Giant cell tumour of the retropharynx

INTRODUCTION: Few pancreatic carcinomas (5-22%) are resectable at the time of diagnosis because this lesion is seldom diagnosed in an early stage. Unresectability is mainly due to the presence of metastases to the liver, peritoneum and lymph nodes and to tumor spread especially to the portal mesenteric trunk where it can invade, compress, reduce, or occlude the vessels. We investigated the diagnostic yield of multiplanar and 3D spiral CT in the assessment of pancreatic carcinoma resectability. MATERIAL AND METHODS: Twenty-seven patients with histologically confirmed pancreatic head cancer were submitted to spiral CT and color Doppler US in the Surgical Clinic I of the Bologna University. The examination results were correlated with the intraoperative findings of careful inspection and palpation and of US studies of the pancreatic mass and adjacent structures. The tumors were classified in relation to some CT parameters: tumor size (T), infiltration of the stomach (S) and/or duodenum, lymph nodes (N) or distant (M) metastases, involvement of vascular structures (V), particularly of portal or superior mesenteric vein, or superior mesenteric artery. Five grades of vascular involvement were considered. The results of these techniques were correlated with intraoperative findings from careful inspection and palpation and with US studies of the pancreatic mass and adjacent structures. RESULTS: Spiral CT revealed vascular involvement in 19 of 27 cases (70.4%): involvement of portal and superior mesenteric vein was found in 14 (73.6%), superior mesenteric vein was involved in 2 (10.6%), the portal vein in one (2%) and, finally the portal, superior mesenteric vein and superior mesenteric artery in 2 cases (10.6%). The spiral CT results were confirmed intraoperatively in 26 of 27 cases (96.3%); spiral CT did not reveal hepatic metastasis only in one case. Spiral CT with multiplanar reconstructions had very high specificity and sensitivity (100%) in the assessment of vascular involvement, while color Doppler US had the same specificity but lower sensitivity (84.2%). Spiral CT was less sensitive (80%) in the detection of liver metastases. CONCLUSIONS: We believe that spiral CT is currently the best technique for pancreatic carcinoma staging, providing useful information for correct surgical planning.     

Does the use in animals of antimicrobial agents, including glycopeptide antibiotics, influence the efficacy of antimicrobial therapy in humans?

PURPOSE: To determine if the cerebral cortical vain sign seen on magnetic resonance (MR) images can be used with color Doppler ultrasound (US) to differentiate enlarged subarachnoid space from subdural collection. MATERIALS AND METHODS: Eighteen infants with pericerebral fluid collection were prospectively examined with color Doppler US and MR imaging. Patients were classified into two groups: group A, with positive cortical vein sign (visualization of color-coded cortical veins that cross fluid collections at cerebral convexities); and group B, without the sign. RESULTS: Positive cortical vein sign was seen at US in 12 patients (group A): nine with benign enlargement of subarachnoid spaces, two with brain atrophy, and one with meningococcal meningitis. The veins were displaced and embedded within the echogenic pia-arachnoid that surrounds the brain or were trapped in the subarachnoid spaces between the neo-membrane and cortical surface (group B, negative cortical vein sign) in four patients with meningitis, two victims of child abuse, and one patient with leukemia. Findings from subsequent MR imaging confirmed the color Doppler US findings. CONCLUSION: Color Doppler US depiction of the cortical vain sign appears to be as effective as MR imaging in differentiating enlargement of the subarachnoid fluid space from subdural effusion.     

Alveolar echinococcosis of the liver: sequelae of chronic inferior vena cava obstructions in the hepatic segment

