Adrenal metastasis: US, CT and MR imaging

The purpose of this study is to illustrate the role of US, CT and MRI in the characterization of adrenal metastases in patients with known primary cancer. Thirty metastatic adrenal masses and 10 adenomas were prospectively identified in 35 oncologic patients on non contrast and contrast enhanced CT scans of the chest and abdomen. All patients were studies with US, CT as well as chemical shift MRI [1.5 T]. Using CT, regions of interest were obtained at non enhanced, dynamic [60 seconds post contrast enhancement], and delayed [10 minutes post contrast enhanced] 3-8 mm thickness CT scans of the adrenal glands. These measurements were used to calculate a relative percentage contrast wash out as follows: 1-HU on delayed images/ HU on dynamic images x 100%. A relative percentage wash out threshold of 50% was applied with calculation of sensitivity and specificity of the protocol. Also the attenuation characteristics, size, shape and relation to nearby structures were determined on CT images. On MRI, the adrenal mass / splenic ratio [ASR] was calculated applying the chemical shift MRI protocol using 2.3 msec [out of phase images] and 4.6 msec [in phase images] echotime. The percentage of signal remaining in the out of phase images relative to the in phase images was determined. Diagnoses were confirmed by fine needle aspiration cytology, imaging findings and follow up findings. The study group included 35 patients with adrenal masses; 25 had 30 adrenal metastases and 10 patients had 10 adrenal adenomas. The malignant metastatic group included 20 men and 5 women. The mean age of 65 years. The non malignant group included 10 patients with adrenal adenomas, 8 women and 2 men, with mean age of 52 years. The primary malignant lesions were bronchogenic carcinoma in 14 patients, hepato-cellular carcinoma, renal cell carcinoma, infiltrating breast duct carcinoma, in 2 patients for each, colorectal, urinary bladder, uterine and prostatic carcinoma in one patient for each as well as one patient with pleural mesothelioma. US was performed as part of the routine diagnostic work up of patients. It could detect 23/30 [77%] adrenal metastases and 5/10 [50%] adrenal adenomas. Analysis of the CT images showed mean size of metastatic lesions of 4 cm [rang 3.3-12 cm], irregular shape in 25/30 [83%] lesion and heterogeneous attenuation in 26/30 [87%] lesion. The mean size of adrenal adenomas was 2.2 cm [range 1-3.2 cm], all were regular in shape and 90% shows homogeneous attenuation pattern. The mean CT attenuation values of the 30 metastatic lesions was 32 +/- 7.2HU. Only one lesion showed attenuation <18 HU. Adrenal adenomas shows mean attenuation values of 6 +/- 9.2 HU [range -20 to 19HU]. Only one adenoma showed attenuation >18 HU. The sensitivity: specificity ratio for the diagnosis of adrenal metastasis applying the CT attenuation characteristics was 97%: 90% at a threshold value of 18HU. Twenty nine of 30 [97%] metastatic lesions were correctly diagnosed as malignant with relative wash out threshold of 50% on delayed scans. All showed <50% contrast wash out. 90% adenomas shows contrast wash out of >50% at delayed post contrast scans. Therefore, the sensitivity and specificity of the protocol were 97% and 90% respectively. The analysis of the MR images revealed that signal intensity was not useful to reliable characterization of the adrenal metastatic lesions. Applying chemical shift imaging, 29/30 [97%] adrenal masses showed no significant signal loss in out of phase images. On the other hand, all adenomas [100%] showed marked signal loss in the out of phase images. The sensitivity and specificity of the protocol was 97% and 100% in differentiation of benign from metastatic adrenal masses. CSI was proved to be the most sensitive technique for differentiating adrenal adenoma from metastases. When CT examinations are equivocal, CSI would be the next imaging study of choice for characterization of adrenal masses

Long term results of truncal vagotomy and [uncut] roux gastrojejunostomy for management of chronic duodenal ulcer with reference to gastric emptying

In the previous reports, we described the surgical technique of truncal vagotomy and "uncut" Roux gastro-jejunostomy [TV+UCRGJ] in management of chronic duodenal ulcer [CDU]. Also, we demonstrated that it is not associated with significant increase in postoperative enterogastric reflux [EGR]. This work represents the long-term results of TV+UCRGJ, with assessment of gastric emptying using gastro-hydro-sonography. Fifty two patients, [mean age: 47.21+12.89 years], with CDU were managed by TV+UCRGJ and were followed-up for a mean duration of 54.71 +/- 9.21 months, for symptomatic outcome. Gastric emptying for semisolids was assessed ultrasonographically, by measuring the percent change of the post-prandial gastric antral area [AA] in patients, pre and at least 12 months post-operative. The results were compared to 50 matching controls. Excellent or fair symptomatic outcome was described by 47 patients [90.3%]. Four patients [7.7%] needed redo gastric surgery, two with ARG [one due to stapler line dehiscence] and two with severe gastric stasis. There was a significant drop in the mean preoperative symptomatic score, following surgery [2.98 +/- 0.92 Vs 0.827 +/- 1.279, p=0.000], to a figure matching the controls [0.827 +/- 1.279 Vs 0.667 +/- 1.046, p=0.514]. Ultrasonographic assessment of gastric emptying, showed insignificant difference in gatric emptying percent at 30 minutes between postoperative and controls values [66.73 +/- 11.75% Vs. 70.19 +/- 10.27%, P=0.810]. As well, there was insignificant difference between post and preoperative values [66.73 +/- 11.75% Vs. 69.85 +/- 11.88%, p=0.074]. Truncal vagotomy and "Uncut" Roux gastrojejunostomy carries good long-term symptomatic and functional outcome. Also, it is associated with normal gastric emptying. So, it can be included as an initial surgical option in the management of uncomplicated CDU

role of computed tomography[CT] in detecting and grading of sequelae of renal trauma

Subjeet: Twenty patients exposed to renal trauma [all of blunt type] were evaluated by CT aiming to detect and grade the sequelae of such trauma as a primary step for the planning of their management. Study Clinical data, vital signs, urinalysis and blood chemistry [blood urea and serum creatinine] were considered. Screening by ultrasound followed by pre and post- contrast helical abdominal CT were done [30 cm tissue scanned in a single 30 second breath hold]. Plain films after CT were taken as a limited intravenous urographie study [IVU]. CT grading was established and treatment was planned for accordingly. Resuit: The age group ranged from 4-50 years, 50% [10 cases] were below 10 years. Grade I was seen in one case [5%], grade II in 4 cases [20%], grade III in 11 cases [55%.]. and grade IV was in 4 cases [20%]. Grade V [pedicle injury] was not encountered in the present siudy. The accuracy of CT in deteciing sequelae of renal trauma was 100%. With referral to CT, scanning by US was accurate in 90% of cases [2 cases-10% were not conclusive]. Grade I and II were treated conservatively while grade III and IV underwent exploration and surgical repair. CT is a safe, non-invasive modality in detecting and grading sequelae of renal trauma. It was found sensitive in clear delineation of parenchymal laceration, detecting urinary exrtavasation, evaluating the size and extent of hematoma and outlining non-viable tissues