Carcinoembryonic antigen induces signal transduction in Kupffer cells

OBJECTIVES: We compared the ability of preoperative abdominal computed tomography (CT) with that of preoperative abdominal ultrasonography (US) in predicting the extent of tumor growth and the curative resectability of gastric cancer. METHODS: Abdominal CT and US were done in 95 patients with gastric adeno-carcinoma. The radiologic findings were prospectively compared with surgical and pathologic findings. RESULTS: The sensitivities of abdominal CT and US in detecting the perigastric lymph node involvement were 26.6% and 20%, respectively. The sensitivity of abdominal CT in predicting the pancreatic invasion (60%) was better than that of abdominal US (20%). However, there were 6 false positive diagnosis of pancreatic invasion by abdominal CT; in contrast, there was no false positive diagnosis of pancreatic invasion by abdominal US. Of 95 patients who underwent surgical exploration, 14 were found to have unresectable tumors because of extragastric organ involvement and distant metastases. Abdominal CT falsely predicted 8 of 14 cases in which curative gastric resection was impossible as resectable. Moreover, abdominal CT falsely predicted 5 of 81 cases in which curative gastric resection was possible as unresectable. Abdominal US falsely predicted 12 of 14 cases in which curative surgery was impossible as resectable. CONCLUSION: Preoperative abdominal Ct and US did not accurately predict the tumor extent and the curative resectability of the gastric cancer. Especially, abdominal CT finding of pancreatic invasion by gastric cancer should not be a contraindication for surgical exploration.     

Video-laparoscopic staging of gastric cancer. A prospective multicenter comparison with noninvasive techniques

BACKGROUND: The high proportion of gastric carcinomas present in an unresectable stage, together with the emergence of multimodal treatments, increases the usefulness of objective staging methods that avoid unnecessary laparotomies. METHODS: A prospective evaluation of the accuracy of laparoscopy in the staging of 71 patients with gastric adenocarcinoma is presented. Serosal infiltration, retroperitoneal fixation, metastasis to lymph nodes, peritoneal and liver metastasis, and ascites were determined in the staging workup. Sensitivity, specificity, and predictive values were calculated and compared with those obtained with ultrasonography (US) and computed tomography (CT). RESULTS: The diagnostic accuracy of laparoscopy in the determination of resectability was 98.6%. Consequently, over 40% of patients were spared unnecessary laparotomies. Laparoscopy yielded diagnostic indices superior to US and CT for all the tumoral attributes studied. Our technique permits accurate assessment and pathologic verification of liver and the peritoneal and retroperitoneal extent of tumor invasion in the majority of patients. CONCLUSIONS: Laparoscopy in gastric adenocarcinoma is a reliable technique that provides accurate assessment of resectability and stage, thus avoiding unnecessary laparotomies in patients in whom surgical palliation is not indicated. A stepwise diagnostic workup combining imaging and minimally invasive techniques is proposed.     

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.     

Preoperative assessment of advanced gastric carcinoma using computed tomography

OBJECTIVES: The role of computed tomography (CT) for the staging of gastric carcinoma is controversial. The purpose of this study was to evaluate the utility of CT in assessing the perigastric spread of advanced gastric carcinoma. METHODS: The study included 56 patients who underwent dynamic CT and laparotomy for the treatment of node-positive gastric adenocarcinoma. Preoperative CT findings were compared with surgical findings, and diagnostic accuracy was estimated. RESULTS: Sensitivity, specificity, and accuracy of preoperative CT in determining the perigastric tumor spreads were 33, 97, and 73% in pancreatic invasion, 36, 97, and 70% in level III lymph node involvement, and 89, 98, and 96% in liver metastasis. Peritoneal dissemination was not detected in 15 of 56 patients (27%), and stage IV disease was not diagnosed correctly in 18 of 40 patients (45%). CONCLUSIONS: Radiologists and surgeons must remember that pancreatic invasion, extended lymph node metastasis, and peritoneal dissemination are sometimes overlooked in CT examination in patients with advanced gastric carcinoma.     

