Cloning of the novel gene intelectin, which is expressed in intestinal paneth cells in mice

OBJECTIVE: The purpose of our study was to assess the accuracy of CT-guided biopsy of musculoskeletal neoplasms with respect to technique, anatomic site, and histology. MATERIALS AND METHODS: During a 3-year period (January 1992 to December 1994), 176 core needle biopsies and 45 fine-needle aspirations were performed under CT guidance on patients with musculoskeletal neoplasms. To assess the accuracy of these procedures, we compared the diagnosis at biopsy with the final diagnosis as determined at the time of definitive treatment of the lesion. All biopsy findings were categorized as a primary malignancy (excluding round cell lesions), round cell lesion, local recurrence, or metastatic carcinoma. In addition, each lesion was analyzed according to which biopsy technique was used, whether frozen tissue section or rapid cytologic evaluation was used, and at which anatomic site the mass was found. RESULTS: The accuracy for needle biopsy was 93% and that for fine-needle aspiration was 80%. The complication rate for both techniques was less than 1%. Accuracy rates for the four categories of primary malignancy, round cell lesion, local recurrence, and metastatic carcinoma were 87%, 75%, 94%, and 100%, respectively. The mismatch rates were similar in soft-tissue lesions (5/52) and bone lesions (16/169). Diminished accuracy was associated with round cell lesions (20%) and lesions located in the spine or the perivertebral region (20%). Nondiagnostic and insufficient specimens were found in 18 (8%) of the 221 patients. CONCLUSION. CT-guided biopsy of musculoskeletal malignancies is a safe and effective procedure if performed by a team of clinicians, pathologists, and radiologists who possess subspecialty expertise.     

Detection of metastatic bone lesions in patients with prostate carcinoma: 99Tcm-monoclonal antibody imaging

Bone scintigraphy has been shown to be sensitive in determining bone involvement in patients with malignancy, but it does not allow the assessment of bone marrow lesions in early disease. The aim of this study was to detect bone marrow invasion using 99Tcm-labelled monoclonal antigranulocyte antibody (AgMoAb) in patients with prostate carcinoma. We studied 56 patients whose mean (+/- S.D.) age was 67 +/- 7 years. The mean prostate-specific antigen level was 6.1 ng ml-1 (normal range 0-5 ng ml-1). Twelve patients were in stage A, 16 in stage B, 17 in stage C and 11 in stage D. Six patients had been receiving chemotherapy and four patients radiotherapy before scanning. Bone scans were obtained 2 h after the intravenous injection of 555 MBq 99Tcm-methylene diphosphonate (99Tcm-MDP). Within a week, bone marrow imaging was performed 4 and 24 h after the injection of 555 MBq 99Tcm-AgMoAb. Metastatic bone lesions were detected on the 99Tcm-MDP scans of 14/56 (25%) patients, of whom one was in stage A, two in stage B, four in stage C and seven in stage D. Hypoactive lesions in bone marrow were detected in 25/56 (45%) patients, of whom two were in stage A, five in stage B, seven in stage C and 11 in stage D. Bone marrow metastases were confirmed in six patients by computed tomography (CT) and magnetic resonance imaging (MRI) and in two patients by marrow aspiration biopsy. A false-positive immune scintigram was found in three patients previously receiving radiotherapy or chemotherapy. We suggest that 99Tcm-AgMoAb scintigraphy is a sensitive procedure for the detection of bone marrow lesions. However, the reason for false-positive and false-negative results should be considered and CT, MRI and marrow biopsy should be performed when clinically necessary.     