BACKGROUND: The clinical pattern and long-term course of chronic inferior vena cava (IVC) obstructions are variable and depend on the underlying cause, the segment involved, and the extension of secondary thrombosis. Pertinent data on IVC obstructions in well-defined series of patients are lacking. We report the sequelae of chronic IVC obstructions in the hepatic segment in 11 consecutive patients derived from a cohort of 104 patients with alveolar echinococcosis of the liver. METHODS: Based on the results of computed tomography scans, 11 patients (7 men, 4 women; mean age, 53.4 years) with IVC obstructions were selected from an ongoing prospective long-term chemotherapy trial comprising 104 patients with alveolar echinococcosis studied at yearly intervals according to a protocol. Obstruction of the IVC in the 11 patients existed for a mean duration of 8.6 years. In these patients, magnetic resonance imaging was performed to assess the morphologic features and extension of the IVC obstruction, as well as the collateral venous pathways. Patency and valvular function of the femoropopliteal veins were analyzed by color-coded duplex ultrasonography. RESULTS: Total occlusions of the IVC were evident in 8 patients (73%) and subtotal stenoses in 3 patients (27%). Only 4 patients (36%) exhibited signs and symptoms of chronic venous insufficiency of the lower extremities; 2 (18%) of the 4 had a history of swelling in the lower extremity. Seven patients (64%) had no lower extremity symptoms. One patient had a history of pulmonary embolism. Abdominal collateral veins were documented in 5 patients (45%) by using magnetic resonance imaging; however, they were clinically evident in only 3 patients (27%). In the 8 patients with IVC occlusion, thrombosis ended at the confluence of the hepatic veins. Obstruction of the IVC was limited to the hepatic segment in 2 patients (18%) and extended to the distal IVC or the iliofemoral veins in 6 patients (54%). Chronic venous insufficiency was present only if the femoropopliteal veins had been involved in the thrombotic process, showing residual venous obstruction, valvular incompetence, or both. Bilateral renal vein thrombosis with moderate proteinuria was observed in 2 patients (18%). The main collateral drainage was achieved through the ascending lumbar, azygos, and hemiazygos veins. CONCLUSIONS: In patients with alveolar echinococcosis, obstruction of the IVC in the hepatic segment often develops asymptomatically and rarely leads to the impairment of renal function. The collateral circulation fully compensates for obstruction of the IVC. Thrombotic involvement and valvular incompetence of the femoropopliteal veins seems to determine the development of chronic venous insufficiency of the lower extremities.     

Hepatic lobar atrophy: association with ipsilateral portal vein obstruction

OBJECTIVE: This study was performed to evaluate the association between hepatic lobar atrophy, bile duct obstruction, and portal vein obstruction. MATERIALS AND METHODS: Thirty cases of hepatic lobar atrophy identified on angiography with CT during arterial portography from August 1992 to March 1995 were retrospectively reviewed by two independent observers. Cases were evaluated for vascular patency and bile duct obstruction. Malignant diagnoses were present in 28 of 30 patients. RESULTS: Twenty-two patients (73%) had atrophy in the left lobe and eight patients (27%) had right lobar atrophy. Portal vein obstruction was unilateral and confined to the atrophic lobe in 26 patients (87%). In contrast, bile duct obstruction was bilateral in 23 patients (77%) and in only four patients (13%) was it isolated to the atrophic lobe. The correlation between atrophy and portal vein obstruction was significant, with 90% sensitivity, 97% specificity, and 96% positive predictive value (p < .00001). For the correlation between atrophy and biliary obstruction, the sensitivity of angiography with CT during arterial portography was 90%, specificity was 23%, and positive predictive value was 54% (p = .17). CONCLUSION: Hepatic lobar atrophy usually occurs in the setting of combined biliary and portal vein obstruction. A significant correlation exists between hepatic lobar atrophy and ipsilateral portal vein obstruction.     

Hepatic vein reconstruction at inferior vena cava confluence using left renal vein graft

BACKGROUND/AIMS: To preserve remnant liver function, extended left hepatectomy combined with middle hepatic vein reconstruction using a left renal vein graft was performed in resection of liver metastasis from sigmoid colon cancer, involving the confluence of the middle and left hepatic veins. METHODOLOGY: The tumor, 5 cm in size, occupied the superior part of segment 4, and involved the confluence of the middle and the left hepatic veins. An extended left hepatectomy, including the left lobe, left caudate lobe and part of segment 8, together with the middle hepatic vein trunk, was performed. The left renal vein was resected as a graft from the confluence of the inferior vena cava just distal to the branches of the gonadal vein, renal-azygos, splenorenal communications and vertebral veins. The middle hepatic vein was reconstructed using the left renal vein 3 cm in length. RESULTS: Impaired values of liver function tests were normalized by the third postoperative day. Renal function was good throughout the postoperative period. The patient was discharged two weeks after the surgery. The reconstructed middle hepatic vein was patent, which was evaluated by a color Doppler ultrasonography, computed tomography and magnetic resonance imaging 60 days after the surgery. The patient remained well in the eight months thereafter. CONCLUSIONS: Hepatic vein reconstruction using a left renal vein graft is a new and preferable addition for the selection of an optimal graft.     