Identification of the aberrant hepatic artery with axial spiral CT

PURPOSE: To determine whether axial spiral computed tomography (CT) allows detection of the replaced hepatic artery as part of preoperative planning for pancreatic tumor resection. MATERIALS AND METHODS: Axial spiral CT scans (8-mm section thickness, 4-mm overlapping reconstructions) were obtained in 50 patients with periampullary tumor and were examined by three radiologists. Readers' interpretations were compared with angiographic results. RESULTS: Eight patients had an aberrant hepatic artery. Two of the three readers detected or suspected all of these abnormalities (100% sensitivity), and one reader identified seven of eight aberrant arteries (88% sensitivity). However, readers requested angiographic confirmation in 14 of 24 tests. Sensitivity, specificity, and accuracy were 96%, 87%, and 88%, respectively, for all readers. CONCLUSION: Axial spiral CT may simplify preoperative evaluation of periampullary tumors. However, angiographic support was necessary in most cases in this study. Improvements in CT techniques may eventually allow spiral CT to replace angiography in the examination of these patients.     

Spiral computed tomography and operative staging of gastric carcinoma: a comparison with histopathological staging

BACKGROUND: Much controversy exists as to the value of computed tomography (CT) in the preoperative staging of gastric cancer, because of its limited ability to identify correctly lymph node (LN) metastases, invasion of adjacent organs, or hepatic and peritoneal metastases. Spiral CT scanners have a number of potential advantages over conventional scanners, including the absence of respiratory misregistration, image reconstruction smaller than scan collimation permitting overlapping slices and optimisation of intravenous contrast enhancement. AIM: To compare the performance of spiral CT and operative assessment against formal (TNM) pathological staging. PATIENTS AND METHODS: A study of 105 consecutive patients who underwent both spiral CT and operative staging was performed. All CT scans were reviewed by a radiologist who commented on tumour location and size, evidence of adjacent organ invasion, lymph node metastases to both N1 and N2 nodes, and evidence of hepatic and peritoneal metastases. All patients underwent careful operative assessment at the time of surgery, along the lines suggested by Rohde and colleagues. RESULTS: Spiral CT remained poor at identifying LN metastases to both N1 and N2 lymph nodes, with sensitivity ranging from 24 to 43%; specificity, however, was 100%. Operative staging was superior, with sensitivities between 84 and 94%, but specificity was much lower (63-74%). Spiral CT correctly detected 13 of 17 cases of invasion of either the colon or the mesocolon (sensitivity 76%) compared with 16 of 17 cases at operative staging (sensitivity 94%). Spiral CT correctly identified three of six cases with invasion of the pancreas (sensitivity 50%) compared with six of six cases on operative staging (sensitivity 100%). Spiral CT correctly identified 12 of 17 cases of peritoneal metastases (sensitivity 71%) and four of seven cases of hepatic metastases (sensitivity 57%). CONCLUSION: Whilst spiral CT remains poor at identifying lymph node metastases, it correctly identified most cases with invasion of either the colon or the mesocolon and half the cases of pancreatic invasion. It was of value in detecting peritoneal metastases and some cases with hepatic metastases. At present, at Leeds General Infirmary spiral CT is performed routinely on all patients with gastric cancer and a selective staging laparoscopy policy is adopted in those patients in whom the status of the peritoneal cavity and liver is in doubt.     

Role of endorectal ultrasonography and CT in preoperative staging of rectal cancer. Personal experience]

We report our personal experience on endorectal US and CT in the preoperative staging of rectal carcinoma. Our series includes 64 cases (38 male and 26 female) evaluated with intrarectal sonography; 38 of these patients underwent also CT-study of the lower abdomen. Using both imaging techniques infiltration of the rectal wall and adjacent structures and lymph node involvement were studied. The results of our study refer to 58 patients who underwent endorectal US, 31 of whom studied also with CT. Referring to the T-parameter with ultrasound 41 correct diagnosis were obtained, in 13 cases the lesion was over-staged and in 4 cases understaged. The sensitivity, specificity and diagnostic accuracy was respectively 89.5%, 60% and 79.3%. With CT 23 diagnosis were correct, in 1 case the lesion was overstaged and in 7 cases understaged; sensitivity, specificity and diagnostic accuracy concerning rectal wall infiltration were respectively 72%, 83.3% and 74.2%. The evaluation of the N-parameter demonstrated low value of sensitivity with both US (15.8%) and CT (42.9%). Considering the results of our series, we feel that it is necessary to use both imaging techniques because results obtained are complementary referring to the T-parameter, although N-parameter were a little significant.     

