Imaging of abdominal manifestations of melanoma

Despite an increasing incidence of melanoma in this country, innovative new therapies are allowing patients to receive aggressive experimental treatments. Diagnostic imaging remains crucial for tumor staging and for follow-up of patients being treated with these protocols. Because metastases occur in the abdomen and pelvis in approximately 60% of patients, it is important to accurately identify all sites of tumor spread. A variety of imaging techniques are used to image these patients, with CT currently being used for staging purposes and to guide diagnostic biopsies. Other imaging techniques, such as MR, ultrasound, and fluoroscopy, are currently reserved for investigating specific complications of melanoma, such as vascular invasion, hemorrhage from a tumor, and small bowel involvement, including intussusception. Recently, whole body positron emission tomography (PET) imaging using 2-deoxy-2-fluoro-D-glucose (FDG) has been shown to be highly accurate in assessing patients with metastatic malignant melanoma. This review illustrates the spectrum of manifestations of metastatic melanoma throughout the abdomen and pelvis, including solid organ, hollow lumen, and retroperitoneal involvement, and demonstrates some of the typical and atypical manifestations that may be identified.     

Current indications and techniques in evaluating inflammatory disease and neoplasia of the sinonasal cavities

Imaging strategies of the sinonasal cavities have undergone extensive revision over the last 5-year period. The traditional imaging examination of the paranasal sinuses, plain film radiography, does reasonably well in diagnosing maxillary, frontal, and sphenoid sinusitis. However, it less reliable in depicting abnormalities in the ethmoid sinuses, the most common area first affected with inflammatory disease. Compared with sinus computed tomography (CT), plain films prove to be less specific and sensitive in depicting the extent of sinus abnormalities. One series plainly concluded that sinus radiographs were not reliable enough to be an integral part of the clinical decision process. The use of plain radiographs of the sinuses has clearly been reduced by medical cost-containment concerns, replacement by superior techniques, and by clear weaknesses of the modality. Although it is inexpensive and easily accessible, the low sensitivities and inaccuracies of plain film radiography have resulted in the current use of CT and high-field-strength (1.5 Tesla) magnetic resonance imaging (MRI). By using this cross-sectional imaging, we now visualize directly the pathologic conditions within the sinuses, as well as the normal anatomy. We discuss current use of diagnostic imaging in the evaluation of patients with nasosinusoidal complaints (most commonly resulting from acute and chronic inflammatory disease), with complications of sinonasal inflammatory disease, and with suspected/documented neoplasia. In addition to developing an imaging algorithm to provide the information affecting clinical decision making, we detail the specific imaging techniques necessary accurately to obtain that information. We also review the specific concerns about imaging patients in the intensive care unit and touch on several emerging imaging techniques. The imaging workup in pediatric patients and patients with congenital anomalies is beyond the scope of this review.     

Police and mental health professionals. Collaborative responses to the impact of violence on children and families

Most pediatric patients with hydrocephalus are treated with ventriculoperitoneal (VP) shunt placement. However, shunt malfunction is common and is usually caused by mechanical failure. Shunt obstructions may be confirmed with radioisotope examination or with fluoroscopically guided injection of iodinated contrast material into the shunt reservoir. Disconnections or breaks are more readily detected at radiography in cases in which barium-impregnated shunt tubing was used. Migration and leakage may also occur. Cerebrospinal pseudocysts may be demonstrated with plain radiography and further evaluated with computed tomography (CT) and sonography. In increasing hydrocephalus, plain radiography may reveal sutural diastasis and increased cranial cavity size, and CT can be used to evaluate ventricle size. In cases of enlarging intracranial cysts, injection of iodinated contrast material followed by CT can help document a connection between the cyst and the ventricles. Ventriculitis and meningitis can be visualized at CT and magnetic resonance imaging as enhancement of the ventricular ependymal lining or cerebral cortical sulci. Other complications associated with VP shunts include surgery-related complications, shunt overdrainage and slit-ventricle syndrome, neoplastic metastasis, pleural effusion, and complications related to shunt variants. Imaging analysis is an essential adjunct to the clinical evaluation of patients with suspected VP shunt malfunctions or complications. Radiologists should be familiar with these potential problems and the diagnostic utility of various imaging modalities.     