MR imaging in pelvic inflammatory disease: comparison with laparoscopy and US

PURPOSE: To assess the value of magnetic resonance (MR) imaging in the diagnosis of pelvic inflammatory disease (PID) and to compare MR imaging with transvaginal ultrasonography (US) and laparoscopy. MATERIALS AND METHODS: Thirty consecutive patients hospitalized because they were clinically suspected of having PID underwent transvaginal US and T1-weighted spin-echo, T2-weighted turbo spin-echo, and inversion-recovery MR imaging at 1.5 T. All patients underwent laparoscopy after MR imaging. RESULTS: PID was laparoscopically proved in 21 (70%) patients. The MR imaging diagnosis agreed with that obtained with laparoscopy in 20 (95%) of the 21 patients with PID. The imaging findings for PID were as follows: fluid-filled tube, pyosalpinx, tubo-ovarian abscess, or polycystic-like ovaries and free pelvic fluid. Findings at transvaginal US agreed with those at laparoscopy in 17 (81%) of the 21 patients with PID. The sensitivity of MR imaging in the diagnosis of PID was 95%, the specificity was 89%, and the overall accuracy was 93%. For transvaginal US, the corresponding values were 81%, 78%, and 80%. CONCLUSION: MR imaging is more accurate than transvaginal US in the diagnosis of PID and provides information about the differential diagnosis of PID. MR imaging may reduce the need for diagnostic laparoscopy.     

Comparison of genetic susceptibility to experimental allergic/immune-mediated blepharoconjunctivitis between Lewis and Fischer rats

BACKGROUND: Changes in hepatic architecture in cirrhosis and chronic active hepatitis affect liver vascular haemodynamics. OBJECTIVE: To determine the criteria for the diagnosis of liver cirrhosis using Doppler US. MATERIALS AND METHODS: Twenty-two children with liver disease of unknown histology were prospectively examined and compared with eight normal children. Doppler US of portal vein velocity, arterio-portal velocity ratio, loss of reverse flow component in the hepatic vein and hepatic artery visualisation were examined prior to liver biopsy. Doppler results were compared with histological activity indices. Twelve patients had cirrhosis and ten had chronic active hepatitis. RESULTS: The most sensitive method (83%) for the assessment of cirrhosis was portal vein velocity less than 20 cm/sec. Arterio-portal velocity ratio (greater than 3) and hepatic artery visualisation were less sensitive (75% and 33% respectively) but specificity was 100% for all three methods. When these three methods were evaluated together, sensitivity increased to 91% and accuracy to 96%. Loss of reverse flow component was less specific (77%) but was sensitive (75%). CONCLUSIONS: Portal vein velocity, arterio-portal vein ratio and hepatic artery visualisation together were reliable in diagnosis of cirrhosis in the paediatric age group.     

Use of preoperative MR to predict dural, perineural, and venous sinus invasion of skull base tumors

PURPOSE: To assess the accuracy of MR imaging in predicting dural, venous sinus, and perineural invasion by skull base tumors. METHODS: The preoperative MR images of 22 patients who had resection of skull base neoplasms were evaluated for the following characteristics: dural enhancement, pial enhancement, local perineural invasion by adjacent tumor, and venous sinus invasion by tumor. The greatest width of dural enhancement was measured, and the character of dural enhancement was noted. The pathologic and surgical reports were reviewed retrospectively with specific attention to dural, venous, and local perineural invasion. RESULTS: Of the 22 patients studied, dural invasion by tumor was confirmed in eight patients, vascular invasion in six patients, and perineural invasion in four patients. The sensitivity of dural enhancement in predicting invasion was 88%, the specificity 50%, and the accuracy 64%. When enhancement and focal nodularity were present, the sensitivity remained at 88%; however, specificity was 100% and accuracy 95%. If the dural enhancement was more than 5 mm thick, sensitivity, specificity, and accuracy were 75%, 100%, and 91%, respectively. Predicting tumor invasion of the dura by the presence of pial enhancement was 50% sensitive and 100% specific. Venous sinus/jugular vein invasion was predicted with 100% sensitivity, 94% specificity, and 95% accuracy. Local perineural invasion was predicted with 100% sensitivity, 50% specificity, and 59% accuracy. CONCLUSIONS: The presence of pial enhancement, focal dural nodules, or dural thickening of more than 5 mm is highly accurate in predicting the presence of neoplastic dural invasion. Linear enhancement of dura does not imply dural infiltration by tumor. Venous invasion by tumor can be predicted accurately with preoperative MR imaging.     

