Value of multislice CT in the diagnosis of pulmonary artery pseudoaneurysm from Swan-Ganz catheter placement.

Perforation of a pulmonary artery after placement of a Swan-Ganz catheter is a serious complication that requires immediate management. Exact description of size and anatomic localization of a pulmonary pseudoaneurysm is crucial for planning further therapy. This report describes a patient who experienced such a complication, but in whom primary pulmonary angiography failed to demonstrate bleeding. However, multislice computed tomography not only correctly demonstrated the anatomic location of the pseudoaneurysm but was also able to directly visualize the feeder vessel and its connection to the aneurysm. This information was essential for subsequent superselective angiographic visualization of the feeder vessel and for successful embolization as the least invasive method of choice.

Neoadjuvant chemotherapy with cisplatin, 5-FU, and leucovorin (PLF) in locally advanced gastric cancer: a prospective phase II study.

BACKGROUND: Patients with locally advanced gastric cancer (cT3, cT4, N+, M0) have a dismal prognosis, despite complete resection. The objective of this study was to evaluate the toxicity and efficacy of neoadjuvant chemotherapy using the PLF (cisplatin/leucovorin [folinic acid]/5-fluorouracil [FU]) regimen in these patients. Primary endpoints of the study were the toxicity and the response to chemotherapy. Secondary endpoints were the rate of complete resection, survival, and first site of failure. METHODS: Forty-nine patients with adenocarcinoma of the stomach were enrolled. Staging was based on abdominal computed tomography (CT) scans, endosonography, and laparoscopy. The intention was to administer two cycles (each containing six courses) of preoperative chemotherapy, consisting of cisplatin 50 mg/m(2), high-dose folinic acid (HD-FA) 500 mg/m(2), and HD 5-FU (HD-5-FU) 2000 mg/m(2) (PLF). Following chemotherapy all patients were referred to surgery. To be evaluable for response, survival, and first site of failure, the patient had to receive at least one cycle of chemotherapy. RESULTS: Toxicity observed was low, with grade 3 toxicity in fewer than 5% of the patients and two events of grade 4 toxicity (diarrhea and pulmonary embolism). Forty-two of the patients (86%) received at least one cycle of chemotherapy. The clinical response rate in these patients was 26% (11/42 patients). In 76% of the patients (32/42), a complete resection was possible. The median duration of follow-up for the surviving patients was 58 months (range, 38 to 80+ months). The median survival time for the 42 patients assessable for response was 25.4 months (range, 6 to 80+ months). After complete resection, median survival time was 32 months (range, 7.6 to 80+ months). The median survival time for clinically responding patients has not yet been determined, but 5-year survival is 90%. Twenty of the 32 completely resected patients (62.5%) had recurrences. First site of failure was peritoneal dissemination in 10 patients; locoregional and distant recurrences were rare. CONCLUSION: Neoadjuvant chemotherapy with PLF in patients with locally advanced gastric cancer has low toxicity and reasonable efficacy, allowing administration on an outpatient basis. Clinically responding patients have an excellent outcome after complete resection. The development of peritoneal dissemination even after neoadjuvant chemotherapy and complete resection remains an unsolved problem in patients with nonintestinal type tumors.

Fluorodeoxyglucose-positron emission tomography in adenocarcinomas of the distal esophagus and cardia.

Adenocarcinomas of the esophagogastric junction (AEG) are now recognized as a separate tumor entity with increasing incidence. The aim of the present study was to evaluate whether positron emission tomography (PET) using the glucose analog F-18-fluorodeoxyglucose (FDG) can be used for metabolic characterization of this tumor type. Fifty-two patients with histologically proven, locally advanced AEG (distal esophagus, type I: n = 31; cardia, type II: n = 21) were studied by FDG-PET. None of the tumors had been previously treated. Findings of endoscopy (growth type), endoluminal ultrasound (uT, uN), computed tomography (cN, cranio-caudal extent, tumor thickness), histological evaluation (Lauren classification, tumor grade), anatomical classification, and survival were correlated with the results of FDG-PET. There was no correlation between FDG uptake and clinical stage, grade, Lauren classification, or survival. All AEG I tumors were visualized by FDG-PET with high contrast, whereas FDG uptake by five AEG II tumors (24%) did not differ from background activity. In a quantitative analysis, mean FDG uptake of AEG I tumors was 1.6 times higher than that of AEG II tumors ( p = 0.0005). PET can be used to visualize type I adenocarcinomas of the esophagogastric junction (AEG I). In AEG II tumors, however, the use of FDG-PET appears to be limited. The significantly higher FDG uptake of AEG I tumors compared to AEG II tumors suggests that these two tumor types differ in glucose utilization. This finding strengthens the hypothesis that AEG I and AEG II are two different tumor entities.

