Metastatic carcinoma of the breast: the appearances of metastatic spread to the abdomen and pelvis as demonstrated by CT.

This review illustrates some CT appearances of metastatic breast cancer in the subdiaphragmatic abdomen and pelvis. Such manifestations are not uncommon in advanced disease and familiarity will enable confident diagnosis in patients at risk for metastatic disease.

The pathway study: results of a pilot feasibility study in patients suspected of having lung carcinoma investigated in a conventional chest clinic setting compared to a centralised two-stop pathway.

UNLABELLED: The best chance of cure in non-small cell lung cancer (NSCLC) is surgical resection, but UK rates of 8% compare poorly to 25% in the USA and Europe. Delays in diagnosis in the current UK system may be one reason for such discrepancy. To address this problem we set up a rapid diagnostic system and compared it to the conventional method of investigations in a pilot randomised trial. METHODS: Eighty-eight patients were prospectively enrolled from three District General Hospitals and randomised to either investigation locally or to the rapid system at The Royal Marsden Hospital. The pilot end-points were feasibility and audit of radical treatment rates to enable estimates for patient numbers for the full study. RESULTS: Forty-five and 43 patients were in the central and conventional arms, respectively (65% male, median age 69 years). There was a 4-week improvement in time to first treatment in those in the central arm (P=0.0025) with 13/30 (43%) and 9/27 (33%) patients having radical treatment in the central and conventional arms, respectively. Patients in the conventional arm felt the diagnostic process was too slow (P=0.02) while those in the central arm seemed to have a better care experience (P=0.01). There were significantly less visits to the general practitioner (GP) in the central arm (P=0.02). CONCLUSIONS: This pilot study demonstrates that the full study is feasible but would require the commitment and involvement of a large number of patients and physicians. The results show several advantages to investigations and diagnosis in the central arm, particularly in time to treatment initiation, patient satisfaction and rate of radical treatments. The improved rate of radical treatment could lead to an improved survival rate.

Vertebral compression fractures in acute lymphoblastic leukaemia and remodelling after treatment.

Three children, aged 7-10 years, with acute lymphoblastic leukaemia presented with back pain, along with a mild kyphosis. Collapse of the vertebral bodies at multiple levels was shown on imaging. Chemotherapy resulted in pain resolution and spontaneous remodelling of the vertebrae.

Dynamic contrast enhanced MRI of prostate cancer: correlation with morphology and tumour stage, histological grade and PSA.

AIM: To quantify MRI enhancement characteristics of normal and abnormal prostatic tissues and to correlate these with tumour stage, histological grade and tumour markers. MATERIALS AND METHODS: Quantitative gradient recalled echo MR images were obtained following bolus injection of gadopentetate dimeglumine in 48 patients with prostate cancer. Turbo spin-echo T2-weighted images at the same anatomical position were reviewed for the presence of tumours (45 regions), normal peripheral zone (33 regions), and normal appearing central gland (30 regions). Time-signal intensity parameters (onset time, mean gradient and maximal amplitude of enhancement and wash-out score) and modelling parameters (permeability surface area product, lesion leakage space and maximum gadolinium concentration) were correlated with tumour stage, histological grade (Gleason score) and serum prostatic specific antigen (PSA) levels. RESULTS: Significant differences were noted between peripheral zone and tumour with respect to signal intensity and modelling parameters (P = 0.0001), except onset time. No differences between central gland and tumour enhancement values were seen. There was weak correlation between MRI tumour stage and tumour vascular permeability (r(2) = 12%; P = 0.02) and maximum tumour gadolinium concentration (r(2) = 14%; P = 0.015). However, no significant correlations were seen with Gleason score or PSA levels. CONCLUSION: Quantification of MR contrast enhancement characteristics allows tissue discrimination in prostate cancer consistent with known variations in microvessel density estimates.

Pneumomediastinum complicating bleomycin related lung damage.

We describe two patients who developed spontaneous pneumomediastinum without pneumothorax against a background of bleomycin-induced pulmonary interstitial disease whilst on treatment for metastatic germ cell tumours of the testis. Pneumomediastinum is a rare but recognized complication of bleomycin-induced lung toxicity, which has previously only been described in association with pneumothorax.

Assessment of response following treatment for malignant disease.

Monitoring tumour response to therapy is an increasingly important aspect of oncological radiology. Cancer is increasing in incidence in the UK and recent advances in treatment have resulted in many more patients surviving with treated disease. Concurrent advances in imaging techniques over the past two decades permit us to obtain detailed morphological and functional information from treated tumours. This article reviews clinical strategies for imaging patients following treatment for cancer with particular reference to techniques which are currently under continuing scientific evaluation.

Oral magnetic particles (ferristene) as a contrast medium in abdominal magnetic resonance imaging.