Localization of abnormal parathyroid glands of the mediastinum with MR imaging

PURPOSE: To determine the sensitivity of magnetic resonance (MR) imaging for preoperative localization of abnormal parathyroid glands in the mediastinum and to compare the sensitivity of MR imaging with those of scintigraphy and ultrasonography (US). MATERIALS AND METHODS: The prospective sensitivity of MR imaging was compared with those of thallium-technetium scintigraphy and US in 25 patients in whom the abnormal gland was located in the mediastinum at surgery. RESULTS: MR imaging had a much higher sensitivity (22 of 25 cases [88%]) than did scintigraphy (11 of 19 cases [58%]) or US (three of 24 cases [12%]). The most common locations for the mediastinal gland were intrathymic (eight of 25 cases) and paraesophageal (six of 25 cases) sites. CONCLUSION: MR imaging should be considered the modality of choice for preoperative localization in this group of patients.     

Neoplastic fixation to the prevertebral compartment by squamous cell carcinoma of the head and neck

OBJECTIVE: The purpose of this study was to determine the accuracy of MR imaging in determining fixation of squamous cell carcinomas to the prevertebral space. MATERIALS AND METHODS: MR images of 15 patients with large pharyngeal carcinoma (n = 13) or laryngeal carcinomas with pharyngeal extension (n = 2) were retrospectively reviewed independently by two head and neck radiologists who were unaware of the surgical findings. MR images were evaluated for four criteria in the prevertebral longus muscle complex: muscle concavity, irregular tumor-muscle interface, T2 hyperintensity, and enhancement. All patients underwent panendoscopy where fixation or mobility of the tumor relative to the prevertebral fascia was assessed by manual manipulation. Tumors in six patients were fixed to the prevertebral space and inoperable. In nine patients whose tumors were not fixed, open neck explorations were performed and tumors were resected in seven patients. MR findings were compared with panendoscopy in all patients and with intraoperative assessment in nine patients. RESULTS: Eleven of 15 patients had at least two of the MR imaging criteria present. None of the MR findings were both sensitive and specific for tumor fixation. Although muscle concavity and enhancement each had a sensitivity of 88%, both criteria suffered from low specificity (14% and 29%, respectively). An irregular tumor-muscle interface and muscle T2 hyperintensity were criteria that suffered from both low sensitivity and specificity. Accuracy of the imaging criteria independently ranged from 53% to 60%. CONCLUSION: Although abnormal muscle contour, T2 hyperintensity, and enhancement are frequently present in neck carcinomas that are fixed to the prevertebral space, these findings may also be present in patients in whom the tumor is mobile and resectable. MR imaging may not be able to differentiate between neoplastic fixation and nonneoplastic changes in the prevertebral space.     

Delineation of segmental liver anatomy. Comparison of ultrasonography, spiral CT and MR imaging for preoperative localization of focal liver lesions to specific hepatic segments

PURPOSE: The purpose of this study was to determine the ability of noninvasive imaging methods to localize focal liver lesions to specific hepatic segments. MATERIAL AND METHODS: In a prospective study we evaluated 24 patients with hepatic masses with ultrasonography (US), spiral CT and MR imaging. RESULTS: The primary segmental location of the lesions was correct with US in 15 of 24 patients (63%), with CT in 21 of 24 patients (88%) and with MR imaging in 17 of 22 patients (77%). The full extent of the lesions was correctly described with US in 9 of 24 patients (38%), with CT in 16 of 24 patients (67%) and with MR in 12 of 22 patients (55%). CONCLUSION: Among the noninvasive imaging methods, CT provides the best information for determining the segmental location and planning the surgical approach to hepatic resections.     

