Evaluation of periampullary pathology with CT volumetric oblique coronal reformations.

OBJECTIVE: The purpose of this article is to show the value of volumetric oblique coronal reformation of CT data sets for assessing the normal anatomy and abnormalities of the ampulla of Vater. CONCLUSION: Volumetric oblique coronal reformations are a useful noninvasive method to provide diagnostic information about periampullary abnormalities as well as show secondary features important for local staging and management. The technique is also valuable in providing a time-efficient method to review pertinent findings with clinicians.

CT of pancreas: minimum intensity projections.

OBJECTIVE: The purpose of this pictorial essay is to showcase the use of minimum intensity projection in the imaging of low attenuation structures such as the pancreatic duct. CONCLUSION: Minimum intensity projection is a valuable adjunct to other processing techniques for the diagnosis and staging of pancreatic adenocarcinoma and cystic tumors of the pancreas.

Effects of growth hormone and pioglitazone in viscerally obese adults with impaired glucose tolerance: a factorial clinical trial.

OBJECTIVE: Recombinant human growth hormone (GH) and pioglitazone (PIO) in abdominally obese adults with impaired glucose tolerance were evaluated under the hypothesis that the combination attenuates GH-induced increases in glucose concentrations, reduces visceral adipose tissue (VAT), and improves insulin sensitivity over time. DESIGN: Randomized, double-blind, placebo-controlled, 2 x 2 factorial design. SETTING: Veterans Affairs Palo Alto Health Care System, Palo Alto, California, United States. PARTICIPANTS: 62 abdominally obese adults aged 40-75 with impaired glucose tolerance. INTERVENTIONS: GH (8 microg/kg/d, or placebo) and pioglitazone (30 mg/d, or placebo) for 40 wk. OUTCOME MEASURES: Baseline and after 40 wk of treatment, VAT content was quantified by CT scan, glucose tolerance was assessed using a 75-g oral glucose tolerance test, and insulin sensitivity was measured using steady-state plasma glucose levels obtained during insulin suppression test. RESULTS: BASELINE: body mass index (BMI), plasma glucose, and visceral fat content were similar. 40 wk: visceral fat area declined 23.9 +/- 7.4 cm(2) in GH group, mean difference from placebo: -28.1 cm(2) (95% CI -49.9 to -6.3 cm(2); p = 0.02). Insulin resistance declined 52 +/- 11.8 mg/dl with PIO, mean difference from placebo of -58.8 mg/dl (95% CI -99.7 to -18.0 mg/dl; p = 0.01). VAT and SSPG declined with GH and PIO combined, mean differences from placebo of -31.4 cm(2) (95% CI -56.5 cm(2) to -6.3 cm(2); p = 0.02) and -55.3 mg/dl (95% CI -103.9 to -6.7 mg/dl; p = 0.02), respectively. Fasting plasma glucose increased transiently in GH group. No significant changes in BMI were observed. CONCLUSIONS: Addition of PIO to GH attenuated the short-term diabetogenic effect of GH; the drug combination reduced VAT and insulin resistance over time. GH plus PIO may have added benefit on body composition and insulin sensitivity in the metabolic syndrome.

Small cystic lesions of the pancreas: clinical significance and findings at follow-up.

BACKGROUND: Our purpose was to correlate the imaging findings of small cystic pancreatic lesions to the incidence of growth on follow-up imaging and their pathologic diagnoses. METHODS: CT images for 159 patients with cystic pancreatic lesions were retrospectively evaluated and lesions were assessed for size, number, connection to the main pancreatic duct (MPD), MPD dilatation, and any presence of loculation, wall irregularity, thick septations, or solid components. A total of 86 patients had follow-up imaging with time periods of less than 6 months (n = 21), 6-12 months (n = 22), 1-2 years (n = 14), and greater than 2 years (n = 29). Lesion histology was available in 20 patients. RESULTS: Lesions with pathologic correlation proved to be: side branch intraductal papillary mucinous neoplasm or tumor (IPMT) (n = 5), combined type IPMT (n = 4), nonmucinous cyst (n = 4), chronic pancreatitis (n = 2), and reactive atypia with nonmucinous fluid (n = 1), combined type IMPT with foci of adenocarcinoma (n = 1), mucinous adenocarcinoma (n = 2), and nonmucinous adenocarcinoma (n = 1). Lesions with solid components were significantly more likely to grow and be malignant (P < 0.05). The presence of MPD dilatation was more common in patients with combined type IPMTs or malignancies. No other factors were predictive of malignancy. CONCLUSIONS: Solid components are predictive of malignancy, and MPD dilatation should prompt consideration of surgery. Other cystic lesions can be followed.

