Assessment of patients with metastatic transitional cell carcinoma of the urinary tract.

PURPOSE: We propose an appropriate assessment of patients with disseminated transitional cell carcinoma of the urothelial tract, and investigate the pattern of metastases relative to pathological features and primary tumor treatment. MATERIALS AND METHODS: A total of 156 consecutive patients with recurrent locally advanced (nonresectable, radioresistant) and/or metastatic transitional cell carcinoma of the urothelial tract were evaluated with blood tests, chest x-ray, bone scintigraphy, bone marrow biopsy, and abdominal and brain computerized tomography. RESULTS: Distant metastases were evident in 86% of the patients, with lymph nodes and bones being the most frequent sites. Bone metastases were mostly in the pelvis or lower spine and were asymptomatic in 19% of patients. Bone marrow metastases were noted in 14% of these patients. However, most of them also had radiological bone metastases and bone marrow biopsy is not recommended for routine evaluation. Approximately 2% of patients had brain metastases without symptoms at recurrence. Elevated lactate dehydrogenase was predictive of disseminated disease. Patients receiving radical radiotherapy as primary treatment had an increased rate of recurrent locally advanced disease but the same frequency of distant metastases compared to those undergoing cystectomy. Primary tumor features did not relate to the pattern of metastases. CONCLUSIONS: We recommend chest x-ray, whole abdominal computerized tomography and routine blood tests, including lactate dehydrogenase, for patients with recurrent locally advanced or metastatic disease. Skeletal symptoms should be examined radiologically, while asymptomatic patients with recurrence in sites other than bone should be evaluated with bone scintigraphy.

Iohexol: effects on uptake of radioactive iodine in the thyroid and on thyroid function.

RATIONALE AND OBJECTIVES: The authors attempted to determine whether the use of nonionic contrast media causes uptake of iodine by the thyroid to be blocked and whether use of these agents could cause iodine-induced hyperthyroidism. MATERIALS AND METHODS: Twenty-eight persons, including 22 with thyroid disease, were included in the study. Subjects underwent computed tomography (CT) of the thyroid after injection of 100 mL of iohexol. Thyroid function variables were measured before CT scanning and 1 week and 1 month later. In 16 subjects, uptake of iodine-131 by the thyroid was measured before and 1 week after CT. RESULTS: I-131 uptake was reduced to 53.4% at 1 week after the injection of iohexol but became normal within a few weeks (followed up in one patient). An accelerated escape of I-131 from the thyroid was seen during the 1st days after the iohexol administration. Eight of 22 patients with an underlying thyroid disease had a temporary change in thyroid function. In four patients, the serum thyrotropin level was increased 1 week after the iohexol administration. In four other patients, temporary hyperthyroidism developed during the following months. CONCLUSION: Iohexol can be used in patients with an underlying thyroid disease, but close monitoring in the following months is necessary.

Plain radiography, renography, and 99mTc-DMSA renal scintigraphy before and after extracorporeal shock wave lithotripsy for urolithiasis.

Eighteen patients were evaluated before and 5 weeks after the first treatment with extracorporeal shock wave lithotripsy (ESWL) using abdominal plain radiography, 131I-hippuran probe renography, and 99mTc-dimercaptosuccinic acid scintigraphy. In 6 patients no urolithiasis was present on the post ESWL plain radiograph, in 7 the size had decreased, and in 5 the stone mass was unchanged. The renograms were within normal range in the 6 patients who were cured by ESWL, whereas this was the case for only 4 of the 12 who still had renal calculi. In 2 patients pelvic stones had descended into the ureter after ESWL, and the renograms indicated obstruction. Another 3 patients had ureteral stones, whereas in the remaining 7 patients only pelvic stones were found on the plain radiographs. In no patient did the scintigrams reveal scars. It is concluded that abdominal plain radiography of the urinary tract and probe renography are complementary and sufficient in the monitoring of patients with urolithiasis post ESWL.

The impact of abdominal computerized tomography on the pretreatment staging and prognosis of small cell lung cancer.

One hundred six patients with small cell lung cancer (SCLC) were prospectively evaluated with regard to the prognostic impact of abdominal CT-scan in the pretreatment staging when compared to ultrasonography of the abdomen. Staging based on abdominal ultrasonography (US) plus bilateral bone marrow examinations gave as a result that 47 patients had extensive disease (ED) (44%). Seventeen patients with proven ED at time of referral were not included in this study. Abdominal CT-scan was performed in 76 of the 106 patients. Thirty patients of these 76 patients (39%) were classified as having ED after staging including US, but abdominal metastases were disclosed in another ten patients at the subsequent CT-scan. Liver metastases seen in two patients at ultrasonography were overlooked on the CT-scans. Median survival of the 36 patients classified as having limited disease (LD) after both procedures was 458 days, which was significantly better compared to 330 days for the ten patients with stage migration from LD to ED based on CT-scan, (p less than 0.05) and compared to 242 days in the 30 patients with ED demonstrated by both US and CT-scans (p less than 0.05). The prognostic impact of the CT-scan was further investigated in a multivariate analysis (Cox). Stage disease, performance status, LDH and alkaline phosphatase were significant prognostic factors in a proportional hazards model based on the original 106 patients. Patients in the best prognostic group were characterized by LD, good performance status (0-1) and normal LDH and alkaline phosphatase serum values. This group consisted of 22 patients (21%).(ABSTRACT TRUNCATED AT 250 WORDS)