Cognitive dysfunction and impaired organization of complex motility in degenerative parkinsonian syndromes

PURPOSE: Our purpose was to present imaging findings of six cases proven or supposed to be von Meyenburg complexes (VMCs) with a basis of reviewing the pathologic literature and to describe imaging points for the diagnosis of typical VMC along with its differential diagnosis. METHOD: Six cases were diagnosed as VMC of the liver with imaging modalities (one had histopathologic proof). Both ultrasound (US) and CT were available for all cases, and MRI was used for three cases. Follow-up with US, CT and/or MRI was performed in five cases. RESULTS: US detected varying abnormalities of the livers in four cases. CT and MRI revealed multiple or numerous intrahepatic tiny (usually < 5 mm) cystoid lesions in all of the cases. The lesions were scattered throughout the livers, and some of them were located more frequently adjacent to the medium-sized portal veins than to the hepatic veins of similar size on CT. Moreover, some lesions were apparently located in the subcapsular areas (up to the hepatic capsules). They were usually irregular in shape and showed no enhancement but increased in number by approximately 80-150% after administration of intravenous contrast medium. The T2-weighted MR images and MR cholangiopancreatography showed the lesions to be much more apparent and to be more numerous than T1-weighted images did. Follow-up of five cases with imaging modalities did not show remarkable change of the lesions. CONCLUSION: Despite our limited experience, VMC lesions seem to show some CT and MR features different from those of other multiple small hepatic lesions. They presented as multiple or numerous intrahepatic tiny cystoid lesions usually with irregular contour, scattered throughout the liver up to the subcapsular areas, and were detected in far greater number by enhanced CT or T2-weighted MR images than by unenhanced CT or T1-weighted images. They showed no remarkable change on long term follow-up imaging. We propose that a diagnosis of typical VMC could be made after analyzing CT or MR images carefully with good understanding of its pathologic basis, but imaging follow-up is necessary in oncology patients.     

Sinusitis in the immunocompromised host

Using retrospective studies, we have investigated the possibility of obtaining characteristic findings of inflammatory pseudotumor of the liver by magnetic resonance (MR) imaging. We examined 8 patients (involving 8 masses) who had been histologically diagnosed as having an inflammatory pseudotumor in the liver. The histological studies were performed on an excised specimen of 1 mass, and on aspiration needle biopsy specimens and the clinical courses of the other 7 masses. T1 weighted images (T1WI) and T2 weighted images (T2WI) were obtained on MR imaging. MR imagings were analyzed for visualized patterns, patterns of internal structure and patterns of contrast enhancement of dynamic MR imaging. The 8 masses were visualized as hypointense on T1WI and hyperintense on T2WI by MR imaging. Dynamic MR imaging revealed that 1 mass was markedly enhanced peripherally while another mass was homogeneously enhanced, and that enhancement was most marked immediately after injection of contrast medium and then gradually disappeared. Vessels were observed in 4 masses (the portal vein in 2 masses, the hepatic vein in 1 mass, and portal and hepatic veins in 1 mass), and these vessels were clearly visualized on T1WI. The MR imaging findings from the early stage of an inflammatory pseudotumor showed a pattern similar to that of hepatic tumors with rich blood flow. The portal vein or hepatic vein was found in the tumor in half the patients, suggesting that this characteristic was useful for diagnosis of an inflammatory pseudotumor in the liver.     

Heart rate variability and baroreflex sensitivity in hypertensive subjects with and without metabolic features of insulin resistance syndrome

PURPOSE: The traditional approach to investigating suspected osteomyelitis in children includes conventional radiography and bone scintigraphy. The roles of US, CT and MR imaging are controversial. Our objective was to determine whether the additional use of these modalities would yield information likely to lead to treatment modification. MATERIAL AND METHODS: Sixty-five children with clinically suspected osteomyelitis took part in a prospective study. All patients underwent conventional radiography and bone scintigraphy. In addition to this, US, CT and MR imaging were all performed in 33 patients; the remaining 32 patients were examined with various combinations of these three modalities. The value of the additional information obtained was estimated retrospectively by a pediatric orthopedic surgeon in terms of possible modification of treatment. RESULTS: MR imaging was the modality with the highest sensitivity and specificity for detecting osteomyelitis. MR yielded information likely to influence treatment in the greatest proportion of patients (45%) followed by US (30%). CONCLUSION: The standard investigation protocol with the addition of US (because of its ability to detect subperiosteal abscesses early and simply) is adequate in uncomplicated cases. When additional imaging is required to outline a lesion, or in complicated cases, and when bone scintigraphy is inconclusive, MR imaging should also be performed. CT should be considered when MR investigation is not available or when anesthesia is required but cannot be provided.     