Pancreatic tumors: comparison of dual-phase helical CT and endoscopic sonography

OBJECTIVE: The purpose of this study was to compare dual-phase helical CT and endosonography for the diagnosis and staging of pancreatic tumors. SUBJECTS AND METHODS: Thirty patients with suspected pancreatic tumors underwent endosonography and dual-phase helical CT. A pathologic diagnosis was obtained in all cases with surgery (n = 23) or biopsy (n = 7), resulting in 27 neoplasms. Dual-phase helical CT and endosonographic findings were correlated with surgical and pathologic findings to determine diagnosis and resectability of pancreatic tumors. RESULTS: Overall diagnostic sensitivity was 92% for dual-phase helical CT and 100% for endosonography (p = .45). Overall accuracy for staging of pancreatic tumors was 93% for both dual-phase helical CT and endosonography. Overall accuracy for predicting resectability was 90% for both dual-phase helical CT and endosonography. Accuracy of predicting unresectability was 100% for dual-phase helical CT and 86% for endosonography (p > .80). Differences were not considered statistically significant. CONCLUSION: Dual-phase helical CT and endoscopic sonography do not differ significantly for diagnosis and assessment of resectability of pancreatic tumors.     

Local staging of pancreatic cancer: criteria for unresectability of major vessels as revealed by pancreatic-phase, thin-section helical CT

OBJECTIVE: This study was conducted to determine the criteria for unresectability of major peripancreatic vessels in patients with pancreatic carcinoma as revealed by optimally enhanced, pancreatic-phase thin-section helical CT. SUBJECTS AND METHODS: Twenty-five patients with pancreatic adenocarcinoma who underwent local dissection during curative or palliative surgery also underwent preoperative pancreatic-phase thin-section helical CT (40- to 70-sec delay, 2.5- to 3-mm collimation). Tumor involvement of the portal and superior mesenteric veins and the celiac, hepatic, and superior mesenteric arteries was prospectively graded on a 0-4 scale based on circumferential contiguity of tumor to vessel. Subsequent surgical results were then correlated with the CT grades. RESULTS: At surgery, definitive evaluation was possible for 80 vessels. Forty-eight of 48 vessels graded 0 and three of three vessels graded 1 were resectable. Four of seven vessels graded 2, seven of eight vessels graded 3, and 14 of 14 vessels graded 4 were unresectable. A threshold of between grades 2 and 3, which corresponded to tumor involvement of one-half circumference of the vessel, yielded the lowest number of false-negatives and an acceptable number of false-positives for unresectability. Such a threshold would have yielded a sensitivity of 84%, a specificity of 98%, a positive predictive value of 95%, and a negative predictive value of 93% for unresectability of the vessels studied. CONCLUSION: A grading system for tumor involvement of the major vessels in patients with pancreatic adenocarcinoma can be based on the degree of circumferential contiguity of tumor to vessel. Involvement of vessel to tumor that exceeds one-half circumference of the vessel is highly specific for unresectable tumor.     