Evaluation of fluorodeoxyglucose positron emission tomography imaging in metastatic transitional cell carcinoma with and without prior chemotherapy.

INTRODUCTION: This study was designed to determine the value of fluorodeoxyglucose (FDG) positron emission tomography (PET) in the evaluation of metastatic transitional cell carcinoma (TCC). METHODS: Fifty-eight FDG PET scans were performed on 46 consecutive patients with TCC. Results were correlated with radiologic, pathologic, and histologic findings in these patients and the sensitivity of PET for detecting malignancy in untreated TCC patients (n = 48) was compared to the sensitivity in patients who had undergone prior chemotherapy (n = 10). RESULTS: Of 48 scans in patients who had no prior systemic chemotherapy, 10 had increased uptake in proven metastatic TCC lesions and 3 PET studies failed to reveal metastatic TCC (sensitivity 76.9%). In patients free of metastatic disease, 33 revealed no abnormal uptake and 1 study revealed a suspicious area in a patient free of metastases (specificity = 97.1%). However, in 10 patients imaged after receiving chemotherapy, the sensitivity fell to 50% for the detection of histologically confirmed residual/recurrent tumor by PET. CONCLUSIONS: FDG PET detects increased metabolic activity. After chemotherapy, viable cancer cells may still be present but with a diminished metabolic rate. As a result, PET imaging is often useful in the evaluation of untreated metastatic TCC metastasis but should be interpreted with caution in patients who have received prior chemotherapy.

MDCT in Pancreatic adenocarcinoma: prediction of vascular invasion and resectability using a multiphasic technique with curved planar reformations.

OBJECTIVE: The objective of our study was to determine the negative predictive value of MDCT with curved planar reformations for detecting vascular invasion and predicting overall resectability in patients with pancreatic adenocarcinoma. MATERIALS AND METHODS: Imaging findings related to vascular invasion and overall tumor resectability in 25 patients who underwent contrast-enhanced biphasic MDCT evaluation were correlated with actual vessel invasion and overall resectability determined at surgery and pathologic examination. The presence of vascular invasion was assessed in 110 major peripancreatic vessels in 22 patients who underwent resection. RESULTS: On MDCT, 23 (92%) of 25 patients were deemed to have resectable pancreatic adenocarcinoma. The tumors in the remaining two (8%) were considered not resectable because of the presence of vascular invasion (which was confirmed in only one patient at surgery). Of those 23 patients deemed to be candidates for curative resection on the basis of MDCT results, 20 were found to have resectable adenocarcinoma at time of surgery, yielding a negative predictive value for MDCT of 87% (20/23 patients) for overall resectability. In the other three patients, adenocarcinoma was deemed to be unresectable because of small metastases to the liver (two patients) or to the peritoneum (one patient) discovered at surgery. For detection of vascular invasion, MDCT yielded a negative predictive value of 100% (108/108 vessels) with no false-negative findings and an accuracy of 99% (109/110 vessels) with 108 true-negative findings, one true-positive finding, and one false-positive finding. CONCLUSION: Our preliminary data on MDCT show that the technique has excellent negative predictive value for vascular invasion and good negative predictive value for overall tumor resectability in patients with pancreatic adenocarcinoma, suggesting an improvement over previous results reported using single-detector CT. The problem of undetected micrometastases to the liver and peritoneum remains.

Local staging of pancreatic carcinoma with multi-detector row CT: use of curved planar reformations initial experience.

PURPOSE: To evaluate the utility of curved planar reformations compared with standard transverse images in the assessment of pancreatic tumors. MATERIALS AND METHODS: Forty-three patients suspected of having pancreatic tumors underwent contrast material-enhanced biphasic multi-detector row computed tomography (CT). Curved planar reformations were generated along the pancreatic duct, common bile duct, and major mesenteric vessels. Three blinded independent readers assessed the curved planar reformations and transverse images separately for the presence of tumor, resectability, and vascular involvement. The results were compared with those of a consensus panel who evaluated the curved planar reformations and transverse images together along with clinical data and surgical findings. RESULTS: Of 43 patients, 20 had pancreatic malignancies as judged by the consensus panel and proven at biopsy and/or clinical follow-up. For tumor detection, transverse images and curved planar reformations had an average sensitivity of 95.0% and 98.4% (P >.05), respectively, and an average specificity of 90.9% and 91.3% (P >.05), respectively. For tumor resectability, transverse images and curved planar reformations had an average sensitivity of 85.7% and 71.4% (P >.05), respectively, and an average specificity of 85.2% and 84.3% (P >.05), respectively. Average interpretation time was 6.4 minutes with transverse images and 4.1 minutes with curved planar reformations. CONCLUSION: Curved planar reformations are equivalent to transverse images in the detection of pancreatic tumors and determination of surgical resectability.