Intermittent complete vascular exclusion of the liver during hepatectomy: technique and indications

BACKGROUND/AIMS: Complete intermittent vascular exclusion of the liver (IVEL) combines clamping of the hepatic pedicle with clamping of the hepatic veins without interruption of the caval flow. The major advantages of this technique are that patient preclamping fluid overload is avoided, major haemodynamic changes due to caval clamping are escaped, and it allows a very long clamping time. Disadvantage of this technique is the necessity of looping the terminal part of the hepatic veins. METHODOLOGY: In this prospective study, 41 cases of IVEL (Representing 19% of the hepatectomies carried out for cancer during the same period) used for difficult hepatectomies were analyzed, and the operative technique is presented. RESULTS: IVEL was feasible in 90% of the 46 attempted cases, and completely controlled the bleeding in 90% of the cases. The mean duration of IVEL was 69.2 minutes (Range: 37 to 140), and was greater than 130 minutes in three patients. No liver failure occurred during the postoperative course. CONCLUSION: We conclude that IVEL without caval clamping is a new, and valuable, technique of vascular exclusion of the liver. Its application is indicated in the following conditions: 1. For patients who should have classical vascular exclusion but cannot tolerate vena cava clamping (18% of the cases), 2. for patients with pathological liver parenchyma when intrahepatic venous pressure is high, 3. for patients with impaired liver parenchyma, requiring conservative surgery that leads to anatomic or non-anatomic resection close to a vein (Example: A tumor located in the dihedral angle of the terminal part of two hepatic veins), 4. for patients with tumors closely located to a hepatic vein that must be preserved and sharply dissected (Example: A left trisegmentectomy that requires pelting of the right hepatic vein), and 5. for the scarce patient with tumors infiltrating the major hepatic veins, constraining a hepatic vein reconstruction to preserve liver function.     

Role of computerized tomography in the evaluation of extraductal extension of hilar cholangiocarcinoma

This study was aimed at assessing the role of CT in the investigation of extraductal spread of hilar cholangiocarcinoma. October 1990 to November 1993, twenty-one patients with hilar cholangiocarcinoma were examined. The diagnosis was made on the basis of the following CT findings: intrahepatic bile ducts dilatation, nonunion of the right and the left bile ducts, normal size of extrahepatic bile ducts and the tumor depicted "per se". As for extraductal spread, we considered parenchymal invasion, involvement of vascular structures and parenchymal, lymph node and peritoneal metastases. In all cases CT demonstrated intrahepatic bile duct dilatation and nonunion at the confluence. CT demonstrated a hypodense mass in 10/21 cases and an isodense mass in 11/21 cases. Portal vein involvement was detected in 7/10 cases and hepatic artery involvement was correctly suspected in 1/8 cases; CT demonstrated parenchymal and lymph node metastases in 1/6 and 2/7 cases. In conclusion, CT proved to be a valuable technique, like PTC and US, to assess tumor resectability.     

Surgical intervention for patients with stage IV-A hepatocellular carcinoma without lymph node metastasis: proposal as a standard therapy

OBJECTIVE: The aim of this study was to evaluate the effects of surgical treatments for patients with stage IV-A hepatocellular carcinoma (HCC) without lymph node metastasis. SUMMARY BACKGROUND DATA: Nonsurgical therapy for highly advanced HCC patients has yielded poor long-term survival. Surgical intervention has been initiated in an effort to improve survival. METHODS: The outcome of 150 patients who underwent hepatic resection was studied. Survival analysis was made by stratifying stage IV-A HCC patients into two groups-those with and those without involvement of a major branch of the portal or hepatic veins. Those with involvement were further divided into subgroups according to major vascular invasions. RESULTS: Patients who had multiple tumors in more than one lobe without vascular invasion had a significantly better 5-year survival rate (20%) than those with vascular invasion (8%) (p < 0.01). The survival rate of patients with hepatic vein tumor thrombi (10%) was better than the rate for those with tumor thrombi in the inferior vena cava (0%), in whom no patients survived more than 2 years, although the survival rate for those with portal vein tumor thrombi in the first branch (11%) was no different from the rate for that in the portal trunk (4%). The operative mortality decreased from 14.3% in the first 6 years to 1.4% in the following 5 years. CONCLUSIONS: Surgical intervention for stage IV-A HCC patients brought longer survival rates for some patients. We recommend surgical intervention as an effective therapeutic modality for patients with advanced HCC.     