Complications of CT-guided biopsy of the spine and sacrum

This study reviews the results of 94 computed tomography (CT)-guided Craig needle biopsies of the spine and sacrum performed at one center. An indication for biopsy in this study was prompted by abnormal findings identified by one or more of the following diagnostic modalities: radiography, CT, magnetic resonance imaging (MRI), or bone scanning. These patients then underwent CT-guided Craig needle biopsy of the spine and sacrum for further evaluation. There were 1 biopsy of the cervical spine, 19 of the thoracic spine, 66 of the lumbar spine, and 8 of the sacrum. Biopsy sensitivity was 94.5% and specificity was 96.8%. This accuracy compared with other diagnostic modalities showed biopsy to be the gold standard for diagnosis of spine or sacral lesions. Of the 94 cases reviewed, 6 complications were noted. All complications were acute in nature and included 1 aortic puncture, 2 psoas punctures with associated psoas hematomas, 1 biopsy of an incorrect level, and 2 aborted procedures secondary to patient discomfort. No infections or neurological sequelae were seen. Although the benefits of CT-guided biopsy over open biopsy have been shown previously, this review demonstrates it is not without significant risk.     

Transthoracic needle biopsy of mediastinal lymph nodes for staging lung and other cancers

PURPOSE: To determine the usefulness of transthoracic needle biopsy of mediastinal lymphadenopathy for staging suspected lung and other cancers. MATERIALS AND METHODS: Transthoracic needle biopsy of the hilum or mediastinum was performed in 111 patients with suspected neoplasms. Most biopsy procedures were performed with computed tomographic guidance on an outpatient basis. Forty-eight adult patients had enlarged lymph nodes (defined as < or = 30 mm in the long axis and > or = 10 mm in the short axis). Sixty-three lesions larger than 30 mm were arbitrarily considered to be masses and were excluded. RESULTS: Carcinoma was diagnosed in 40 patients. Four patients had true-negative and one patient had false-negative results. Sensitivity for carcinoma was therefore 98% (40 of 41). One patient with a negative biopsy result did not have surgical confirmation and was excluded from analysis. Lymphoma was excluded from analysis. Lymphoma was diagnosed in two patients (positive in one and suspicious in one). Pneumothorax occurred in 19 (34%) of 56 biopsy procedures. Chest tube treatment was required in eight (14%). CONCLUSION: Transthoracic needle biopsy of mediastinal lymphadenopathy is a safe, accurate diagnostic staging procedure. It can frequently be used as an alternative to mediastinoscopy in patients with lymphadenopathy.     

Metabolic imaging of malignant pleural mesothelioma with fluorodeoxyglucose positron emission tomography

BACKGROUND: The diagnosis of malignant mesothelioma is a challenging medical problem. CT often cannot differentiate between benign diffuse pleural thickening and malignant mesothelioma, while thoracentesis and CT-guided biopsies are insensitive. We have assessed the value of positron emission tomography (PET) with 2-fluoro-2-deoxy-D-glucose (FDG) in the evaluation of malignant mesothelioma. METHODS: Twenty-eight consecutive patients referred for the evaluation of suspected malignant mesothelioma were evaluated by FDG-PET imaging. Measured attenuation correction was performed in 26 of 28 cases for quantitation with the standardized uptake value (SUV) method. The results of PET imaging were compared with those of video-assisted thoracoscopy or surgical biopsies. RESULTS: Surgical biopsy specimens confirmed the presence of malignant disease in 24 patients and demonstrated benign processes in the remaining four. The uptake of FDG was significantly higher in malignant than in benign lesions (SUV=4.9+/-2.9 and SUV=1.4+/-0.6, respectively; p<0.0001). With a SUV cutoff of 2.0 to differentiate between malignant and benign disease, a sensitivity of 91% and a specificity of 100% could be achieved, although the activity in some epithelial mesotheliomas tended to be close to this threshold. FDG-PET images provided excellent delineation of the active tumor sites. Hypermetabolic lymph node involvement was noted on FDG-PET images in 12 patients, 9 of which appeared normal on CT scans. Histologic examination in six patients confirmed malignant nodal disease in five cases and indicated granulomatous lymphadenitis in one. CONCLUSION: In this highly selected population, FDG-PET imaging was a sensitive method to identify malignant mesothelioma and determine the extent of the disease process.     

