Percutaneous computed tomography lymphography in the rabbit by subcutaneously injected nanoparticulates

RATIONALE AND OBJECTIVES: Surgical lymphangiography is infrequently used in staging cancer because of its inherent limitations. Radiopaque nanoparticulates target lymph nodes draining interstitial tissues and could make percutaneous lymphography feasible. METHODS: Experimental nanoparticulate contrast agent formulations were injected subcutaneously in the forepaw or hindpaw of normal rabbits or rabbits with induced reactive nodal hyperplasia. Axillary and popliteal nodes were imaged with thin-section computed tomography (CT) using quantitative methods to measure node enhancement. Dose-response (0.1-2.0 ml) and time course (4 hr to 10 weeks) of enhancement were assessed. RESULTS: Nodal enhancement above 100 Hounsfield units was consistently obtained. Enhancement was significantly related to dose and peaked at 10 hr with slow washout over the observation period. Nodes with reactive hyperplasia were larger and had heterogeneous enhancement patterns distinctly different from normal nodes. CONCLUSION: Percutaneous CT lymphography effectively depicts the macroscopic intranodal architecture in rabbits.     

全身扩散加权成像在恶性淋巴瘤诊断与疗效评估中的价值

Objective:The aim was to evaluate the role of whole body diffusion weighted imaging (WB-DWI) of magnetic resonance in the diagnosis and efficacy evaluation of malignant lymphoma.Methods: The clinical manifestation of whole body diffusion weighted imaging of 47 patients with malignant lymphoma being pathologically proved were carried on by retrospective analysis and to compare with 10 healthy volunteers.There were 8 cases of Hodgkin's lymphoma (HD) patients, of which WB-DWI examination of 5 cases were carried out before and after treatment and 3 cases were done after treatment.There were 39 cases of non-Hodgkin's lymphoma (NHL) patients, of which WB-DWI examination in 19 cases were acted before treatment, 11 cases were done before and after treatment and 9 cases done after treatment.In apparent diffusion coefficient (ADC) diagram the ADC values of lymph nodes in patients with malignant lymphoma and healthy volunteers were measured respectively, among 16 patients the ADC values of parts of lymph node being consistent with the initial inspection were determined again and compared the values before and after, and compared with healthy volunteers.Results: Whole body magnetic resonance diffusion weighted imaging (MR-DWI) showed more sensitive to lymphoma, and 372 lymph nodes greater than 1 cm were detected with MR-DWI.Before treatment, mean ADC value of 35 patients with malignant lymphoma was (0.86 0.21) × 10-3 mm2/s, of which an average ADC values of 28 cases after treatment was (1.22 0.31)× 10-3 mm2/s, before and after treatment difference of the average ADC values of patients was statistically significant (P < 0.05); the average ADC value of cervical lymph nodes of 10 healthy volunteers (1.29 0.12) × 10-3mm2/s and of 30 patients with malignant lymphoma before treatment was statistically significant (P < 0.05), and to compare with 28 patients after treatment difference of the ADC values was not statistically significant (P > 0.05).Conclusion: WB-DWI and ADC values being measured in the clinical diagnosis of malignant lymphoma, staging and evaluation of efficacy of monitoring is a fast and effective technology, with some clinical value.     

Indirect computed tomography lymphography of subdiaphragmatic lymph nodes using iodinated nanoparticles in normal dogs

RATIONALE AND OBJECTIVES: We evaluated the imaging characteristics of an iodinated particulate contrast agent for indirect computed tomography (CT) lymphography of normal subdiaphragmatic lymph nodes in dogs. METHODS: Four milliliters of a 15% (wt/vol) iodinated nanoparticle suspension was injected into the gastric, colonic, rectal, or cervical submucosa, loose paraprostatic fascia, or metatarsal subcutaneous tissues in 10 healthy beagles. Endoscopic, CT, or ultrasound guidance was used when necessary to facilitate contrast agent delivery. CT and radiographic images were obtained prior to contrast administration and at 4 hr, 24 hr, and 7 days postcontrast injection. Postmortem examinations were then conducted. RESULTS: CT images showed enhancement of regional lymph nodes draining the various injection sites. The mean attenuation of opacified nodes was 678 +/- 463 Hounsfield units 24 hr after injection and remained elevated 7 days later. Lymph node opacification on CT images correlated well with the node location observed on postmortem examinations. CONCLUSION: Subdiaphragmatic lymph nodes can be effectively opacified using an iodinated nanoparticle contrast agent for indirect CT lymphography.     

