Labral-ligamentous complex of the shoulder. Evaluation with double oblique axial MR arthrography.

PURPOSE: To assess the ability of double oblique axial (DOA) MR arthrography in evaluating labral-ligamentous complex compared with conventional axial (CA) MR arthrography. MATERIAL AND METHODS: MR arthrography of 51 shoulders, subsequently examined with arthroscopy, were retrospectively reviewed. DOA imaging was performed in all 51 shoulders and both DOA and CA imaging in 37 using a 1.5 T unit with gradient recalled-echo T2*-weighted sequences. DOA imaging was performed using perpendicular planes to the long axis of the glenoid fossa obtained by an oblique sagittal scout image. We compared the ability of DOA with that of CA MR arthrography to assess labral injuries and to demonstrate the whole length of the anterior band of the inferior glenohumeral ligament (AIGHL), which were shown to be intact by arthroscopy. RESULTS: For anterior labral injuries, sensitivity and specificity were 87% and 93% with CA, and 94% and 100% with DOA imaging, respectively. For posterior labral injuries, sensitivity and specificity were 47% and 100% with CA, and 79% and 96% with DOA imaging, respectively. There were no statistically significant differences between CA and DOA images, except for the ability to diagnose posterior labral injuries, where DOA imaging had a significant superior sensitivity (p=0.0327). DOA images also demonstrated the whole length of the intact AIGHL in 10 of 11 shoulders, while CA imaging showed this in only 3 of 11. CONCLUSION: DOA imaging was equal or better than CA imaging for evaluating the labral-ligamentous complex.

[Gadolinium-enhanced MR imaging, T2-weighted MR imaging, and transurethral ultrasonography].

PURPOSE: To assess the value and problems of dynamic gadolinium-enhanced MR imaging, T2-weighted MR imaging, and transurethral ultrasonography(TUUS) in staging of urinary bladder cancer. MATERIALS AND METHODS: Dynamic gadolinium-enhanced MR imaging and FSE T2-weighted MR imaging of 64 patients with urinary bladder cancer who subsequently had surgery were retrospectively reviewed and compared with TUUS findings. RESULTS: Specificity for muscular invasion was 90.5% with TUUS, significantly better than with dynamic MR imaging (64.9%) (p < 0.05). The rates of overestimation of superficial cancer(pT1) with dynamic MRI and T2-weighted MR imaging were 35.1%(13/37) and 24.3%(9/37), respectively. The staging accuracy of invasive cancer(pT2 or over) was 85.2% with dynamic MR imaging, which was better than the rate of 75.0% achieved with T2-weighted MR imaging. CONCLUSION: Although TUUS was a better modality for diagnosing superficial cancer(pT1), dynamic MR imaging was found to be better for diagnosing invasive(pT2 or over) cancer.

Chondromyxoid fibroma of the scapula associated with aneurysmal bone cyst.

A rare case of chondromyxoid fibroma of the scapula in a 21-year-old man is presented. This case is of interest because of its unusual site and association of aneurysmal bone cyst. Although chondromyxoid fibroma is uncommon bone tumor of the scapula, it should be considered in the differential diagnosis of expansile osteolytic lesion of the scapula.

[MR diagnosis of internal derangement of the knee by SE T1 and GRE T2* weighted images: evaluation of 300 arthroscopically proven knees].

To evaluate whether or not the combination of sagittal and coronal spin-echo (SE) T1 and sagittal gradient echo (GRE) T2* weighted imaging is adequate to diagnose internal derangement of the knee, a study was done in 300 knees of 293 consecutive patients who underwent both MR imaging of the knee and arthroscopy. In prospective analysis, the MR imaging had an accuracy, sensitivity and specificity of more than 90% in the evaluation of medial meniscus (MM) and of 97% in the evaluation of anterior cruciate ligament (ACL). In the evaluation of lateral meniscus (LM), accuracy was 83%, sensitivity 76%, and specificity 88%. In a review of false-negative MR diagnoses (n = 42) of menisci, the most significant lesion was not in the meniscus but in the ACL in 32 knees (76%). Conservative treatment was selected in 25 knees (60%), rather than partial meniscectomy (n = 13) or meniscoresis (n = 4). There were 21 false-positive MR diagnoses of menisci even in retrospective analysis, and 17 of them (81%) had findings of tear in the posterior zone, which is known to be a difficult area for arthroscopic examination. The results were similar to those of other authors' with SE T1 and/or proton density and T2 weighted images. The combination of sagittal and coronal SE T1 and sagittal GRE T2* weighted images could be sufficient as a routine MR protocol for diagnosing the internal derangement of the knee.

[Double oblique MR images of the shoulder: comparison with conventional images].

PURPOSE: Because the scapula is not only slanted on transverse sections but also inclines on sagittal section, we now perform shoulder MR imaging using double oblique images (DOI), which are planes perpendicular or parallel to the long axis of the scapula obtained with oblique sagittal scout imaging. The purpose of this study was to evaluate the usefulness of double oblique shoulder MR imaging. MATERIALS AND METHODS: MR images of shoulders with operatively or arthroscopically proven lesions (20 cases) that had been examined on both conventional images (CI) and DOI were retrospectively reviewed. DOI were compared with CI not only in terms of diagnostic performance but also in their ability to identify the details of shoulder anatomy. All MR studies were done with a shoulder coil on a high-field (1.5T) unit. RESULTS: Although the accuracy of DOI in diagnosing shoulder disorders such as rotator cuff tear and labrum injury was not as good as that of CI, DOI were better for identifying or discriminating muscles and tendons of the rotator cuff, labralbicipital junction and anterior band of the inferior gleno-humeral ligament, and for recognizing the correct position of the glenoid labrum. CONCLUSION: MR double oblique imaging of the shoulder provides more detailed information about shoulder anatomy and disorders than conventional imaging.