Preoperative assessment of blood vessel involvement in patients with pancreatic cancer

The major prerequisite for resection of a pancreatic tumor is non-involvement of large blood vessels. Preoperative assessment of blood vessel infiltration may prevent unnecessary surgery. The aim of our study was to investigate the accuracy of endoscopic ultrasonography (EUS) in diagnosis of pancreatic cancer and in preoperative staging. Thirteen patients (7 females, 6 males; mean age 64 years) with a pancreatic tumor, but no evidence of distant metastases, underwent EUS and computerized tomography (CT) in order to assess blood vessel involvement by the tumor. The results were compared with intraoperative findings in 12 patients and with postmortem findings in 1 patient. A tumor was demonstrated by EUS in 12 patients and was confirmed at surgery in all 12 patients. In one patient no tumor was demonstrated by EUS, although a tumor was visible by CT; no tumor was found at surgery. In two patients CT failed to demonstrate a pancreatic tumor that was demonstrated by EUS; at surgery a tumor was detected in both patients. EUS detected blood vessel involvement in seven patients, which was confirmed at surgery in six of them. In the other six patients surgery confirmed the EUS finding of no blood vessel involvement. CT detected blood vessel involvement in two patients only. The overall accuracy of EUS and CT for detecting the tumor was 100% and 77% respectively, and for blood vessel involvement 92% and 61% respectively. In conclusion, EUS is an accurate procedure for preoperative assessment of blood vessel involvement in patients with pancreatic cancer. This procedure may enable the selection of those patients who may benefit from surgery, and should be part of the evaluation of patients with pancreatic cancer who are candidates for curative surgery.     

Use of a life events calendar approach to elicit occupational history from farmers

BACKGROUND: The usefulness of and problems associated with an ultrasound catheter probe in the pretreatment staging of endoscopically early gastric cancer remain unexplored. METHODS: Endoscopic ultrasonography using a 15 MHz catheter probe of 2.6 mm diameter was performed in a prospective study to determine the pretherapy staging of endoscopically early gastric cancer in 78 patients. The results of the ultrasound images were compared with the histologic findings of the specimens obtained by endoscopic mucosal resection or surgical resection. RESULTS: The accuracy of the catheter probe for depth of invasion of endoscopically early gastric cancers was 67% (52 of 78 patients). The accuracy in determining depth of invasion in relation to endoscopic type was significantly higher for the elevated type (91%) than for the depressed type of early cancer (56%) (p < 0.01). The staging accuracy classified by histologic type was significantly higher for differentiated (86%) than for undifferentiated (18%) cancer (p < 0.01). Staging accuracy decreased as tumor size increased. The accuracy, sensitivity, and specificity for nodal staging were 80%, 17%, and 90%, respectively. CONCLUSIONS: A 15 MHz ultrasound catheter probe is most useful for determining depth of invasion when the tumor is histologically differentiated and endoscopically of the small elevated type early gastric cancer, but it is unreliable in the diagnosis of metastatic lymph nodes.     

Preoperative parathyroid gland localization with technetium-99m sestamibi in secondary hyperparathyroidism

Technetium-99m sestamibi scintigraphy has become a valuable tool in locating parathyroid glands in patients with primary hyperparathyroidism. The aim of this study was to evaluate its usefulness in secondary hyperparathyroidism. Twenty patients were injected intravenously with 740 MBq of 99mTc-sestamibi and images were obtained at 15 min and 2 h post injection. All patients underwent parathyroid ultrasonography (US) as well as bilateral surgical neck exploration and 64 parathyroid glands were removed. US revealed at least one enlarged gland in 15/20 patients (75%), while 99mTc-sestamibi scintigraphy showed focal areas of increased uptake in at least one gland in 17/20 patients (85%). When imaging results for all glands were evaluated according to surgical results, sensitivity was 54% for parathyroid scintigraphy and 41% for US, and specificity was 89% for both imaging techniques. There was a discrepancy between the two imaging modalities in 28 glands (35%). The mean surgical weight of US-positive glands (1492+/-1436 mg) was significantly higher than that of US-negative glands (775+/-703 mg) (P<0.05). However, there were no significant differences in weight between sestamibi-positive and sestamibi-negative glands. When only sestamibi-positive glands were considered, a positive correlation between uptake and weight was found (r=0.4, P<0.05). In conclusion, parathyroid US and 99mTc-sestamibi scintigraphy are complementary imaging techniques in the preoperative localization of abnormal parathyroid glands in patients with secondary hyperparathyroidism. The limited sensitivity of the techniques means that patients will still require bilateral neck exploration; therefore routine preoperative parathyroid scanning in renal patients is not justified.     