Influence of luminal obstruction on oesophageal cancer staging using endoscopic ultrasonography

BACKGROUND: Despite encouraging results from Europe and the USA, endoscopic ultrasonography has yet to become established in the UK for imaging gastrointestinal lesions. The aim of this prospective study was to investigate the accuracy of endoscopic ultrasonography for local tumour (T) and lymph node (N) staging of oesophageal cancer. METHODS: Endoscopic ultrasonography was performed in 50 consecutive patients with operable oesophageal cancer. Its accuracy for locoregional tumour staging was assessed and a detailed analysis of the distribution of ultrasonographically detected lymph nodes performed. RESULTS: Endoscopic ultrasonography was highly accurate for both local tumour (92 per cent correct T stage prediction) and lymph node (86 per cent correct N stage prediction) staging compared with final histology. The procedure was also superior to open surgical staging performed by the surgeon; it had a tendency to overestimate malignant involvement of individual lymph nodes and had only limited ability to identify small benign lymph nodes, particularly in the abdomen. CONCLUSION: Endoscopic ultrasonography was reliable for both local tumour and lymph node staging of oesophageal cancer.     

Lymphographic evaluation of 250 patients with malignant melanoma

Foot lymphography was performed in a selected group of 250 patients with malignant melanoma, with different sites of origin and of various stages. The overall incidence of metastases was 40%. The case material was evaluated in detail; the tumors of the inferior limb and those on different sites, e.g., vulva and abdomen, were considered separately. In the group of 188 patients with melanoma of the inferior limb, the incidence of metastases was 42%. In 51%, histologic confirmation was obtained. In the group of 62 patients with melanoma of different sites of the body, the incidence of metastases was 34% and histologic confirmation was obtained in 21 patients. The values of accuracy, sensitivity, and specificity based on the histologic confirmation of the lymphographic reports ranged from 88% to 96%. These data justify the use of lymphography in the initial diagnostic work-up and in the follow-up of these patients.     

Treatment of hypothyroidism

A series of 77 gallium-67 citrate (67Ga citrate) scans of the abdomen revealed lymphoma in 12 cases (nine of non-Hodgkin's lymphoma, three of Hodgkin's disease). Scanning was undertaken (i) to confirm the suspicion of lymphoma, or (ii) as part of a staging procedure when the diagnosis of lymphoma had been established, or (iii) as a follow-up investigation after treatment of lymphoma. The diagnosis of lymphoma in the upper part of the abdomen is difficult with conventional techniques such as lymphography, and it is in this area that 67Ga citrate scanning is shown to be of value.     

Echography at "high resolution" in the diagnosis of cervical lymphadenopathies in follow-up of thyroid carcinoma

BACKGROUND: In the diagnosis and follow-up of differentiated thyroid cancer (DTC) patients, a major clinical objective is to differentiate whether the cause of enlarged neck lymph nodes is either tumorous or inflammatory. High-frequency (7.5-10 MHz) ultrasound examination proved to be highly informative in this regard. An oval shape of the examined lymph node (longitudinal/anteroposterior diameter ratio, L/A > 1.5) and a central echogenic hilus indicate a benign lymphadenopathy. Roundness (L/A < or = 1.5), absence of the central echogenic hilus and a parenchymatous echogenicity are considered as signs of malignancy. METHODS: A series of 131 lymph nodes in DTC patients were examined at ultrasound and, on the basis of round shape (L/A < or = 1.5) in association with either one or both the other features (absence of central echogenic hilus, homogenous internal echo), 94 lymph nodes were classified a "malignant" and 37 "benign". The ultrasonographic diagnosis was evaluated with either cytologic or histologic diagnosis in all "malignant" nodes and in 7/30 "benign" nodes. In the other 30 "benign" nodes volume shrinkage or lymph node disappearance was observed during follow-up period. RESULTS: According to the results obtained, the ultrasound features utilized provided a good diagnostic accuracy (87%) with only 5 false positive case. CONCLUSIONS: High-frequency sonography, therefore, must be considered a useful and accurate method for evaluating suspected lymphadenopathy in DTC patients.     

Imaging of nodal metastases in the head and neck

Therapeutic outcome of head and neck cancer is influenced strongly by the presence of nodal metastases. Sensitivity and specificity of the physical examination for the diagnosis of nodal metastasis is unsatisfactory, resulting in both false negatives and false positives of 25 to 40%. Preoperative detection of nodal metastases therefore becomes one of the important goals of imaging studies of patients with head and neck cancer. Despite several advanced techniques and the wide clinical use of MR, MR has surprisingly added little to the diagnostic accuracy of contrast-enhanced CT. Although CT and MR allow detection of abnormally enlarged nodes or necrotic nodes, neither borderline-sized nodes without necrosis nor extracapsular spread are reliably differentiated from reactive or normal nodes in patients with head and neck cancer. Lack of definitive diagnostic methods of metastatic lymph nodes is a serious shortcoming in the preoperative workup for patients with head and neck cancer. To avoid missing small metastatic nodes, a large number of patients clinically staged as N0 have undergone elective neck dissection to exclude metastases. With development of more tissue-specific imaging techniques, patients can be better characterized according to the status of nodal disease so that an appropriate therapeutic protocol can be designed for an individual case.     