Multidetector-row CT and volumetric imaging of pancreatic neoplasms.

Multidetector-row CT provides excellent visualization of the pancreas and peripancreatic structures, yielding information that is crucial for detecting pancreatic neoplasms and accurately determining their staging. This new technology enables the acquisition of large volumetric data sets to create high-quality curved planar reformations that clearly depict the common bile duct, the pancreatic duct, and the peripancreatic vasculature. Additionally, curved planar reformations highlight critical anatomic and pathologic relationships which are useful for surgical planning in patients with resectable disease.

Imaging for suspected appendicitis: negative appendectomy and perforation rates.

PURPOSE: To determine which patients suspected of having acute appendicitis benefit from preoperative imaging. MATERIALS AND METHODS: The medical records of 462 consecutive patients who underwent appendectomy for clinically suspected acute appendicitis and underwent preoperative evaluation at our institution were retrospectively reviewed. Patients were divided into four groups: women (n = 166), girls (n = 46), men (n = 178), and boys (n = 72). Preoperative computed tomography (CT) or ultrasonography (US), requested by the referring clinician, was performed in 313 of the 462 patients. Unnecessary, or negative, appendectomy and perforation rates were calculated for each group for preoperative evaluation with CT, with US, and with neither CT nor US. In addition, the sensitivity and positive predictive value of CT and US were calculated for diagnosing appendicitis. RESULTS: In women, the negative appendectomy rate was significantly lower for those who underwent preoperative CT (7% [six of 85 patients], P =.005) or US (8% [four of 49 patients], P =.019), as compared with 28% [nine of 32 patients] for those who underwent no preoperative imaging (P >.35 for all groups). The negative appendectomy rates for girls, men, and boys were not significantly affected by preoperative imaging. The sensitivity of CT and US for diagnosing acute appendicitis exceeded 93% and 77%, respectively, in all groups. The positive predictive values for both CT and US were greater than 92% in all groups. CONCLUSION: Women suspected of having appendicitis benefit the most from preoperative CT or US, with a statistically significantly lower negative appendectomy rate than women who undergo no preoperative imaging. Therefore, we propose that preoperative imaging be considered part of the routine evaluation of women suspected of having acute appendicitis.

The effects of colostomy on the quality of life in patients with spinal cord injury: a retrospective analysis.

PURPOSE: The purpose of this study was to evaluate the effects of colostomy on the quality of life (QOL) in patients with spinal cord injury (SCI) by designing a questionnaire that used self-reported data and correlating these data with the clinical information obtained from patients' medical records. MATERIALS AND METHODS: A comprehensive QOL questionnaire was designed to specifically address the following 5 domains: physical health, psychosocial adjustment, body image, self-efficacy, and recreation/leisure. This questionnaire was completed during a telephone or an in-person interview. The subjective data derived from the questionnaire were correlated with objective medical information obtained from a review of medical records. RESULTS: The QOL improved significantly (t = 9.1 28, P < .0001) after colostomy. All 27 (100%) patients were "satisfied," and 16 (59%) of them were "very satisfied" with colostomy. Nineteen (70%) patients would have preferred to have the colostomy done earlier, and only 3 (11%) patients wished it reversed. Colostomy reduced the number of hospitalizations caused by chronic bowel dysfunction by 70.4%. After colostomy, the average amount of time spent on bowel care was reduced from 117.0 min/day to 12.8 min/day (t = 7.964, P < .0001). All patients stated that colostomy simplified bowel care routine and increased independence. Significant improvements were recorded in the areas of physical health, psychosocial adjustment, and self-efficacy. Stoma prolapse and wound dehiscence were the most common complications of stomal surgery. When compared with medical data, patients were able to reliably recall average time with bowel problems (r = .881, P < .0001) and stomal surgery complications (r = .810, P < .0001). CONCLUSION: Colostomy is a safe and effective treatment for chronic bowel dysfunction in patients with spinal cord injury. It is well accepted by the patients and significantly improves QOL and bowel management procedures. Correlation analysis indicates that subjective patient-reported data are consistent with objective data obtained from the medical records.