Significance of CT in the detection of regional lymph node metastases in colorectal carcinoma

PURPOSE: For preoperative staging of colorectal cancer a CT scan is frequently performed. This report examines the sensitivity of CT for regional lymph node metastasis of colorectal cancer using different criteria. MATERIALS AND METHODS: Preoperative CT scans of 153 patients with colorectal cancer were analyzed using different criteria for N1. The results were then compared to the postoperative histological findings. RESULTS: For N1 = lymph nodes (LN) > 1 cm the sensitivity was 47%. For N1 = LN > 1 cm or an increased number of LN < 1 cm the sensitivity was 71%. In patients with a primary tumor seen on CT, sensitivity rose to 87%. DISCUSSION: Evidence of regional nodal metastatic disease is only relevant for rectal cancer, colon polyps, and for locally excised tumors when considering present surgical concepts for the treatment of colorectal cancer. In these cases CT analysis using the broadened criteria for N1 proposes a valuable argument regarding possible preoperative radiotherapy or an operative revision.     

The use of EUS to diagnose malignant portal venous system invasion by pancreatic cancer

BACKGROUND: CT scanning and mesenteric angiography are insensitive tests diagnosing vascular invasion by pancreatic cancer. Endoscopic ultrasound (EUS) has been proposed as an alternative. The sensitivity, specificity, and accuracy of specific EUS criteria for diagnosing malignant invasion of the branches of the portal venous system have not been determined. METHODS: This is a prospective blinded evaluation of EUS and angiography to diagnose malignant invasion of the portal venous system by pancreatic cancer in 45 patients, 28 of whom underwent surgery. Surgical staging was used as the gold standard for determining the accuracy of EUS and angiography. RESULTS: Four EUS criteria were studied and the overall accuracy rates were as follows: irregular venous wall (87%), loss of interface (78%), proximity of mass (73%), and size (39%). Although "irregular venous wall" was the most accurate, it suffered from a low sensitivity rate (47%) because of its relative inability to detect superior mesenteric vein invasion (sensitivity of 17%). The angiographic criteria had accuracy rates of 73% to 90% with low sensitivity rates (20% to 77%). The clean resection rate was 86% when all tests were used, 78% if EUS was used without angiography, and 60% if only angiography was used. CONCLUSION: EUS is highly sensitive for detecting portal and splenic vein invasion by pancreatic cancer, but may be insensitive for superior mesenteric vein involvement.     

Adenocarcinoma of the pancreas: detection of occult metastases in regional lymph nodes by a polymerase chain reaction-based assay

BACKGROUND: Stage I (T1-2NOM0) adenocarcinoma of the pancreas is associated with a 5-year survival rate of 15-25%. Despite apparently curative resection and pathologic staging indicating localized disease, these cancers recur. The authors hypothesized that there exists microscopic regional disease that is not detected by surgical exploration or routine histopathology. METHODS: Because 90-95% of pancreatic cancers exhibit codon 12 K-ras mutations, the authors examined regional lymph nodes for mutated K-ras as a marker of metastasis. DNA was extracted from paraffin embedded archival specimens (primary tumors and histologically negative lymph nodes) of patients with Stage I pancreatic adenocarcinoma. The target region of K-ras was amplified by polymerase chain reaction (PCR) and tested for codon 12 mutation by BstN1 restriction digestion (restriction fragment length polymorphism [RFLP]) that recognized normal but not mutated sequences. Cell lines that harbored normal or mutated K-ras and resected jejunum or gallbladder were used as controls. The regional lymph nodes of 22 patients whose tumors harbored mutated K-ras were tested. RESULTS: Dilution experiments with normal and mutant control cell line DNA demonstrated an assay sensitivity for mutated K-ras of 0.1%. Mutated K-ras was found in at least 1 regional lymph node in 16 (73%) of 22 patients with pathologic Stage I pancreatic adenocarcinoma, which suggested metastases not detected by routine histopathology. DNA sequence analysis was performed in four patients and confirmed identical point mutations in the primary tumor and accompanying PCR/RFLP positive lymph nodes. CONCLUSIONS: Pathologic examination of regional lymph nodes in pancreatic adenocarcinoma specimens fails to detect metastases in many patients. Lymph node micrometastasis is one reason for the poor survival rates observed among patients with Stage I cancers. PCR/RFLP may have a role in staging early pancreatic cancers.     