The value of palpation as basis for decision on lymph node excision

The purpose of the study was to evaluate palpation of the regional lymph nodes in control examinations of patients with malignant disease. A retrospective review of the medical records of 188 cases in which the patients had had an extirpation of the regional lymph nodes was performed. We have compared the preoperative findings through palpation with the histological diagnosis. The patients were grouped according to the region in which the lymph node removal had been done. The specificity of palpation when the histological diagnosis was malignant was (with 95% confidence limits), in the axilla 0.65 (0.54-0.75), in the inguinal region 0.86 (0.75-0.94) on the neck 0.83 (0.52-0.98) and in the suprahyoid region 0.58 (0.28-0.85). In conclusion, palpation of regional lymph nodes is not a sufficient control examination in the estimation of the course of malignant disease. Supplementary examination methods are recommended.     

Re-mediastinoscopy in the assessment of resectability of lung cancer

OBJECTIVE: Thirty-one patients underwent re-mediastinoscopy in the diagnostic assessment of lung cancer. The reason for a repeat mediastinoscopy was either a negative result at the first operation in spite of CT indication of enlarged nodes or an incomplete first mediastinoscopy. METHODS: All patients underwent a conventional mediastinoscopy. RESULTS: In 22 patients with enlarged mediastinal lymph nodes at computed tomography, 10 had a positive lymph node histology at re-mediastinoscopy, while 12 were negative. In 9 patients with no enlarged mediastinal nodes at CT scan, but incomplete biopsies at the first mediastinoscopy, 1 patient had lymph node metastases. The median duration from the first to the second mediastinoscopy was 43 days. No major complications occurred. The staging of the patients was greatly affected by the re-mediastinoscopy. Of 31 patients judged as operable according to the initial mediastinoscopy only 60% were found to be operable following the second mediastinoscopy. CONCLUSION: This study has demonstrated the value of re-mediastinoscopy in assessment of resectability of lung cancer.     

Imaging of mediastinal lymph nodes: CT, MR, and FDG PET

The evaluation of mediastinal lymph nodes is an important aspect of staging in patients with non-small cell lung cancer. Anatomic imaging of lymph nodes with computed tomography (CT) and magnetic resonance (MR) imaging has been limited by the relatively low sensitivity and specificity of these techniques. Advances in physiologic imaging of mediastinal lymph nodes with 2-[fluorine-18] fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) have resulted in improved diagnostic accuracy in the determination of nodal status. Despite the limitations of CT, this technique still plays an important role by aiding in the selection of the most appropriate procedure for staging, by guiding biopsy, and by providing anatomic information for visual correlation with FDG PET images. At present, anatomic MR imaging of lymph nodes is primarily a problem-solving tool for cases with inconclusive CT results. Physiologic MR imaging with iron oxide is an exciting area of investigation, and the accuracy of this technique is being assessed in clinical trials. Anatomic and physiologic imaging techniques should be considered complementary rather than competitive imaging strategies.     

Lymphography in patients with suspected malignancy or fever of unexplained origin

Forty-four patients underwent bipedal lymphography for evaluation of fever of unexplained origin, or because a malignant tumor (usually lymphoma) was suspected clinically. Extensive prior medical evaluation was inconclusive. The lymphograms were of no apparent value in detecting the etiology of the illness. Reactive follicular hyperplasia was frequently seen and sometimes simulated lymphoma on the lymphogram. The primary value of lymphography in such cases is as an aid in planning biopsy and surgery.     