RATIONALE AND OBJECTIVES: In this phase III study, we evaluated the efficacy and safety of a negative contrast medium, ferristene (oral magnetic particles), among 277 patients undergoing magnetic resonance (MR) imaging of the abdomen. METHODS: Enhanced (800 ml ferristene) MR images were compared with unenhanced MR images in an intraindividual-patient control design. Adverse events were recorded. The examinations were performed on 1.5-T MR systems (T1- and T2-weighted sequences). RESULTS: Ferristene increased the diagnostic information in 50.9% of the patients, particularly in those with abdominal masses, lymphoma, or pancreatic disease. Distribution of ferristene in the stomach, duodenum, jejunum, and ileum was complete or sufficient in 70.5-85% of the studies. In 64% of the patients, we were confident in the MR findings after the use of ferristene, and ferristene disclosed additional findings in 22% of the patients. The incidence of adverse events was 9.0%, but only 3.6% of all patients experienced ferristene-related adverse events (e.g., nausea, vomiting). Most events were mild or moderate in intensity. CONCLUSION: Ferristene was well tolerated, and for 50% of the patients it added useful diagnostic information.

The role of intravenous contrast enhancement in magnetic resonance imaging of prostatic carcinoma.

Although magnetic resonance imaging (MRI) has been shown to be a promising technique for staging prostatic carcinoma, its accuracy in detection of extraprostatic spread and seminal vesical invasion is subject to considerable error. The role of dynamic MRI, following bolus intravenous contrast medium, in depicting carcinoma of the prostate was evaluated and the information provided by this technique compared with unenhanced images. Spin-echo T1-weighted, T2-weighted, bolus contrast enhanced and delayed post-contrast enhanced T1-weighted images were obtained in 20 patients with histologically proven adenocarcinoma of the prostate. Tumour was identified in all of the patients studied. When compared with unenhanced and delayed post-contrast enhanced images, dynamic bolus contrast enhanced images enabled the best definition of tumour within the gland in 50% of patients and demonstrated extracapsular spread more clearly in 80% of patients. It is concluded that dynamic bolus contrast enhancement may be useful in selected patients with prostatic carcinoma by enabling tumour margins to be depicted more clearly.

Radiology in the staging of bladder cancer.

Careful staging of bladder cancer at presentation is necessary for a rational choice of treatment and gives a clear indication of the long-term prognosis. In the past 20 years computer-based imaging technology has improved the precision of staging.

Case report: ossifying fibromatosis of the breast.

We report the first described case of ossifying fibromatosis of the breast. This condition warrants consideration as a rare differential diagnosis of carcinoma of the breast and dense calcification on mammography.

Imaging after titanium cranioplasty.

Titanium cranioplasty has been used in our unit for reconstruction of cranial defects following trauma, tumour resection and bone loss due to postcraniotomy infection. It has previously been assumed that imaging to assess recurrence of disease progression after cranioplasty would be severely compromised in the presence of metallic material. Titanium is a non-ferrous metal of low atomic number, which is relatively radiolucent and allows exceptionally clear images to be obtained without significant degradation of image quality, on CT and magnetic resonance (MR) imaging. Cases are presented that demonstrate the use of CT contrast cisternography and MR imaging after titanium cranioplasty. On the basis of its strength, biocompatibility and excellent handling characteristics, allied to its suitability for all post-operative imaging techniques, we conclude that titanium plate is the material of choice for cranioplasty.

Role of magnetic resonance imaging in predicting relapse in residual masses after treatment of lymphoma.

PURPOSE: This prospective study of patients treated at the Royal Marsden Hospital Lymphoma Unit was designed to evaluate the role of magnetic resonance imaging (MRI) in the assessment of residual masses evident on computed tomographic (CT) scanning following treatment of lymphoma. PATIENTS AND METHODS: All patients had MRI, gallium-67 single-photon emission CT (67Ga SPECT), and erythrocyte sedimentation rate (ESR) performed within 3 months of completing therapy. Patients were monitored for 1 year posttreatment and observed for signs of relapse. Investigation results were correlated with disease status, and the sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) calculated. Time-to-relapse curves were derived and the log-rank test used to determine whether patients with a positive result were more likely to have a relapse within the mass than those with a negative result. RESULTS: Thirty-four patients were studied, 14 of whom relapsed, 11 within the area of residual mass. Overall, MRI had a high specificity (90%), PPV (71%), and NPV (75%), but poor sensitivity (45%). The results for 67Ga SPECT were similar, apart from lower sensitivity (33%). ESR had inferior performance in predicting relapse compared with the other tests. MRI was the only investigation to show statistical significance (P = .14) in predicting relapse, and this was particularly evident in Hodgkin's lymphoma (P = .003). Combining results of 67Ga SPECT and MRI did not improve predictive power. CONCLUSION: These data demonstrate that MRI is a valuable tool in the setting of a residual mass after treatment, giving clinically useful prognostic information. 67Ga SPECT also has a role, but is less effective in predicting relapse than MRI.

Phase III trial of oral magnetic particles in MRI of abdomen and pelvis.

A prospective Phase III trial was performed to evaluate the efficacy in clinical practice of a new gastro-intestinal contrast agent, Oral Magnetic Particles (OMP), for use in abdominal and pelvic magnetic resonance imaging (MRI). This was an open study comprising 35 patients each given 800 ml of OMP at a concentration of 0.5 g/l. Distribution of the agent was most reliable in the small bowel. General contrast effect was satisfactory, and image quality and diagnostic confidence were enhanced. Administration of OMP increased diagnostic information in the magnetic resonance (MR) image in 50% of patients. No clinically significant adverse effects were observed. The results confirm in a clinical setting a potential role for this new contrast agent.