Imaging methods in intensive care

Imaging procedures are important for diagnosis and surveillance of patients in intensive care units. Radiologic examination, ultrasound and echocardiography are of paramount importance because they can be done bedside. Portable chest x-ray examination is the procedure of choice for documentation of tubes, lines and devices, estimation of cardiopulmonary function, demonstration of pulmonary edema, ARDS pneumonia, atelectasis and pneumothorax Plainfilm radiologic imaging of the abdomen is indicated when perforation ileus or acute intestinal pseudoobstruction is suspected Echocardiography can give information about ventricular function, pericardial effusion, cardiac valves, functional importance and complications of myocardial infarction, and hemodynamic changes of pulmonary embolism. Transesophageal echocardiography (TEE) is the method of choice when endocarditis, aortic dissection or cardiac thromboembolism is considered. Ultrasound can show many pathologic changes important for the management of intensive care patients concerning liver, gallbladder, bile duct, pancreas, kidney, spleen, pleural space and vessels. Other imaging procedures such as CT, methods of nuclear medicine, MRT, angiography etc. are done outside the intensive care unit and therefore need a more restricted indication.     

Neurological and neuroradiological findings in long-term survivors of allogeneic bone marrow transplantation

The aim of this study was to assess neurological, neuropsychological, and neuroradiological findings in long-term survivors of allogeneic bone marrow transplantation (BMT) who were recruited from a hematological outpatient clinic. In addition, risk factors for the development of late neurological complications were identified. In contrast to previous studies on autopsied patients, our study design provoked a bias away from increased neurological sequelae, because patients with early complications after BMT were excluded. Fifty-nine allogeneic patients and 7 autologous BMT patients underwent clinical examination, short neuropsychological testing, and cranial magnetic resonance imaging (MRI) 34 +/- 26 months after BMT. The pathological results of the neurological examination (abnormal 64%) and the MRI examination (white matter lesions, 54%; atrophy, 11%) were associated with the occurrence of chronic graft-versus-host disease (GvHD) evolving from acute GvHD, with corticosteroid therapy and with cyclosporine medication. Neuropsychological impairment (cognitive deficits, 37%) was associated with long-term cyclosporine medication and age. No influence of pre-BMT disease, BMT donor status, or the conditioning regimen was found. These results suggest that the frequent neurological abnormalities in long-term survivors of allogeneic BMT are associated with chronic GvHD and with the resulting immunosuppression as major risk factors.     

Trauma of the facial bones and skull

Facial trauma is frequent and mainly caused by motor vehicle accidents. Due to this main etiologic factor, trauma to the facial skeleton is often associated with serious injuries, commonly involving the brain, chest or abdomen. As a consequence, the initial clinical management of these patients includes control of hemorrhage and immediate assessment of life-threatening injuries, including the maintenance of the airways. Patients presenting with facial trauma are initially evaluated with a systematic clinical examination because many fractures can be accurately diagnosed by inspection and palpation alone. In these cases plain film radiographs serve only for confirmation and documentation of the diagnosis. In many other cases accompanying and extensive soft tissue swelling may clinically obscure fractures. A complete and accurate evaluation of these patients requires additional radiological imaging methods. A series of plain films may be generally sufficient but in most of the cases they can be regarded as initial screening methods for more thorough diagnosis with computed tomography (CT). In trauma patients CT is the imaging method of choice because it shows more fracture lines and displaced fragments than any other imaging modality. CT delineates soft tissue and bony structures and can localize and even characterize foreign bodies. A complete and accurate characterization of the fracture type and potentially associated complications in mandatory for the appropriate treatment and can only be achieved by careful radiological (CT) evaluation.     