Mediastinal lymphadenopathy in cryptogenic fibrosing alveolitis: the effect of steroid therapy on the prevalence of nodal enlargement

PURPOSE: To determine the prevalence of enlarged mediastinal lymph nodes in cryptogenic fibrosing alveolitis (CFA) and to assess whether this frequency was related to steroid administration. MATERIAL AND METHODS: Retrospective review of chest radiographs and high-resolution computed tomography (CT) of 54 patients with proven cryptogenic fibrosing alveolitis (CFA). Twenty-two of the 54 patients received oral steroids up to 2 months before the time of high-resolution CT examination (group 1); the remaining 32 patients had not taken steroids for at least 6 months before study entry (group 2). The prevalence, distribution, and size of enlarged mediastinal lymph nodes was determined in all groups. The diagnosis of CFA was histologically established in 44 patients. In 10 patients the diagnosis of CFA was based on clinical and high-resolution CT findings. RESULTS: Mediastinal lymphadenopathy was present in 26 of 54 patients with CFA. The prevalence of enlarged nodes was 14% (three of 22) in patients who had received oral steroids up to 2 months before the time of CT examination, and 71% (23 of 32) in patients that had not taken steroids for at least 6 months before study entry. CONCLUSION: We conclude that patients with CFA on steroid therapy had a significantly lower prevalence of mediastinal adenopathy (P < 0.001) than patients who had not taken steroids.     

Surgical treatment of penile cancer: a follow-up report

One hundred and fifteen patients with penile cancer were treated at Roswell Park Memorial Institute from 1952 to 1975. A full follow-up is reported and factors involving the prognosis are analyzed. Although the clinical error of staging was near 30%, the lymphography results suggest that this study may result in added improvement in preoperative staging. Early diagnosis, adequate surgical resection, and lymph node dissection will improve the survival significantly. When dealing with an individual patient the prognosis is poor when any one or more of the follow factors are present: the lesion involves the shaft; there is a positive margin at the surgical resection; total penectomy is necessary to obtain tumor-free margin; lymphography is positive for tumor involvement of lymph nodes; lymph node dissection has not been performed; positive lymph nodes are found on surgical exploration. The good prognostic factors include: a lesion confined to the glans and partial penectomy is sufficient to obtain a tumor-free margin of resection; no clinical evidence (including lymphography) of lymph node invovlement; performance of lymph node dissection. The histological grading of the tumor should not influence the clinical decision for treatment in our opinion at this time, based on our current results. Further prospective studies of different factors involved in etiology, diagnosis, and treatment of penile cancer are suggested.     

Usefulness of computerized tomography in the study of pleural effusion with no presumed diagnosis

To establish the diagnostic yield of computerized tomography (CT) in pleural effusions with no presumed diagnosis arising from standard clinical examination. A prospective protocol study enrolling all cases of effusion admitted to our hospital between January 1994 through July 1995 without a presumed diagnosis after initial testing that included thoracocentesis. Twenty-two patients were enrolled. All were given a CT scan as well as other complementary examinations considered appropriate and were referred to our outpatient clinic for follow-up. The CT images were read by an expert radiologist and their contribution was classified as "diagnostic", "suggestive" or "nil". A definitive etiologic diagnosis was achieved in 14 cases (8 neoplasms, 4 benign due to asbestos, 1 tuberculosis and 1 pulmonary embolism). The CT contribution was nil in 13 cases (59%), "diagnostic" in 6 (2 mesotheliomas, 1 hypernephroma, 1 lymphoma, 1 adenocarcinoma of the colon and another of the ovary) and "suggestive" in 3 (2 benign due to asbestos and 1 lymphoma). Positive information was obtained in 9 cases (41%). CT gives good yield in the investigation of pleural effusions with no presumed diagnosis and should be made available to this group of patients before other more invasive procedures are resorted to. It is especially useful for detecting neoplastic disease of the upper abdomen, mesothelioma and sings of unsuspected exposure to asbestos.     

Small lymph nodes of the abdomen, pelvis, and retroperitoneum: usefulness of sonographically guided biopsy

PURPOSE: To evaluate the usefulness of sonographically guided percutaneous biopsy of small lymph nodes in the abdomen, retroperitoneum, and pelvis. MATERIALS AND METHODS: From May 1995 through January 1997, 35 sonographically guided lymph node biopsies were performed in 34 patients. All biopsies were performed with a 20- (n = 18) or 22-gauge (n = 10) self-aspirating needle alone or in combination (n = 7). To determine the amount of compression achieved with the transducer, the skin-to-lesion distance on reference computed tomographic (CT) scans was compared with that on sonograms. A biopsy was considered successful if a specific benign or malignant diagnosis was rendered by the pathologist. RESULTS: Of 35 sonographically guided biopsies, 30 (86%) were successful. Diagnoses included 26 (74%) cases of carcinoma, three (9%) cases of benign reactive lymphocytosis confirmed at open biopsy, and one (3%) case of a lymph node with a positive acid-fast bacilli stain. The average lymph node diameter was 2.1 cm (range, 0.9-4.3 cm). With sonography, a mean of 2.5 needle passes (range, 1-5) were made per biopsy. Transducer compression reduced the skin-to-lesion distance from an average of 8.8 cm (at CT) to 4.5 cm. CONCLUSION: Sonographic guidance seems to provide a reasonable alternative to CT in biopsy of small abdominal, pelvic and retroperitoneal lymph nodes.     