Additional information from percutaneous cutting needle biopsy following fine-needle aspiration in the diagnosis of chest lesions

OBJECTIVE: To determine the contribution of percutaneous cutting needle biopsy (PNB) subsequent to fine-needle aspiration (FNA) in the diagnosis of chest lesions. DESIGN: A retrospective review of 220 patients who underwent CT-guided FNA followed immediately by PNB performed at our center between 1988 and 1995 was undertaken. Thirty-eight patients were excluded because FNA and/or PNB specimens were nondiagnostic, yielding a study group of 182 patients. RESULTS: A diagnosis of malignancy was made in 141 (77.5%) and nonmalignancy in 41 (22.5%) cases. The yield of histospecific diagnosis due to FNA was marginally higher than PNB in malignant lesions (86.5% vs 78%, respectively). In contrast, PNB was superior to FNA for the histospecific diagnosis of benign lesions (87.8% for PNB vs 31.7% for FNA, p<0.00001) and lymphomas (88% for PNB vs 56% for FNA, p<0.05). In 58.8% of the patients with benign lesions and in 37.5% of the patients with lymphoma, PNB performances altered clinical management, either by avoiding further surgery or allowing specific medical treatment. Pneumothorax occurred in 24.7% of the cases but only five patients (2.7%) required hospitalization. CONCLUSION: PNB is extremely effective for making a specific diagnosis in benign lesions compared with FNA. PNB does not increase the yield of histospecific diagnosis for malignant lesions except for the subset of lymphoma, where it seems to provide important additional information in many instances. We recommend that FNA be performed as the initial procedure, followed by PNB in cases of equivocal diagnosis of carcinoma, for lymphoma and for suspected benign lesions.     

Stereotactic and ultrasound core needle breast biopsy performed by surgeons

BACKGROUND: The authors evaluated outcomes and treatment costs of stereotactic core needle biopsy (SCNB) and ultrasound core needle biopsy (UCNB), and needle localization biopsy (NLB) in managing patients with mammographic abnormalities presenting to the surgeon. METHODS: Data for all patients with mammographic lesions who underwent SCNB or UCNB since their introduction at this institution were prospectively collected over 17 months. Mean inclusive costs of the three procedures were accumulated and compared. RESULTS: Stereotactic core needle biopsy was performed for 342 lesions in 319 women, for a malignancy rate of 19%; UCNB was performed for 157 lesions in 144 patients, yielding a malignancy rate of 17%. With a mean follow-up of 13.5 months, 1 patient with in situ carcinoma was diagnosed late. Absolute cost savings for the period studied was $721,963. CONCLUSIONS: Minimally invasive breast biopsy procedures can safely and reliably be performed by surgeons in clinical practice with increased patient convenience and decreased costs.     

Sleep disturbance in spinocerebellar ataxias: is the SCA3 mutation a cause of restless legs syndrome?

OBJECTIVE: We sought to determine possible technical causes of inconclusive results on CT-guided core biopsies of lesions suggestive of malignancy and to determine the frequency with which such lesions are eventually found to be malignant. MATERIALS AND METHODS: We retrospectively reviewed 116 consecutive CT-guided thoracic and abdominal core biopsies performed with a 20-gauge automatic biopsy system. Biopsy results were conclusive (n = 94) if pathology confirmed malignancy and inconclusive (n = 22) if pathology results were negative for malignancy or were nondiagnostic. Lesion volume, location, number of cores, and biopsy technique (paraxial or coaxial) were compared for the conclusive and inconclusive biopsy results. Malignancy within the group of inconclusive biopsy results was determined from a second biopsy, radiographic follow-up, or surgery. RESULTS: Regression analysis identified only the biopsy method as a significant factor affecting biopsy outcome: The paraxial method was more likely to yield a conclusive result than the coaxial method (p < .002). For the two biopsy methods, lesions had similar volumes, locations, and numbers of cores obtained. For single core biopsies, both methods were equivalent. However, if two or more cores were obtained, a conclusive result was achieved in more than 90% of biopsies with the paraxial method versus 65% for the coaxial method. On follow-up, results of 14 (64%) of 22 inconclusive biopsies were malignant, indicating an overall false-negative rate of 12%. CONCLUSION: CT-guided core biopsy performed with 20-gauge automatic biopsy systems and the paraxial method will yield conclusive results significantly more often than the coaxial method. In the event of inconclusive results, malignancy will exist often enough to warrant follow-up.     

