Intraductal papillary neoplasm of the bile duct (IPN-B): also a disease of western Caucasian patients. A literature review and case series.

Cholangiocarcinoma (CCa) is an aggressive malignancy, which often presents with advanced, inoperable disease. Early detection of any premalignant condition could improve the dismal prognosis of cholangiocarcinoma (5% 5-year survival). There are two premalignant precursors of CCa: biliary intraepithelial neoplasia (BilIN) and intraductal papillary neoplasm of the bile duct (IPN-B). BilIN is only visible microscopically; imaging has no role in identification. IPN-B is a recent diagnostic entity, arising from a World Health Organization (WHO) reclassification of tumours. IPN-B is visible macroscopically, and can be identified on imaging. With its propensity to spread preferentially along the biliary epithelium, only infiltrating the duct wall at a late stage, it may be more amenable to complete resection than typical CCa. The lead time with early detection, during which dysplasia could progress to invasive carcinoma, is an opportunity where resection may be curative. The literature on IPN-B has originated from Asia, but awareness of this condition in the western world is limited. We report a case series of IPN-B occurring in Caucasian patients from the UK, with radiological-pathological correlation. The protean imaging appearances present a unique challenge, but also a great opportunity, for radiologists. Early identification and resection of lesions, even in asymptomatic or minimally symptomatic patients, should be considered.

Pneumothorax post CT-guided lung biopsy: a comparison between detection on chest radiographs and CT.

Pneumothorax is reported to be a more common complication of lung biopsy performed under computed tomography (CT) than under fluoroscopic guidance. This may simply reflect the greater sensitivity of CT over chest radiographs (CXRs) in the detection of small pneumothoraces. This study aimed to determine the incidence of pneumothorax detected by CXR and by CT after CT-guided biopsy of non-pleurally based pulmonary masses, and to compare these incidences with previous reports in the literature of pneumothorax incidence post fluoroscopic biopsy. 88 consecutive CT-guided lung biopsies of masses not abutting the pleural surface were included. Immediate post-biopsy CT images, and 1 and 4 h CXRs were assessed independently by two observers for the presence and size of pneumothorax. 72 biopsies were fine needle aspirations (FNAs) performed with 22 G spinal needles only, seven were cutting needle biopsies (CNBs) performed with 18 G cutting needles only, and nine were both. 37 patients (42%) developed a pneumothorax. 35 were detected on CT (40%) and 22 on CXR (25%). None required tube drainage. Of the patients in whom CT demonstrated a pneumothorax, the average depth of this was significantly greater for those in whom CXR also detected a pneumothorax compared with those in whom CXR was negative (7.3 mm versus 3.4 mm, p < 0.05). The incidence of pneumothorax detected on CXR post CT-guided biopsy is similar to the reported incidence post fluoroscopic biopsy.

Cutting needle biopsy in the diagnosis of clinically suspected non-carcinomatous disease of the lung.

Most patients referred for lung biopsy have a focal lesion that is likely to be a carcinoma, and fine needle aspiration is usually sufficient to confirm the diagnosis. When non-carcinomatous disease is suspected, tissue architecture is important and potential diagnostic techniques include percutaneous cutting needle biopsy (CNB). We retrospectively reviewed 37 CNBs performed for clinically suspected non-carcinomatous disease; recording the biopsy result, final diagnosis, radiological nature of the pulmonary abnormality, distance from the pleura of the lesion biopsied and biopsy complications. 9 patients had a single pulmonary nodule/mass; 13 had multiple nodules/masses; 8 had a lobar consolidation/mass; and 7 had multifocal consolidation. The lesion abutted the pleura in 31 cases, lying within 1 cm in the other 6 cases. The minor complication rate was 14%, with no major complications. Specific malignant diagnoses were made in 9 patients, and specific benign in 23, in all of whom clinicoradiological follow-up was concordant. CNB did not yield a specific diagnosis in five patients, including two lymphomas and one case of unsuspected tuberculosis in which the sample was not cultured. The overall accuracy of CNB was 32/37 (86%). CNB is a safe and accurate means of achieving a tissue diagnosis for patients with peripheral pulmonary parenchymal disease thought not to represent carcinoma.