Study of FHIT transcripts in normal and malignant breast tissue

The purpose of this study was to determine the utility of intraoperative Doppler ultrasound for the diagnosis and reduction of the vascular complications in liver transplantation. This study included 19 pediatric and 5 adult patients. In the pediatric group, 12 patients received living related liver transplantation (LRLT), two splitting liver transplantation (SLT), three reduced-size liver transplantation (RLT) and two full-size pediatric liver transplants (FPLT). The hemodynamics and waveform of the hepatic vein, portal vein and hepatic artery were evaluated by intraoperative Doppler ultrasound (US) after reperfusion of the graft. Unsatisfactory hemodynamics was identified in nine cases, including decrease hepatic venous flow (6-9 cm/s) with non-pulsative flat waveform (adults, n = 2 and LRLT, n = 2); portal vein thrombosis (LRLT, n = 1); decrease portal flow (8 mL/min/kg) (LRLT, n = 1); occlusion of the portal vein (SLT, n = 1); poor arterial flow with dampened artery waveform (FPLT, n = 2). These abnormalities were all successfully re-reconstructed by surgical procedures and achieved a graft survival rate of 100%. Two late vascular complications including hepatic venous thrombosis and recurrent portal vein stenosis with splenorenal shunt were discovered 1 month later. They were treated effectively by surgical thrombolectomy and percutaneous balloon dilatation and metallic coils embolization respectively. Three patients died of non-vascular complications and all patients who underwent LRLT survived with a resultant 87.5% overall survival rate. In conclusion, intraoperative Doppler US is efficient in detecting abnormal hepatic hemodynamics, which permits early intervention and hence a better prognosis for the patients. Re-reconstructive procedures were monitored closely under Doppler US guidance until proper flow and wave-form were established. This reduces post-transplant vascular complications and thereby eliminates the likelihood of a lethal complication that might call for re-transplantation.     

Value of asymmetry criterion in MRI for the diagnosis of small pelvic lymphadenopathies (inferior or equal to 1 cm)

The purpose of this study was to determine if lymph node asymmetry in small (< 1.0 cm) pelvic nodes was a significant prognostic feature in determining metastatic disease. 216 patients who presented pelvic carcinoma underwent MR imaging. They were correlated to pathological findings obtained by surgery. We considered on the axial plan the maximum diameter (MAD) of both round or oval-shaped suspicious masses. Two different cut-off values were determined: node diameter superior to 1.0 cm (criterion 1) and node diameter superior to 0.5 cm with asymmetry relative to the opposite side for nodes ranging from 0.5 cm to 1.0 cm (criterion 2). With criterion 1 MR Imaging had an accuracy of 88%, a sensitivity of 65%, a specificity of 96%, a PPV of 88% and a NPV of 88% in detection of pelvic node metastasis. By considering criterion 2, MR Imaging had an accuracy of 85%, a sensitivity of 75%, a specificity of 89%, a PPV of 71% and a NPV of 91%. Normal small asymmetric lymph nodes were present in 5.6% of cases. Asymmetry of normal or inflammatory pelvic nodes is not uncommon. It cannot be relied on to diagnose metastatic involvement in cases of small suspicious lymph nodes, especially because of its low specificity and positive predictive value.     

Hepatic and portal surface veins: a new anatomic variant revealed during abdominal CT

OBJECTIVE: The objective of this paper is to describe a new finding on CT of hepatic and portal vein segments located in a subcapsular location on the surface of the liver. SUBJECTS AND METHODS: From a series of more than 11,000 contrast-enhanced abdominal CT scans performed from 1993 to 1997, 14 patients were identified as having hepatic or portal vein segments or both in a subcapsular location on the surface of the liver. RESULTS: We found seven portal vein surface segments in seven patients and 14 hepatic vein surface segments in 12 patients. Of the 14 patients, five had both portal and hepatic vein surface segments. Therefore, in a cohort that exceeded 11,000 patients, the incidence of this finding was 0.1%. Four patients had cirrhosis, two had small hypervascular liver lesions, and eight had healthy livers. The surface veins were not associated with any other recognized vascular anomalies or with anastomoses to extrahepatic systemic veins. CONCLUSION: Hepatic and portal veins can course to a subcapsular location on the surface of the liver. This anatomy is believed to be a normal variant and can be found in patients with healthy livers and normal hepatic vein hemodynamics and in patients with portal hypertension.