Clinical applications of composite and realtime megavoltage imaging

The versatility of electronic portal imaging devices (EPIDs) is best demonstrated by their ability to perform novel megavoltage imaging protocols, which are still pertinent to good radiotherapy practice. This paper examines two such techniques: composite and realtime imaging. Our EPID can be programmed to acquire and manipulate images very easily, allowing images from segmented treatment protocols to be mixed and displayed, giving a composite image of the effective treatment result. Its use for verifying the efficacy of spinal shielding using a segmented, offset collimator technique is described. By acquiring images very quickly, realtime imaging sequences can be obtained and used to analyse anatomical movement within a single treatment field. The technique is employed here to investigate movement in radical lung, breast, abdomen, pelvis and thyroid treatments. Our results show that the protocol is vital for treatment sites involving the lungs; changes up to 5 mm have been observed in the maximum lung depth for breast treatments, and displacements up to 16 mm for radical lung treatments. It is also useful in other anatomical sites for ensuring that no movement occurs.     

Elevated interleukin-8 serum concentrations in beta-thalassemia and graft-versus-host disease

Neutrophil chemotactic and functional defects occur in beta-thalassemia and in patients after bone marrow transplantation (BMT). Interleukin-8 (IL-8) is a novel chemotactic and activating peptide for neutrophils and can be detected in the circulation. IL-8 serum concentrations were evaluated in 30 beta-thalassemic patients before and after BMT. Serial samples from 16 patients were also studied. Fourteen sera from healthy children, 43 patients with chronic viral hepatitis, 16 patients on chronic transfusion treatment for various hematologic disorders, and 28 healthy adults were studied as controls. IL-8 was evaluated by an enzyme-linked immunosorbent assay. Patients with beta-thalassemia had higher IL-8 concentrations than did normal controls, patients with liver disease, and patients on chronic transfusion. beta-Thalassemic patients with severe liver siderosis and fibrosis had the highest IL-8 concentrations. After BMT in patients with successful engraftment, IL-8 concentrations decreased significantly. In contrast, in patients with acute graft-versus-host disease (GVHD), IL-8 concentrations were not statistically different from the concentrations found before BMT and were higher than in patients with no complications and patients with graft rejection. IL-8 may play a part in the immune dysregulation that occurs in beta-thalassemia and may be involved in the immune mechanisms leading to GVHD.     

Computed tomography in evaluation of patients with stage III melanoma

BACKGROUND: Metastatic disease is detected infrequently by computed tomography (CT) in early stage melanoma. The diagnostic yield of routine CT for stage III melanoma is less established, despite extensive use in clinical practice. METHODS: Charts from 347 asymptomatic patients with stage III melanoma were reviewed. Findings suggestive of metastatic melanoma identified by head or body CT, chest radiography, bone scan, or liver function studies were confirmed histologically or by progression of disease. RESULTS: Individual CT scans identified 33/788 (4.2%) instances of metastatic melanoma, with 66/788 (8.4%) false positive studies. No metastases were identified among 104 head CT scans. Chest CT had the highest yield in patients with cervical adenopathy (7/35, 20%), and the lowest yield with groin adenopathy (1/50, 2%). Pelvic CT diagnosed metastases in 7/94 (7.4%) patients with groin adenopathy, but no patients with palpable axillary (n = 76) or cervical (n = 21) nodes. Metastatic melanoma was diagnosed in 11/136 (8.1%) patients having complete body CT imaging (chest, abdomen, and pelvis), including six patients (4.4%) identified by CT alone. CONCLUSIONS: Routine CT in patients with clinical stage III melanoma infrequently identifies metastatic disease. Head CT in the asymptomatic patient, chest CT in patients with groin adenopathy, and pelvic CT in the presence of axillary or cervical adenopathy are not indicated. Selective use of chest CT in patients with cervical adenopathy or pelvic CT in the presence of groin disease may be useful.     