Measurement of renal function with iohexol. A comparison of iohexol, 99mTc-DTPA, and 51Cr-EDTA clearance.

The nonionic iodinated contrast medium, iohexol, introduced for clinical urography, is eliminated from the human organism mainly by glomerular filtration. The aim of this study was to analyze the applicability of iohexol for glomerular filtration rate (GFR) measurement by comparing the plasma clearance of iohexol to the plasma clearance of the traditionally employed substances, chromium-51-EDTA and technetium-99m-DTPA. Iohexol concentration was measured by x-ray fluorescence. To analyze for possible acute effect of iohexol on renal function, additional measurements of 99mTc-DTPA clearance were made prior to the injection of iohexol. In 15 patients having clearance values between 30 and 130 ml/min per 1.73 m2, there were close correlations (r = 0.95-0.98) among iohexol, 51Cr-EDTA, and 99mTc-DTPA clearance. No significant acute renal effect of iohexol was demonstrated. It is concluded that measurement of iohexol clearance provides information about GFR that is as valid as measurements of 51Cr-EDTA and 99mTc-DTPA clearance. Thus, it is possible to perform urography and a determination of GFR using a single injection of iohexol.

Prospective study of malabsorption induced risk of gall stone formation in relation to fall in plasma cholesterol.

The relationship between cholesterol in plasma and risk of gall stone formation was investigated in 210 obese patients who underwent jejunoileal bypass surgery and were free of gall stone disease at the time. Among 185, successfully reexamined on average 19 months after surgery, 26 (14%) developed gall stones. The fall in plasma cholesterol after surgery exhibited a U-shaped relation to risk of gall stone formation with a minimum risk around the average fall (2.6 mmol/l). This was confirmed by multivariate logistic regression analysis (p less than 0.01) taking into account other possible determinants. The relation was not significantly dependent on weight loss or ratio between jejunum and ileum left in function. The study suggests that malabsorption induced fall in plasma cholesterol is related to risk of gall stone formation by two oppositely working mechanisms, one enhancing and one reducing the risk.

Balloon-dilatation of esophageal strictures in children.

Dilatation of benign esophageal strictures by means of a balloon-catheter is a well-established procedure in adults. This method is also useful in children. The technique is described and the results of treatment in 10 children are reported. In all our patients the stricture developed after an operation for esophageal atresia with an end-to-end anastomosis. Dilatation with a balloon-catheter seems to have the same or an even better effect than the traditional dilatation with bougies. Complications following balloon-dilatations have been few and negligible in this series and dilatations can be performed using sedation instead of general anaesthesia. Therefore, this method is recommended.

Comparison of splenoportography and transhepatic portography in the diagnosis of portal vein thrombosis.

Accurate diagnosis and localization of thrombosis in the portal venous system is essential for proper surgical treatment. We compared the results of percutaneous transhepatic portography and splenoportography in 66 patients with cirrhosis of the liver. The two methods agreed on absence of thrombosis in 48, and in presence of thrombosis (verified later by surgery/autopsy) in four patients. In 12 patients an apparent thrombosis diagnosed by splenoportography was disproved by transhepatic portography, and vice versa in two patients. Free portal pressure and splenic pulp pressure did not differ significantly irrespective of the 'diagnosis' of thrombosis. We conclude, that transhepatic portography is better than splenoportography in making the diagnosis of thrombosis in the portal venous system although failure to visualize the splenic vein may indicate splenoportography.

Contrast enhancement of the liver and blood. Nonionic versus ionic contrast media in the pig.

The contrast enhancement of low-osmolality (iohexol) and high-osmolality (diatrizoate) contrast media was compared in 18 pigs following intravenous bolus administration. Liver and blood attenuation and blood sample iodine concentration were measured during the first 3 minutes after injection. Iohexol produced a significantly higher contrast enhancement in the blood during the period from 0.5 to 3 minutes after injection. Diatrizoate produced a significantly higher contrast enhancement in the liver during the period from 9 to 30 minutes after injection. The greater contrast enhancement of iohexol during the acute phase should be advantageous in dynamic CT.