A pilot study of preoperative chemoradiation for patients with localized adenocarcinoma of the pancreas

BACKGROUND: We hypothesized that delivering adjuvant radiotherapy (RT) preoperatively with chemotherapy might enhance local control of the cancer and patient tolerance for the intervention. METHODS: Thirty-four patients with localized pancreatic cancer (24 head, 8 head and body, 2 body and tail) were treated during the past 6 years with an intramural protocol consisting of 5-fluorouracil (1,000 mg/m2 on days 2 to 5 and 29 to 32) and mitomycin-C (10 mg/m2 on day 2) given with preoperative external beam RT (median 5,040 cGy). Nine patients did not have surgery: 1 refused, 1 died of cholangitis, and 7 were noted to have distant (5) or unresectable local cancer (2) after RT. Of the 25 patients who underwent celiotomy, 11 had liver (8) or peritoneal (3) metastases and 3 had palliative pancreatectomies (2 with liver metastasectomy and 1 with hepatic artery and portal vein replacement). The remaining 11 patients (44% of the cohort with surgery, 32% of all patients) had potentially curative (PC) resections (5 total pancreatectomy, 5 Whipple, 1 distal pancreatectomy). Median tumor diameter by computed tomographic scan was 3.75 cm (range 3 to 5) for the 11 patients who received PC resections and 4.5 cm (range 3 to 7.5) for all patients. Of the 11 patients with PC resections, 8 had evidence of superior mesenteric, portal or splenic venous involvement and 4 had been deemed unresectable at previous celiotomies. RESULTS: One patient developed respiratory failure and one died postoperatively, yielding a 9% rate of major morbidity and mortality. Median follow-up of the surviving patients with curative resection is 33 months (range 14 to 70). Their median survival from the time of tissue diagnosis is 45 months with a median disease-free survival of 27 months. The product limit estimate of 5-year survival is 40% (95% confidence bounds +29%, -30%). One patient had a microscopically positive resection margin, which was a falsely negative frozen section margin at the pancreatic neck. Two patients had positive regional lymph nodes. Five patients have been diagnosed with recurrent cancer. Only 1 has had a local/regional component to the recurrence. CONCLUSIONS: Preoperative RT and chemotherapy followed by resection is well tolerated and safe for patients with locally advanced pancreatic cancer. This approach provides tumor free resection margins and offers prolonged survival to patients with truly localized pancreatic cancer.     

Median sternotomy: the preferred incision for resection of lung metastases

OBJECTIVE: To describe our experience with median sternotomy for resection of lung metastases and to assess whether computer tomography (CT) accurately predicts the number and extent of lung metastases. DESIGN: Retrospective case record study. SETTING: University hospital/Cancer Centre, The Netherlands. SUBJECTS: 78 patients with pulmonary metastases from various histological types of tumours who were operated on through a median sternotomy during the 10-year period January 1985-January 1995. INTERVENTION: Median sternotomy for resection of lung metastases with the intention to cure. Extension of the incision in case of extended disease. MAIN OUTCOME MEASURES: Presence of unilateral or bilateral metastases in relation to preoperative CT. RESULTS: 78 patients underwent a total of 82 sternotomies. CT did not accurately diagnose the extent of disease in 38 patients (49%). In 72 cases metastases were excised. In 58 patients (81%) histological examination showed tumour-free margins microscopically. 36 patients had bilateral metastases. CT showed unilateral disease in 49 patients. 14 (29%) had bilateral involvement. 4 patients required lobectomy and in two patients anterolateral extension of the sternotomy was necessary. Eleven patients (15%) developed minor complications. There was no operative mortality. CONCLUSION: Bilateral staging and finding of occult metastases, complete surgical clearance in a one stage procedure, and lower morbidity are the reasons that we suggest that median sternotomy is the procedure of choice of resection of pulmonary metastases. For eligible patients the choice of surgical approach should not be made conditional on the results of CT alone.     