Ultrasound-guided fine-needle aspiration biopsy of focal liver lesions

The ultrasound guided percutaneous fine needle biopsy (US-FNAB) of focal lesions in the liver is indispensable in many clinical situations. During the last 12 years, 657 US-FNAB were performed on patients with suspected neoplastic involvement of the liver with 22-gauge Chiba needles at our department. US-FNAB was performed mostly with the "free hand" technique. Sufficient material for cytologic analysis was obtained in 84% of the cases. The biopsies confirmed malignancy in 39.3%, including 9% primary hepatocellular carcinoma, 8% of the cases were suspect for malignancy, and in 36.7% were diagnosed benign lesion. 233 cases were confirmed histologically and with other follow up methods. The sensitivity rate was 91%, and specificity was 100%. There was no false positive diagnosis and no noteworthy complications were observed. US-FNAB is a highly reliable, safe, inexpensive and easy diagnostic procedure. On the basis of our experience, we recommend US-FNAB as a routine, first level procedure for the diagnosis of focal liver diseases.     

Lung cancer and mesothelioma in the pleura and peritoneum among Swedish insulation workers

RATIONALE AND OBJECTIVES: The purpose of this study was to determine whether laser-guided computed tomographic (CT) biopsy is more accurate than CT-guided biopsy with conventional freehand techniques. MATERIALS AND METHODS: Two independent operators performed an equal number of freehand and laser-guided needle passes at varying single and double angles (0 degree, 30 degrees, 60 degrees, 25 degrees/30 degrees, and 25 degrees/60 degrees) on targets within six pork and beef phantoms. A total of 180 biopsy passes were performed, and error distances of needle tip to target were tabulated. Data were analyzed by means of repeated measures analysis of variance (ANOVA) to compare the accuracy of laser guidance with freehand passes. ANOVA and correlation analysis were also used to confirm the relative equivalency of phantom targets and biopsy parameters. RESULTS: Overall, laser-guided passes were statistically significantly more accurate than freehand passes. Mean error with laser guidance was 5.01 mm (standard error [SE] = 0.41 mm), whereas mean error with freehand techniques was 10.58 mm (SE = 0.82 mm) (F = 52.0, df = 1.17, P = .0001). Ninety-three percent of laser-guided passes and 56% of freehand passes were within 1 cm of the intended target. Error increased for both laser-guided and freehand techniques with larger angles or double-angle biopsies, but the increases were greater with freehand technique. No statistically significant differences existed between the targets themselves or biopsy parameters for the two operators. CONCLUSION: Laser-guided CT biopsies were more accurate than freehand CT biopsies. Practical advantages of laser guidance over freehand CT biopsy methods may include decreased procedure times and reduced patient morbidity.     

Improved retroperitoneal and gastrointestinal sonography using oral contrast agents in a porcine model

PURPOSE: To evaluate use of functional imaging with positron emission tomography (PET) versus computed tomography (CT) for detection of extranodal lymphoma spread. MATERIALS AND METHODS: Eighty-one consecutive and previously untreated patients with malignant non-Hodgkin lymphoma (n = 43) or Hodgkin disease (n = 38) were examined with 2-[fluorine-18]fluoro-2-deoxy-D-glucose (FDG) PET and contrast material-enhanced CT. Concordant findings at both CT and FDG PET were regarded as actual locations of disease; discordant results were resolved on the basis of biopsy or follow-up results when possible. RESULTS: Forty-two lesions were identified at both PET and CT, and 19 were verified with biopsy results. PET demonstrated a further 24 lesions. Verification was possible in 15 of these lesions with biopsy (n = 10), magnetic resonance imaging (n = 1), scintigraphic (n = 1), or follow-up (n = 3) results. In 14 of these 15 lesions, PET findings were confirmed (bone marrow, nine; spleen, three; other, two). Seven lesions not visualized at FDG PET were identified at CT, six of which were verified with biopsy (n = 2) or follow-up (n = 4) results. Five of these six CT findings were found to be erroneous. In 13 patients, PET findings led to changes in tumor staging. CONCLUSION: PET may provide more information about extranodal lymphoma than does incremental CT.     