Diagnostic imaging in otorhinolaryngology--assessment of current status

BACKGROUND: The first conventional x-rays of the paranasal sinuses were received in 1897, just two years after the detection of x-rays. During the following decades several modifications and extensions of conventional radiologic techniques were developed, but routine imaging procedures of the head and neck were mainly restricted to pictures of the paranasal sinuses and the temporal bone. In the fifties, tomography was developed, which gave us a more detailed insight of the anatomy and pathology of the paranasal sinuses and temporal bone. During the last two decades the development of new techniques, i.e. computed tomography (CT) and magnetic resonance imaging (MRI), has significantly increased the importance of modern imaging for the diagnostic evaluation of head and neck diseases. These diagnostic tools enable us to visualize anatomical structures and pathological entities with an accuracy never been expected beforehand. The pace of the improvement of these diagnostic tools, however, requires that both radiologist and otorhinolaryngologist keep up with the adequate indications of CT and MRI in the different areas of the head and neck. A close relationship and cooperation between radiologist and ENT surgeon is therefore indispensible for a fruitful and cost-effective use of modern imaging. Otherwise the patient is exposed to modern medical technology without an equivalent benefit. The purpose of the present paper is mainly to give an update and state of the art of modern imaging techniques in otorhinolaryngology, head and neck surgery. Different areas i.e. paranasal sinuses, temporal bone, salivary glands, oral cavity and oropharynx as well as the neck are discussed in terms of adequate indications for modern imaging in the diagnostic evaluation of different lesions.     

Plasmodium yoelii sporozoite infectivity varies as a function of sporozoite loads in Anopheles stephensi mosquitoes

PURPOSE: This prospective study was undertaken to determine the incremental yield of combined abdominal and pelvic CT in searching for clinically suspected postoperative abscess in oncologic patients. METHOD: One hundred seventeen oncologic patients underwent CT to exclude a clinically suspected abscess within 30 days of abdominal or pelvic surgery during an 8 month period. Scans were evaluated for the presence of ascites, loculated fluid collections, or other possible sources of fever. The clinical course and any intervention in the abdomen or pelvis within 30 days after CT were recorded. RESULTS: After abdominal surgery, 44 of 69 [64%; confidence interval (CI) 51-75%] patients had loculated fluid collections in the abdomen; no patient (0%; CI 0-5%) had a loculated fluid collection present only in the pelvis. After pelvic surgery, 22 of 48 (46%; CI 31-61%) patients had loculated fluid collections in the pelvis; no patient (0%; CI 0-7%) had a loculated collection present only in the abdomen. Loculated collections were present in both the abdomen and the pelvis in 4 of 69 (6%; CI 1.6-14%) patients after abdominal surgery and 3 of 48 (6%; CI 1.3-17%) after pelvic surgery. CONCLUSION: Isolated pelvic abscesses after abdominal surgery and isolated abdominal abscesses after pelvic surgery appear to be very uncommon in oncologic patients. CT initially need be directed only to the region of surgery in this particular patient population.     

Discography 2000

Discography is an invasive and controversial procedure that can be used as a complementary test to MR imaging or a CT myelogram prior to surgery. The examination may be performed in the prone or decubitus position. Pain provocation is the most important part of the examination. CT discography provides valuable information regarding pattern, number, extent, and degree of annular tears. Correlation of discography with cross-sectional imaging studies is reviewed and the surgical outcome is discussed.     

Complications and liver transplantation: diagnostic strategy

Liver transplantation is currently the treatment of choice for end-stage liver failure in children and adults. 670 liver transplantations were performed in France in 1990. The 2-year survival rate in adults is 65%. Significant progress in terms of survival has been achieved as a result of improvement of surgical techniques and postoperative surveillance, the development of effective immunosuppressant therapy and a better organization of donor organs. Surgical techniques depend on the recipient and the transplant available. Imaging is useful in pretransplantation assessment, but especially during the immediate and long-term follow-up to assess transplant vitality and to detect any complications, which are of four types: vascular, biliary, or related to rejection or infection. Postoperative surveillance of the transplant must be based on a diagnostic approach conducted according to the following optimal sequence: laboratory parameters, histological examination and imaging, performed systematically from the 1st day onwards, including examination of the hepatic parenchyma, bile ducts, hepatic vessels and search for effusions and collections. The role of imaging in the context of rejection is not so much to visualize of rejection, as to eliminate a vascular, biliary or even infectious cause for the altered laboratory parameters. In the context of surgical vascular, biliary, infectious or complex complications, the examination sequence always includes clinical and laboratory findings, histology, angiography in the context of vascular complications and CT scan to assess the vitality of the hepatic parenchyma and to identify any intrahepatic or perihepatic collections. Interventional radiology plays an important role in the treatment of these vascular, biliary and infectious complications and should be considered prior to any surgical revision.     