Lymphoma: role of whole-body 2-deoxy-2-[F-18]fluoro-D-glucose (FDG) PET in nodal staging

PURPOSE: To compare 2-deoxy-2-[fluorine-18]fluoro-D-glucose (FDG) positron emission tomography (PET) with computed tomography (CT) in primary nodal staging of malignant lymphoma. MATERIALS AND METHODS: Sixty consecutive patients with untreated, histopathologically proved malignant lymphoma (aged 7-72 years; 33 with non-Hodgkin lymphoma, 27 with Hodgkin disease) underwent FDG PET and contrast material-enhanced CT for nodal staging. Lymph node regions identified at both CT and PET were regarded as actual locations of disease. Discordant results were verified with biopsy or clinical follow-up whenever possible. RESULTS: One hundred sixty of 740 evaluated lymph node regions were identified as diseased at both CT and PET. Of the 25 additional regions seen with PET, seven were true-positive; two, false-positive; and 16, unresolved. CT showed six additional disease manifestations; three were false-positive, and three were unresolved. Staging was changed in the four patients with the seven confirmed additional PET findings: from stage I to II in one patient and from stage II to III in three patients. Staging was changed from stage II to I in one of the three patients with false-positive CT findings. CONCLUSION: FDG PET may be more accurate for detecting nodal lymphoma than incremental CT.     

Ophthalmic findings with partial trisomy (duplication) of the long arm of chromosome 7

BACKGROUND: The sensitivity of diagnostic imaging of processes in the parotid gland has been increased by improved spatial resolution, yet specificity remains unchanged. The purpose of this study was to determine whether the low-flow color duplex technique alters the specificity of B-mode ultrasonography. PATIENTS AND METHODS: Forty-one patients with tumors of the parotid gland were examined by color duplex echography as well as histologically. Twenty-eight of the 41 patients had benign tumors and 13 had malignant disease. In 17 of 41 patients, color duplex ultrasonography failed to detect any vascularization within the tumor. Histopathological examination showed that 3 of these 17 tumors were malignant and 14 of 17 were benign. Intranodal vascularization was detected in 24 cases. Ten of these patients were found to have malignant tumors of the parotid gland; 14 had benign parotid tumors. RESULTS: Our present findings show that marked intratumoral vascularization especially appears in malignant tumors. In contrast to lymph nodes, the location and texture of intranodal blood vessels do not provide information about the nature of the neoplasm. CONCLUSIONS: Low flow duplex ultrasonography does not increase the specificity of preoperative examination in tumors of the parotid gland.     

Efficacy of sonographically guided biopsy of thyroid masses and cervical lymph nodes

OBJECTIVE: We performed a prospective study in 96 patients to determine accuracy of sonographically guided fine-needle aspiration biopsy of thyroid masses and cervical lymph nodes. MATERIALS AND METHODS: Real-time sonography was used to guide biopsy of 112 cervical masses in 96 patients (71 patients with impalpable masses, 16 with failed unguided attempts, patient's or physician's preference in nine). The diameters of all masses were less than 3 cm, with a mean of 1.5 cm and a median of 1.5 cm. Twenty-nine masses measured 1 cm or less in diameter, 60 masses between 1.1 and 2.0 cm, and 23 masses between 2.1 and 3.0 cm. Cervical masses that were sampled by biopsy included 75 thyroid masses and 37 lymph nodes. RESULTS: Diagnostic specimens were obtained in 102 (91%) of 112 masses sampled. Sixty-eight (91%) of 75 biopsies of thyroid tissue and 34 (92%) of 37 biopsies of lymph nodes were diagnostic. Nondiagnostic thyroid biopsies included four of complex cysts and three of solid nodules. Sonographic follow-up (1 year) revealed no change or decrease in size of those seven lesions. Sixty of 68 diagnostic thyroid biopsies showed benign processes: 42 macrofollicular adenomas, six colloid adenomas, five microfollicular adenomas, four probable cases of thyroiditis, and three hemorrhagic cysts. The remaining eight diagnostic thyroid biopsies showed malignant processes: seven papillary carcinomas and one metastatic small-cell carcinoma. Of 34 diagnostic biopsies of lymph nodes, 26 showed malignant processes and eight showed benign processes. Surgery in the three patients with nondiagnostic biopsies of lymph nodes revealed two recurrent medullary cancers and one benign node. CONCLUSION: Sonographically guided fine-needle aspiration biopsy of neck masses has a high sensitivity (91%) and should be routinely used to evaluate indeterminate masses in the neck.