CT-assisted needle biopsy in pulmonary and mediastinal space-occupying lesions. The effect of spiral CT and various biopsy needles on results

The efficacy of percutaneous CT-guided needle biopsies was investigated in 68 patients with pulmonary lesions and in 65 patients with mediastinal masses. In comparison with conventional multisectional CT, the time needed for the localization of the needle tip could be reduced by use of spiral CT. Comparing aspiration and cutting biopsy needle we achieved a higher accuracy of 94% in case of mediastinal masses and of 90% by using cutting needles. The rate of complications, such as pneumothoraces, is relatively low.     

The value of immediate cytologic evaluation for needle aspiration lung biopsy

RATIONALE AND OBJECTIVES: The authors evaluate the role of immediate cytologic evaluation (ICE) with fine-needle aspiration biopsy (FNAB) for lung lesions at highest risk for pneumothorax. METHODS: A prospective randomized study was conducted of 80 patients with lung lesions surrounded by aerated parenchyma undergoing FNAB with and without ICE (47 and 33 patients, respectively). An analysis of needle passes, procedure time, complications, specimen adequacy, diagnostic yield, and accuracy of procedure was made. RESULTS: There was an increased number of needle passes with ICE (> or = three passes: 23% [11 biopsies] versus 3% [1 biopsy]; P = 0.01). Fluoroscopic procedures took longer with ICE (median time: 15 versus 9 minutes; P = 0.002) with no difference in complication rates. Specimen adequacy was similar (74% and 64%) and the procedure was diagnostic in 79% (37 biopsies) with ICE and in 70% (33 biopsies) without ICE. There were no significant differences in the sensitivity, specificity, or accuracy of the biopsy. CONCLUSIONS: Immediate cytologic evaluation improved results marginally with increased procedure time and needle passes. Immediate cytologic evaluation may be most useful for lesions at lowest risk of complications to assure that a second procedure is not required.     

Radiological features of focal nodular hyperplasia of the liver in children

BACKGROUND: Focal nodular hyperplasia (FNH) is an unusual hepatic tumour in children and should be distinguished from other hepatic lesions. OBJECTIVE: To describe the imaging characteristics of FNH in children. MATERIALS AND METHODS: We examined five patients (three boys and two girls, mean age 9.4 years) with pathologically confirmed FNH. The diagnosis was obtained by tumour resection (n = 4) and percutaneous needle biopsy (n = 1). One patient with multiple FNHs showed recurrent lesions after tumour resection. All patients were studied with US (including colour and power Doppler US [n = 3]) and CT. Dynamic enhanced CT scans were available in three patients. MRI (n = 2) or coeliac angiography (n = 1) was performed in three patients. RESULTS: Seven of eight FNH lesions in five patients were demonstrated by imaging. The average size of the lesions was 6.5 cm. Six lesions detected on US showed variable echogenicity with a central hyperechoic scar (n = 2). On Doppler examination, central or peripheral hypervascular areas were seen (n = 3). Six lesions detected on contrast-enhanced CT showed high attenuation (n = 4) or iso-attenuation (n = 2). On early phase scans, all the lesions (n = 3) showed high attenuation. Irregular linear or ovoid central scars were detected in two patients on CT. MR demonstrated three lesions in two patients, one of which had not been detected by US or CT. A central low signal intensity scar (n = 1) was seen on T2-weighted MRI. Coeliac angiography performed in one patient showed a hypervascular mass with homogeneous staining. CONCLUSION: FNH in children shows a wide spectrum of imaging findings on various radiological examinations and the typical central scar was not always seen on imaging studies. Dynamic enhanced CT obtained in the early phase and colour Doppler studies may be helpful in the diagnosis of FNH by allowing characterisation of tumour vascularity. FNH should be included in the differential diagnosis of liver mass in children.     