Primary epiploic appendagitis: US and CT findings

A retrospective review is presented of seven cases of epiploic appendagitis, with surgical confirmation in one case. The main clinico-analytical data and the US and CT findings are described, as well as the histopathologic features in the sole case that underwent surgical resection. We also calculated the frequency of this entity in patients undergoing emergency abdominal US on clinical suspicion of diverticulitis. In all seven cases the clinico-analytical evidence was nonspecific (localized acute abdominal pain and slight leukocytosis), mimicking in six cases the clinical presentation of sigmoid diverticulitis and in one case that of acute appendicitis. US imaging findings were characteristic: a hyperechoic mass localized under the point of maximum pain, adjacent to the anterior peritoneal wall and fixed during deep breathing. In none of the cases did color Doppler US show flow. CT findings were also typical and showed a mass with a peripheral hyperattenuated rim surrounding an area of fatty attenuation. Overall 7.1 % of patients investigated to exclude sigmoid diverticulitis finally showed findings of primary epiploic appendagitis. Primary epiploic appendagitis thus shows characteristic US and CT findings that allow its diagnosis and follow-up. This entity is much more frequent than previously reported, especially in patients referred for US to exclude sigmoid diverticulitis.     

Projections of the ventral tegmental area of the midbrain, the substantia nigra, and the amygdaloid body in different parts of the putamen in the dog

INTRODUCTION: We investigated the accuracy of endorectal coil Magnetic Resonance Imaging (MRI) and Fast Spin Echo (FSE) technique in staging prostate cancer. MATERIAL AND METHODS: MRI was performed in 70 patients with biopsy proved prostatic cancer. A total of 33 patients subsequently underwent radical prostatectomy. T2-weighted FSE sequences (TR 3400-4100, TE 120, Echo train length 13) were acquired in all patients. Axial, sagittal and coronal 4-5 mm images were obtained with 13-14 cm field of view and 256 x 256 matrix. Additional T1-weighted spin echo images were acquired in 9 patients. Lesion staging on MR images was performed according to the American Urological System. MR data were compared with the pathologic findings of whole-mount sections of the surgical specimens. RESULTS: Overall accuracy for endorectal coil MR imaging was 60%; ten cases were underestimated and 3 cases were overestimated. The sensitivity and the specificity of endorectal coil MRI in diagnosing capsular penetration were 77% and 81%, respectively. Seminal vesicle invasion was detected with 87% sensitivity and 96% specificity. CONCLUSIONS: Endorectal coil MRI provides a more accurate preoperative local staging.     

Mediastinal lymph node metastasis from lung cancer: evaluation with Tl-201 SPECT--comparison with CT

PURPOSE: To assess the usefulness of thallium-201 single photon emission computed tomography (SPECT) in detection of mediastinal lymph node metastasis from lung cancer. MATERIALS AND METHODS: Computed tomography (CT) and Tl-201 SPECT were performed in 113 patients with lung cancer. Surgical staging was performed in all patients, and the results of the two modalities were compared with the pathologic findings in 364 node stations. RESULTS: Cancerous nodes were found in 32.7% of the patients. The sensitivity of CT in detecting mediastinal node metastasis was 62%; specificity was 80%. These rates were higher for Tl-201 SPECT (76% and 92%, respectively). Furthermore, these rates were excellent in patients with enlarged mediastinal nodes at CT (87% and 93%, respectively). However, Tl-201 SPECT had more limited spatial resolution than did CT. CONCLUSION: Tl-201 SPECT is useful in evaluation of mediastinal node metastasis in lung cancer, especially for patients with enlarged nodes at CT.