111In octreotide scintigraphy in the evaluation of head and neck lesions

PURPOSE: To evaluate indium 111 octreotide scintigraphy for the detection of suspected neuroendocrine lesions of the head and neck. METHODS: After receiving 6 mCi of 111In octreotide, 22 patients with suspected lesions of the head and neck were examined with both planar and single-photon emission CT (SPECT). Static images, obtained at 4 hours, included the head/neck, chest, abdomen, and pelvis. Additional SPECT images were obtained at 4 or 24 hours. Studies were compared with available conventional radiologic examinations (12 CT, 11 MR, and three angiographic studies) as well as with clinical and pathologic findings. RESULTS: Eighteen of the 22 patients had abnormal findings at scintigraphy. Eleven paragangliomas were seen in 10 patients, metastatic medullary thyroid carcinoma in three patients, thyroid adenoma in two patients, and Merkel cell tumor, carcinoid, and plasmacytoma in one patient each. Surgical confirmation was available in 13 patients. The smallest lesion detected was 1.5 cm. There was one false-positive and one false-negative examination. CONCLUSION: 111In octreotide scintigraphy is a useful imaging tool for the detection of primary and metastatic neuroendocrine tumors of the head and neck that are larger than 1.5 cm. This technique enables distinction of glomus tumors from other masses (such as neuromas) and can be used in the postoperative setting to distinguish scar from recurrent paraganglioma. Since it is an examination of the entire body, it has great utility for detecting multicentric paraganglioma and for screening patients with familial paraganglioma.     

Ovarian cancer: comparison of findings with perfluorocarbon-enhanced MR imaging, In-111-CYT-103 immunoscintigraphy, and CT

PURPOSE: To determine the accuracy of breath-hold gadolinium- and perflubron-enhanced magnetic resonance (MR) imaging, immunoscintigraphy with indium-111-CYT-103 (planar and single photon emission computed tomography [CT]), and contrast material-enhanced CT for the detection of ovarian cancer prior to laparotomy. MATERIALS AND METHODS: Sixteen patients with primary (n = 3) or treated (n = 13) ovarian cancer underwent imaging of the abdomen and pelvis with each modality. All images were reviewed prospectively for tumor location, and results were compared with findings at surgery. RESULTS: With CT or MR imaging, tumor was detected in 11 of 13 (85%) patients compared with 11 of 12 patients (92%) with immunoscintigraphy. Per patient accuracy for CT was 81% compared with 75% for MR imaging and 86% for immunoscintigraphy. For detection of individual sites of tumor, the sensitivity of MR imaging was highest (81%) compared with CT (51%, P < .001) and immunoscintigraphy (50%, P < .01). The combination of MR imaging and immunoscintigraphy depicted 89% of sites of tumor involvement confirmed at laparotomy. CONCLUSION: MR imaging and immunoscintigraphy show promise for the evaluation of patients with ovarian cancer.     

Brain iron and neurological disorders

The use of metal stents for the relief of prostate obstruction in the elderly has increased in popularity since 1980. The finding that fine metal wire stents become covered with prostatic epithelium led to the recent use of stents that can be left in place permanently. Because the prostatic urethra does not always conform to the cylindrical shape of these stents, and because the bladder neck/urethral angle is not a right angle and may not be circular in outline, problems may occur with positioning and subsequent inadequate epithelial covering. Three-dimensional imaging of the prostatic urethra using transrectal ultrasound scanning during voiding may give additional help in defining the variety of possible shapes of this area, but more work on the compliance of prostate tissue and the shape of the prostatic urethral lumen is essential in order to improve stent design and reduce the risks and complications of these useful devices.     

