case of exercise-induced spontaneous thrombosis of the left spermatic vein. The sonographic appearance mimicked an incarcerated left inguinal hernia by demonstrating a tubular, hypoechoic, noncompressible, cystic appearing inguinal mass with no flow evident on color Doppler imaging.

The incidence of deep venous thrombosis in anterior cruciate ligament reconstruction.

We prospectively studied the incidence of deep venous thrombosis (DVT) in anterior cruciate ligament reconstruction. A total of 67 male patients (aged 19 to 39 years) were examined by compression ultrasonography to determine the presence of DVT in the operated extremity. All patients were studied preoperatively and 2 to 3 days postoperatively. The area of examination was from popliteal vein to inguinal ligament; no DVT prophylaxis was used. No patient had clotting preoperatively. The incidence of DVT was 1 in 67. One patient had an asymptomatic noncompressible lesion in the proximal femoral vein on postoperative day 3; repeat examination at day 10 was normal. Unless other risk factors are present, we do not recommend routine prophylaxis for male patients younger than 40 years of age who are undergoing anterior cruciate ligament reconstruction.

CT of the normal appendix.

We conducted a prospective evaluation of the normal vermiform appendix in 203 patients. Conventional CT techniques were utilized with an 8 mm slice thickness and 10 mm slice interval. The normal appendix was definitely identified in 51% of the patients studied. Computed tomographic appearance of the normal appendix is demonstrated, and potential pitfalls are described.

Postembolic colonic infarction.

From a total of 23 cases from five hospitals, acute colonic mucosal necrosis developed in three patients following transcatheter embolotherapy for colonic hemorrhage. Although embolic therapy for lower gastrointestinal bleeding is associated with appreciable risk, these risks are less than those of emergency operation for hemorrhage. The alternative transcatheter therapeutic modality, vasopressin infusion, is often associated with continued or recurrent hemorrhage, is relatively contraindicated in patients with coronary disease, and produces numerous complications. Transcatheter embolotherapy is recommended for patients with colonic bleeding who have a contraindication to vasopressin administration, who are refractory to vasopressin, or who rebleed following treatment with vasopressin.

Self-localization in US of appendicitis: an addition to graded compression.

Graded-compression ultrasound (US) of the right lower quadrant (RLQ) has been a valuable addition to the diagnostic evaluation of acute appendicitis. In an effort to expedite the sonographic evaluation and improve diagnostic accuracy, a method of self-localization was added to the standard graded-compression examination. A total of 236 patients with signs of appendicitis were studied. Eighty-five percent (121 of 142) of the patients with proved appendicitis were able to decisively self-localize their pain. Of the patients without appendicitis who still had significant disease in the RLQ, 88% (29 of 33) were able to self-localize their pain, with an accuracy rate of 86% for significant disease. Among patients without significant disease, only 15% (nine of 61) self-localized their pain. This "sonographic self-localization sign" reduced the time of the examination and was a valuable addition to standard graded-compression US of the appendix.

Hill-Sachs lesion: comparison of detection with MR imaging, radiography, and arthroscopy.

Magnetic resonance (MR) imaging has proved to be a valuable method for documenting Hill-Sachs lesions. The authors retrospectively analyzed the diagnostic interpretations at plain film radiography, arthroscopy, and MR imaging in 76 patients. The analysis revealed that neither radiography nor arthroscopy displayed the lesion with sufficient accuracy to represent a true standard of reference for the evaluation of MR imaging in the diagnosis of the Hill-Sachs lesion. The data from the diagnostic interpretations were analyzed in three ways, each of which revealed that findings at MR imaging were more helpful than findings at radiography and/or arthroscopy in the diagnosis of the Hill-Sachs lesion. When the agreement of findings in two or three methods was used to assign a final diagnosis, MR imaging resulted in sensitivity of 97%, specificity of 91%, and accuracy of 94% in the detection of Hill-Sachs lesions.

Cholecystokinin enhanced hepatobiliary scanning with ejection fraction calculation as an indicator of disease of the gallbladder.

Chronic acalculous cholecystitis represents 5 to 20 per cent of electively treated diseases of the gallbladder. A 70 per cent success rate in relieving these patients of chronic pain was reported when surgical treatment was recommended based on symptoms alone. The cholecystokinin ejection fraction, which is a quantitative measure of emptying of the gallbladder, was 95 per cent accurate in predicting which patients would be relieved of symptoms by surgical treatment. In this study, we report our consecutive experience during a 20 month period with 83 patients.

Tears of the glenoid labrum: MR imaging of 88 arthroscopically confirmed cases.

Two hundred eighty-one patients underwent magnetic resonance (MR) imaging of the shoulder over a 2-year period. Eighty-eight patients underwent arthroscopic surgery, and their surgical results were correlated with the findings at MR imaging. MR imaging enabled accurate prediction of anterior labral tears, with a sensitivity of 95%, a specificity of 86%, and an accuracy of 92%. MR imaging was less effective in the prediction of tears of the superior labrum, with a sensitivity of 75%, a specificity of 99%, and an accuracy of 95%. These two categories accounted for the majority of the surgically correctable disease. MR imaging was found to be unreliable in the prediction of posterior (sensitivity, 7.7%) or inferior (sensitivity, 40%) labral tears, isolated cases of which occurred in only two (2%) of those undergoing surgery. MR imaging proved to be a highly accurate, noninvasive technique for the clinical evaluation of shoulder instability.