Dynamic MR pancreatography after secretin administration: image quality and diagnostic accuracy.

OBJECTIVE: The objective of our study was to assess the improvement of image quality and diagnostic accuracy of secretin-enhanced MR pancreatography compared with conventional MR pancreatography. SUBJECTS AND METHODS: Ninety-five patients were studied with a 1.5-T scanner using a T2-weighted single-slice fast spin-echo sequence. Image quality and diameter of the head, body, and tail portion of the pancreatic main duct, the accessory duct, and the side branches were assessed before and after IV administration of secretin. Diagnoses before and after secretin administration were evaluated in a blinded fashion and correlated to the final diagnoses based on endoscopic retrograde cholangiopancreatography (ERCP), intraoperative results, and clinical follow-up as the reference standard. RESULTS: In patients with a normal pancreatic duct, the visualization of all portions of the main pancreatic duct and the accessory duct was significantly improved with dynamic MR pancreatography (p < or = 0.001). In patients with chronic pancreatitis, the visualization of the main duct was also significantly improved with dynamic MR pancreatography (p < or = 0.05). However, the visualization of the minor duct and the side branches was significantly improved only in patients showing no ductal stricture (p < or = 0.05), compared with those with ductal stricture (not significant). The overall sensitivity for the detection of chronic pancreatitis increased from 77% to 89% using secretin-enhanced MR pancreatography. A pancreas divisum was found in eight patients before and 13 patients after secretin administration. The overall negative predictive value of MR pancreatography increased from 84% to 98% after secretin administration. CONCLUSION: Improvement in image quality after secretin stimulation increases the diagnostic value of MR pancreatography in patients with a normal or nondilated main pancreatic duct and may obviate invasive procedures such as ERCP.

A prospective comparison of the diagnostic accuracy of ERCP, MRCP, CT, and EUS in biliary strictures.

BACKGROUND: The differential diagnosis of biliary strictures remains a challenge. This study evaluated magnetic resonance cholangiopancreatography (MRCP) as a new procedure in comparison with the established methods of diagnosis including ERCP or percutaneous transhepatic cholangiography (PTC), CT, and EUS. METHODS: Fifty patients (21 men, 29 women, mean age 65.7 years) with jaundice but no pain suspected to have biliary strictures were enrolled in this prospective study. MRCP, ERCP/PTC, CT, and EUS were performed prospectively; images and videotapes (EUS) of these tests were reviewed blindly under standardized conditions. Reference standards for comparison were surgery, a biopsy confirming malignancy, or the clinical course during follow-up (at least 12 months) in cases without histopathologic proof of malignancy. RESULTS: Seven patients ultimately proved to have jaundice caused by parenchymal liver disease and 43 had a biliary stricture (17 benign, 26 malignant). Forty patients underwent all 4 imaging tests. There were 10 patients in whom patient-specific problems precluded some procedures but who were included in an intention-to-diagnose analysis. The sensitivity and specificity for diagnosis of malignancy in the 50 patients were as follows: 85% / 75% for ERCP/PTC, 85% / 71% for MRCP, 77% / 63% for CT, and 79% / 62% for EUS, with similar values in the 40 patients who underwent all 4 imaging methods. The combination of MRCP and EUS improved specificity. CONCLUSIONS: Although MRCP provides the same imaging information as direct cholangiography, it has limited specificity for the diagnosis of malignant strictures. In the differential diagnosis of biliary strictures, several tests including ERCP-guided tissue diagnosis are still required, and MRCP has only a limited clinical role.