Core needle biopsy of synchronous ipsilateral breast lesions: impact on treatment

OBJECTIVE: The purpose of this study was to evaluate the role of core biopsy in the diagnosis of multiple synchronous ipsilateral breast lesions and to determine the impact of this information on patients' management. MATERIALS AND METHODS: Of 371 patients who underwent core-needle breast biopsy under stereotaxic (n = 278) or sonographic (n = 93) guidance, 20 (5%) underwent core biopsy of two mammographically separate lesions in the ipsilateral breast on the same date. Fourteen of these 20 patients subsequently underwent surgery. We retrospectively reviewed the medical, radiographic, and histopathologic records in these 14 patients and in 91 patients with single mammographic lesions diagnosed as carcinoma by means of core biopsy during the same period. RESULTS: In 11 patients, core biopsy revealed two sites of carcinoma. Core biopsy findings in these 11 patients were two areas of infiltrating ductal carcinoma (n = 5), one infiltrating ductal carcinoma and one infiltrating lobular carcinoma (n = 2), one infiltrating ductal carcinoma and one ductal carcinoma in situ (n = 1), and two foci of ductal carcinoma in situ (n = 3). All 11 patients with two core biopsy-proven foci of carcinoma underwent mastectomy. Patients were significantly more likely to be treated with mastectomy if core biopsy revealed two rather than one site of carcinoma (100% versus 38%, p < .001). CONCLUSION: Core-needle biopsy is useful in diagnosing multiple synchronous ipsilateral breast lesions. By showing whether carcinoma is present in one or more sites in the breast, core biopsy can provide information of critical importance in making treatment decisions.     

Interactive MR imaging-guided biopsy and aspiration with a modified clinical C-arm system

OBJECTIVE: This investigation was performed to test the hypotheses that interactive guidance of MR image acquisition during needle-directed procedures using a clinical 0.2-T C-arm open MR imaging system integrated with a frameless optically linked stereotaxy system is feasible, and that procedure times can be sufficiently short to be well tolerated by the patient. SUBJECTS AND METHODS: One hundred six MR-guided procedures were performed in 86 patients (ranging in age from 5 months to 88 years) using a clinical C-arm imaging system supplemented with an in-room RF-shielded liquid crystal display monitor, a frameless stereotaxy system, rapid gradient-echo sequences for needle guidance, and MR-compatible monitoring and surgical lighting equipment. We performed 50 biopsies and aspirations of the head and neck in 37 patients, 23 biopsies of musculoskeletal lesions in 22 patients, 16 biopsies of abdominal sites in 10 patients, six biopsies of the thoracolumbar spine or sacrum in six patients, and 11 shoulder joint injections for MR arthrography in 11 patients, in addition to 38 MR arthrographic injections on the same imaging system described in a previous report. Tissue sampling included fine-needle aspiration (n = 90) and cutting needle core biopsy (n = 41). Thirty-five patients underwent both procedures. Procedures were evaluated for success of needle placement, procedure time, and complications. RESULTS: Needle placement was successful in all cases, and no complications occurred. Tissue was sufficient for pathologic diagnosis for all but eight patients. Passes per patient averaged 2.1. For fine-needle aspiration, instrument time averaged 7 min 42 sec per pass, cutting needle core biopsy averaged 6 min 24 sec, and shoulder injection averaged 8 min. CONCLUSION: MR imaging guidance for needle procedures on a clinical 0.2-T C-arm system with supplemental interventional accessories is feasible, with relatively rapid needle placement.     