The role of radiology in the diagnosis and follow-up of Langerhans cell histiocytosis

Diagnostic imaging plays a major role in the management of patients with Langerhans cell histiocytosis. Plain radiography depicts most lesions. Nuclear scintigraphy may detect additional areas of bone involvement, but its routine use is controversial. Ultrasonography may be used to evaluate the abdomen for evidence of solid organ involvement. CT and MR imaging are often of great value in clarifying and delineating findings seen on plain radiographs and other imaging modalities. Ultimately, the choice of imaging study depends on the patient's clinical presentation and the body part affected.     

Computed tomography in injuries to the respiratory system in children. The correlation with adults

INTRODUCTION: Diagnostic imaging in emergency rooms may be inadequate and delayed, which makes chest traumas in children more severe and difficult to treat. We carried out a retrospective study on adults and children who had survived major chest traumas involving the respiratory tract to assess the differences between the two age groups and the role of emergency CT. MATERIAL AND METHODS: Our series consisted of fourteen children admitted to the emergency department for various accidents. Home accidents prevailed (9/14 = 64.3%). On admission, chest radiography was performed in most cases (11/14 = 78.6%); CT was carried out in 21.4% (3/14 patients). RESULTS: Trauma involved more organs in pediatric patients (11/14 = 78.6%) and lung involvement was always associated with other types of injury, namely contusion (14/14 = 100%), pneumothorax (11/14 = 78.6%), hemothorax (10/14 = 71.4%), tear (4/14 = 28.6%). CT corrected or integrated the radiographic findings of contusion focus in 67% (8/14) and that of pneumothorax in 63.6%; both patterns cannot be demonstrated otherwise. DISCUSSION: Mixed and multiple posterior parenchymal injuries with no rib fractures prevail in young subjects because their bones and ligaments are more elastic, which may lead to trauma underestimation. Tracheobronchial ruptures and pneumomediastinum are much more severe in children than in adults. Chest plain film is often the only diagnostic tool used, despite its major technical and interpretative limitations, also because skull and abdomen are the most investigated regions. Executive limitations are stronger in childhood, increasing the margin of error and the risk of delayed treatment. CT is as cost-effective as radiography and shows even the injuries missed or poorly depicted on conventional images; CT also gives accurate information on damage severity and nature. CONCLUSIONS: Traumatic injuries are more severe in pediatric patients due to their build and to biomechanical, clinical and management factors. Spiral CT should be considered the examination of choice to be performed in the emergency department equipped also for pediatric re-animation.     

Whole body spiral CT in primary diagnosis of patients with multiple trauma in emergency situations

PURPOSE: The aim of this study was to evaluate the role of a fast whole body helical CT scanner for primary diagnosis in trauma patients. METHODS: 27 severely injured patients (9 women, 18 men; mean age 43 years) were first examined with a helical CT scanner allowing for digital radiograms up to a length of 1024 mm and continuous helical scans of up to 70 seconds (slice thickness 3 to 10 mm, pitch factor up to 2). The primary CT diagnosis was verified either by x-ray after the CT examination or during the subsequent days, by abdominal ultrasound, by additional CT scans in the following days, and by clinical follow-up. RESULTS: CT showed all clinically relevant injuries of the head, spine, chest, abdomen and pelvis. The diagnosis and classification of vertebral fractures was performed immediately. 4% of the fractures of the extremities and the ribs were not seen primarily. 6% of the injuries were outside the CT scan field. CONCLUSION: Helical CT is a reliable and fast method to obtain vital information and to improve management planning in severely injured patients. It reduces the number of conventional x-ray examinations. In certain cases, additional x-rays of extremity fractures may be required.