Osteonecrosis in patients with malignant lymphoma. A review of 31 cases.

Osteonecrosis of the femoral and humeral heads is a serious complication of therapy for Hodgkin's disease and non-Hodgkin's lymphoma. Twenty-five patients were reassessed 5 years after being initially reported, in order to study the further progress and natural history of this complication. In addition, six recent patients who have also developed this condition are presented. With 5-year additional follow-up, no patient had developed symptoms of osteonecrosis in any bone other than those initially involved. Five patients developed severe complications thought to arise from their therapy suggesting that this group of patients were more sensitive to radiation injury than other patients treated with this modality. During the relatively short follow-up 5-year period, a surprising finding was the fact that 31% of the patients with Hodgkin's disease and 50% with non-Hodgkin's lymphoma had died. It is recommended that patients treated for lymphoma with steroid containing chemotherapy and radiotherapy be observed carefully for the occurrence of joint pain. Early diagnosis should lead to attempts to prevent total joint destruction.

Percutaneous needle biopsy of deep pelvic masses: a posterior approach.

The classical approach for the fine-needle aspiration biopsy of deep pelvic masses has been through the lower anterior abdominal wall. With this approach, and using either CT or sonographic guidance, bowel or bladder may be unavoidably traversed to reach the mass. We have been using a posterior approach through the sciatic notch, which is a safe and simple procedure, with good results. The biopsy is done with the patient in a prone position, using a 22-gauge biopsy needle. With this technique we have successfully biopsied various neoplastic pelvic entities.

Accessory fissures of the liver: CT and sonographic appearance.

Invaginations of the liver by the diaphragm form accessory fissures that may mimic the major hepatic fissures on sectional images. Accessory fissures are most common in the superior right hepatic lobe. Their average incidence on computed tomographic (CT) scans is 25%. Their frequency increases with age, approaching 70% in the seventh and eighth decades. Their depth may equal or exceed 2 cm in one-third of cases. Multiple accessory fissures may mimic pathologic liver nodules on CT and may be associated with diaphragmatic scalloping or eventration on the chest film. When only parts of these fissures are seen sonographically, they may be mistaken for echogenic liver lesions. The differentiation of accessory fissures from the major hepatic fissures, from pathologic lesions, and from sonographic pseudofissure artifacts is discussed.

CT appearance of diaphragmatic pseudotumors.

Invaginations of the muscular fibers of the diaphragm into the upper abdomen may appear as nodules of soft tissue density on computed tomographic (CT) sections in deep inspiration. If these nodules indent the adjacent stomach or distal transverse colon, they may mimic small mural tumors or metastatic implants. Similar nodules protruding from the diaphragmatic crura into the adjacent retroperitoneal fat may be mistaken for enlarged lymph nodes on CT. Differential diagnosis of these pseudotumors from pathologic lesions is based on their continuity peripherally with the diaphragm and their separation from the hollow viscera by subdiaphragmatic fat. Decubitus and expiratory CT sections are valuable diagnostic aids.

Large posterior abdominal masses: computed tomographic localization.

Large posterior abdominal masses, particularly those in the right upper abdomen, may be difficult to localize correctly into the peritoneal or retroperitoneal compartments. The following signs were found to be reliable CT indicators of retroperitoneal location: obliteration of the perinephric fat outlining the psoas muscle; lateral displacement of the fat outlining the posterior right lobe of the liver; rotation of the intrahepatic portal veins to the left; anterior displacement of the inferior vena cava and renal veins; and anterior displacement of the ascending colon, descending duodenum, or pancreatic head.

CT diagnosis of mediastinal and thoracic inlet venous obstruction.

The diagnosis of mediastinal or thoracic inlet venous obstruction can be made reliably by chest computed tomography (CT), and depends on the opacification of collateral venous channels during the continuous infusion of intravenous contrast media. The sectional anatomy of these collateral pathways is illustrated by examples from 50 consecutive patients. An understanding of this anatomy facilitates the diagnosis of obstruction of the superior vena cava or its major tributaries during routine chest CT. Although CT was inferior to contrast venography in opacifying peripheral collateral veins and determining the degree of obstruction, the information provided by CT obviated venography in most patients in this series. CT may be the initial procedure of choice in suspected mediastinal venous obstruction.

Neurosurgical intra-operative ultrasound: tumor localization and characterization.

Intra-operative real-time ultrasound provides useful information for the neurosurgeon faced with the task of localization and extirpation of small subcortical brain tumors.

Osteonecrosis in patients with malignant lymphoma: a review of twenty-five cases.

A retrospective study of 25 patients with malignant lymphoma who had osteonecrosis of either the femoral or humeral head(s) was undertaken. The common factor present among all patients was the administration of intermittent steroid-containing combination chemotherapy. Seventeen Hodgkin's disease patients received chemotherapy predominantly consisting of an alkylating agent, vincristine, procarbazine, and moderate amounts of prednisone. The non-Hodgkin's lymphoma patients were on various moderate dosage steroid-containing protocols, except three who received prolonged high-dose steroid-containing chemotherapy regimens. Sixteen of the 17 Hodgkin's disease patients and five of the eight non-Hodgkin's lymphoma patients received radiotherapy to the bones that subsequently developed osteonecrosis. Two of the three non-Hodgkin's lymphoma patients who were not irradiated were treated with high-dose steroid-containing chemotherapy regimens. Symptoms developed in patients 12 months and 32 months after completion of chemotherapy and radiotherapy, respectively. Osteonecrosis was a long-term complication of treatment between 1970 and 1979 and occurred in 1.6% of the Hodgkin's disease and 0.12% of the non-Hodgkin's lymphoma patients treated. The authors conclude that the patients at highest risk for this complication are those who receive both radiotherapy to the affected bone(s) and intermittent steroid-containing multiple drug chemotherapy.