Thymic uptake of iodine-131 in the anterior mediastinum

Two thyroidectomized patients with a history of differentiated thyroid carcinoma are presented who had nonmetastatic mediastinal 131I uptake following therapeutic doses of 131I. Chest CT scans in both patients demonstrated an anterior mediastinal mass. Surgical excision in one patient and a percutaneous CT-guided fine needle aspiration biopsy in the other disclosed normal thymus tissue. Iodine-131 uptake in the anterior mediastinum in patients thyroidectomized for follicular or papillary thyroid carcinoma may represent the thymus.     

Clinical analysis of inflammatory masses of the pancreatic head region

BACKGROUND/AIMS: Inflammatory masses of the pancreatic head are a dilemma for surgeons, especially when the differences between these lesions and pancreatic head carcinoma are not so clear. The surgical management of these inflammatory benign lesions is also a topic with conflicting opinions. A clinical analysis was performed in an attempt to differentiate between these lesions and malignancy. The results of our observatory strategy of these lesions are also presented. METHODOLOGY: From 1992 to 1994, 73 patients with ultrasonographically (US) or computed tomographically (CT) heterogenous pancreatic head lesions were diagnosed at the Department of Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan. Forty-nine of these lesions were neoplastic (Group I), but the remaining 24 patients had inflammatory non-neoplastic lesions (pancreatic inflammatory masses, IPM, Group II), which were diagnosed during laparotomy by core needle biopsy. Surgery and outcome were reviewed. Ten of the 24 patients in group II received biopsy only, and the remaining 14 patients received bypass procedures. At follow-up of at least 16 months of the surviving patients (n=21), only 9.5% were with residual lesions. All cases in group II revealed shrinkage of masses. We focused on the clinical features, hematology, biochemistry, image study, serum CEA and CA 19-9, and compared these variances between the 2 groups. RESULTS: Three clinical features were statistically different between groups I and II: mean age at presentation of disease (group I vs II = 53.3 vs 65.1), the tendency of a past history of alcoholism (Group II), and presence of abdominal pain (Group II). Group II also showed a higher level of serum alkaline phosphatase and a lower level of total bilirubin as well as a lower level of CA19-9. These inflammatory masses could not be distinguished from the true neoplasms pre-operatively on endoscopic appearance, US, or CT. CONCLUSIONS: Pre-operative differentiation between these pancreatic lesions may be difficult but laparotomy and core needle biopsy remain safe and reliable procedures. Our short-term follow-up justified the bypass surgery and that observatory strategy is enough for those patients with pancreatic head inflammatory masses.     

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.     

The role of laparoscopy in the management of suspected pancreatic and periampullary malignancies

Laparoscopic evaluation of patients with suspected periampullary malignancies has been utilized more frequently in recent years. Its exact role with regard to staging and surgical bypass for palliation have yet to be clearly defined. To better define the role of laparoscopy in the evaluation and palliation of periampullary malignancy, a retrospective review of the Duke experience was carried out. Fifty-three patients with suspected pancreatic or periampullary malignancies were referred for surgical evaluation at Duke University Medical Center between 1993 and 1995. All patients underwent CT scanning and lesions were classified as resectable or unresectable based on previously established criteria. Patients either underwent laparoscopic evaluation (n = 30; 11 with laparoscopic palliation) or proceeded directly to celiotomy (n = 23). Charts were reviewed for postoperative course including complications, length of stay, and hospital costs. Although laparoscopy had a sensitivity of 93.3% for metastatic disease, CT scans accurately staged 86.8% of patients missing only one patient with peritoneal/hepatic disease. Based on these results, laparoscopy may not be beneficial for every patient with a suspected pancreatic malignancy. Retrospectively an attempt was made to determine which patients benefited from laparoscopy and which patients are best served by proceeding directly to open exploration. From these data we devised an algorithm that outlines an efficient and cost-effective approach for this patient population.