Three-day regimen improves faecal tagging for minimal preparation CT examination of the colon.

This study set out to determine whether extending the length of oral contrast administration in minimal preparation CT of the colon improves faecal tagging. Two cohorts of 50 patients each were compared, one with a 2-day the other with a 3-day faecal tagging regimen. The degree of faecal tagging was graded by two blinded observers. The 3-day regimen showed significantly better tagging in the rectum and sigmoid colon (p = 0.006 and p = 0.009, respectively, using the Mann-Whitney test). The percentage of patients who had faecal tagging in the sigmoid colon graded as "complete" was 64% for the 3-day regimen as opposed to 34% for the 2-day regimen. The corresponding percentages for the rectum were 64% for the 3-day regimen and 36% for the 2-day regimen. Extending the length of oral contrast administration from 2 to 3 days significantly improves the quality of faecal tagging in the rectum and sigmoid colon.

An evidence-based review for the management of cystic pancreatic lesions.

The incidental finding of pancreatic cysts is becoming more common because of the increased use of cross-sectional imaging. As a result, the perspective from historical series of symptomatic patients is not always applicable to the current cohort of patients with cystic lesions in their pancreas. In this review, the characteristic radiological features that aid diagnosis are highlighted, and the complementary role of different imaging methods and the appropriate use of tissue sampling are identified. Based on the literature regarding the diagnostic role of imaging in characterizing cystic pancreatic lesions, it is possible to recommend a practical imaging algorithm for the diagnosis of cystic pancreatic lesions.

CT of staphylococcal anterior mediastinal abscess in an infant.

A 6-week-old girl presented with bronchiolitis secondary to respiratory syncytial virus. Eight days after admission she developed a Staphylococcus aureus infection at a previous intravenous cannula site. Despite antibiotic therapy this led to an anterior mediastinal staphylococcal abscess, which was drained surgically and the patient recovered. Mediastinal abscesses are rare in children: haematogenous spread of infection is an unusual aetiological factor and we believe this to be the first case reported due to an infected cannula site.

An evaluation of computed tomography as an aid to diagnosis in patients undergoing bronchoscopy for suspected bronchial carcinoma.

AIM: To determine whether computed tomography (CT) can predict the likelihood of obtaining a positive tissue diagnosis at fibreoptic bronchoscopy (FOB), or demonstrate an alternative means of achieving a tissue diagnosis, in patients presenting with a high clinical suspicion of primary bronchogenic carcinoma and an abnormal chest radiograph (CXR). MATERIALS AND METHODS: Sixty-two patients presenting with a high clinical suspicion of carcinoma and an abnormal CXR had chest and liver CT and FOB performed. All patients subsequently had histocytological confirmation of malignancy. Features recorded from the CTs included: the site and characteristics of a mass if present, and its relationship to adjacent airways; the presence of presumed metastatic disease; and a CT prediction of the likelihood of positive FOB was made. RESULTS: Of the patients, 41/62 (66%) had inoperable stage IIIb/IV disease. Fibreoptic biopsy yielded positive tissue diagnoses in 38/62 (61%). Computed tomography features predicting a positive FOB in this group included: ill-definition of the mass (12/15, 80%); a mass <4 cm from the origin of the nearest lobar bronchus (36/53, 68%); an endobronchial component of mass (22/24, 92%); a segmental or larger airway leading to the mass (30/35, 86%). Overall, CT had positive and negative predictive values for positive FOB of 85% and 78% respectively. The accuracy of the overall CT prediction of positive FOB was better than the accuracy of any of the individual factors. Seventeen of 62 (27%) patients had presumed metastatic disease suitable for percutaneous biopsy. CONCLUSION: Computed tomography is useful in predicting the likelihood of achieving positive histocytology at FOB. The overall CT prediction is superior to any of the individual CT features taken alone.Bungay, H. K. (2000). Clinical Radiology 55, 554-560.