Contrast media for CT. An analysis of the early pharmacokinetics.

Iohexol and meglumine-sodium diatrizoate were injected intravenously into 18 pigs as either a 99:1 or 1:99 mixture. Blood samples were taken for 30 minutes and the concentration of each of the two contrast media was measured by means of a double labeling technique with 125I and 131I. Relative concentrations of iohexol were significantly higher during the first 3 minutes when it was injected as a moderately hyperosmolar (99% iohexol) solution than when it was injected as a very hyperosomolar (99% diatrizoate) solution. The greater intravascular dilution of the 99% diatrizoate solution by extravascular water may explain this finding as well as the significantly longer rapid disposition phase and the slightly lower distribution volume of iohexol.

Comparison of the diagnosis of oesophageal varices by oesophagoscopy and transhepatic portography.

We compared the diagnosis of oesophageal varices obtained by oesophagoscopy and percutaneous transhepatic portography in 78 patients with hepatic cirrhosis who were suspected of having oesophageal varices because of ascites and/or preceding upper gastrointestinal haemorrhage. Portograms were evaluated independently of the clinical and endoscopical findings. Endoscopy showed varices in 59 patients and portography in 54 patients. The two methods agreed on the presence of varices only in 46 patients (59%), on the absence of varices in 11 patients (14%), and disagreed in 21 patients (27%). Among the patients showing varices by endoscopy, portography agreed on the diagnosis in 78%, and among patients without endoscopical varices, portography agreed in 58%. The corresponding rates of agreement expected by chance alone are 69% and 31%, respectively. The free portal pressure was lowest in patients with no varices according to both techniques, highest in patients with varices by both techniques and intermediate in patients in whom there was disagreement on the diagnosis. Modification of the criteria for endoscopical and portographical diagnosis of varices and distinction between patients with and without ascites and preceding haemorrhage had no appreciable effect on the agreement. We conclude that endoscopy and portography show only moderate agreement in the diagnosis of oesophageal varices.

The free portal pressure in awake patients with and without cirrhosis of the liver.

The free portal pressure was measured by percutaneous transhepatic catheterization of the portal vein in 106 patients with cirrhosis of the liver and in 19 patients without liver disease and with normal portography. Patients with cirrhosis had a median portal pressure of 38 cmH2O and patients without liver disease had a median portal pressure of 16 cmH2O. Among the cirrhotic patients the free portal pressure showed no relationship to etiology of cirrhosis, ascites, variceal bleedings or extrahepatic shunting. The median portal pressure was significantly higher in patients with (40 cmH2O) than without (30 cmH2O) gastroesophageal varices (p less than 0.01). The pressure was not related to the size of the varices.

Recanalized umbilical vein in portal hypertension.

Experience with splenoportography suggests that patency of the umbilical vein occurs in about 9% of the patients with portal hypertension. A widely patent umbilical vein might serve as a decompressive portosystemic shunt. Percutaneous transhepatic portography was performed in 107 patients with cirrhosis of the liver and portal hypertension. A patent umbilical vein was found in 28 patients (26%). This finding significantly paralleled the number and size of other collateral veins, apart from gastroesophageal varices. No significant relation was found between umbilical vein patency and portal pressure, extrahepatic shunting, variceal bleeding, or ascites. It is concluded that a large patent umbilical vein does not effectively relieve portal hypertension, prevent gastroesophageal varices, or protect against variceal bleeding or ascites.

Ultrasonic localization of the porta hepatis prior to percutaneous transhepatic cholangiography.

Sixtyfour jaundiced patients were randomly allocated to have fine needle PTC performed with or without prior ultrasonographical localization of the porta hepatis. The general success rate was 97% and complications occurred in two patients (3%). Ultrasonography prior to PTC did not significantly reduce the number of needle passes in the liver parenchyma, the failure rate or the number of complications. Ultrasonic scanning, however, should precede PTC to disclose patients with obstructive jaundice and reveal hepatic and perihepatic abnormalities.

Ultrasonography, 99mTc-DIDA cholescintigraphy, and infusion tomography in the diagnosis of acute cholecystitis.

Ultrasonography, 99mTc-DIDA cholescintigraphy, and infusion tomography of the gallbladder were compared in a prospective study comprising 45 consecutive patients clinically suspected of having acute cholecystitis. The diagnosis of acute cholecystitis was established or excluded by operation in 35 patients, by oral cholecystography in 5, and by intravenous cholangiography in 5. The predictive values of a positive and a negative test were 100% and 83%, respectively, by ultrasonography and 98% and 88% by cholescintigraphy. Corresponding values for infusion tomography were 87% and 33%. The results suggest that in patients suspected of having acute cholecystitis, 99mTc-DIDA cholescintigraphy and ultrasonography provide a rapid and reliable diagnosis.