Combination therapy consisting of arterial infusion chemotherapy (EPF, EAP) and transcatheter arterial embolization (TAE).

From January 1988 to January 1993, 45 patients with unresectable advanced hepatocellular carcinoma (HCC) were treated with a new combination therapy consisting of arterial infusion chemotherapy and TAE. The combination therapy was performed according to our treatment schedule as follows: two courses of arterial infusion chemotherapy were given first, and then transcatheter arterial embolization (TAE) using a mixture of Lipiodol and cisplatin powder was performed. Two arterial infusion chemotherapeutic regimens were employed: EPF (etoposide, cisplatin, and 5-fluorouracil) and EAP (etoposide, Adriamycin or Epi-adriamycin, and cisplatin). The anticancer drugs were infused through a catheter inserted into the proper or common hepatic artery. Assessment was made of the anticancer effect and survival rate of each treatment method. The response to each therapy was evaluated on the basis of CT performed prior to and after the treatment. In the EPF.TAE group, the response rate was about 46%, whereas in the EAP.TAE group it was 48%. Overall, 21 of 45 patients attained a regression rate of 50% or more. Furthermore, daughter nodules decreased in size or disappeared in about 67% of 15 patients. Additionally, tumor thrombi tended to show a similar response. In all of the cases, the average duration of survival was 30.3 months, and the 1-year survival value was 68%, the 2-year survival value was 44%, and the 3-year survival value was 35%. These results were superior to those obtained with TAE therapy alone.

[Dynamic MR imaging of the pituitary gland by the fast spin echo (RARE) sequence].

The Fast Spin Echo (RARE: Rapid Acquisition with Relaxation enhancement) sequence for the dynamic MRI of the pituitary gland was performed in 18 patients suspected of the intracranial lesions. The SNR of the plain image of 5 pituitary glands was measured on the FSE 400 and 200/17/8/2 (TR/effective TE/echo train length/excitation) and the spin echo 100/11/2 (TR/TE/excitation) sequence. The FSE (TR = 400) provided the highest SNR than others, The FSE sequence was able to acquire increased spatial resolution and reduced acquisition time, and was the significant sequence for the dynamic MRI of the pituitary gland.

[Angiography in arteriosclerosis].

Advances in angiography of arteriosclerosis have been made possible by improvement of angiographic techniques, materials, such as narrow catheters and gliding guidewires, x-ray apparatus and equipments, including digital subtraction angiography (DSA), computed radiography and magnetic resonance angiography and contrast media. Improved, narrow and yet wide lumen catheters have made it possible to insert the catheter via the axillary or brachial artery. The matrix of DSA was increased to 1024 x 1024 from 512 x 512, and resolution of DSA has been greatly improved. Intravenous DSA has made examination of aneurysm or arterial stenosis or occlusion, easier without much harmful invasion. Ionic or non-ionic low osmolar contrast media has greatly reduced the irritation to the vessels.

[A case with hepatocellular carcinoma effectively treated by continuous hepatic arterial infusion of etoposide, epirubicin and CDDP].

A 53-year-old man who suffered from advanced hepatocellular carcinoma (HCC) was treated with hepatic arterial infusion (HAI) of Etoposide, Epirubicin and CDDP. Treatment consisted of a continuous HAI of Epirubicin (50 mg/body, day 1.7), CDDP (75 mg/body, day 2.8) and Etoposide (80 mg/body, day 4-6). He had two series of infusions and was treated by transarterial embolization using CDDP powder (100 mg) added to lipiodol and aluminum stearate as suspension following HAI. The tumor regression rate was about 60% after HAI, but the remaining tumor seemed to be almost necrotic. AFP and PIVKA-II reached the normal range after TAE. We could not find lipiodol accumulated in tumor on CT carried out eight weeks after TAE. No recurrence has been noticed in the following 8 months. Toxicity was not so severe and was well tolerated.

Arterial infusion chemotherapy for advanced hepatocellular carcinoma using EPF and EAP therapies.

Arterial infusion chemotherapy of EPF (etoposide, cisplatin, and 5-fluorouracil) or EAP (etoposide, Adriamycin, and cisplatin) was carried out in 28 cases of advanced hepatocellular carcinoma (HCC) between January 1988 and December 1990, and assessment was made of the anticancer efficacy of each treatment method. In all, 13 patients were treated with EPF therapy and 15 received EAP therapy. The anticancer agents were infused through a catheter inserted into the proper or common hepatic artery. The catheter was inserted via the axillary artery or common femoral artery using Seldinger's method or the cut-down method. The results of each therapy were analyzed in relation to the tumor regression rate and the side effects encountered. The tumor regression rate was determined on the basis of two-dimensional evidence obtained by computed tomography performed before and after treatment. The treatment results were also compared with the results of chemoembolization therapy using a mixture of cisplatin (CDDP), Adriamycin (ADM) and lipiodol. Of the 28 patients treated with arterial infusion chemotherapy, 14 (50%) attained a regression rate of 50% (PR). In all, 46% of the EPF group and 53% of the EAP group achieved a PR. These results were superior to those obtained using chemoembolization therapy. In general, the side effects were relatively mild and transient.

[Results of combined therapy of irradiation and intra-arterial one-shot injection of cisplatin for head and neck cancers].

Thirty-six previously untreated cases of head and neck cancer were given a combined therapy of irradiation and intra-arterial, one-shot injection of Cisplatin. As a result, the primary lesions in 35 cases were seen to achieve a 66% complete remission (CR) and a 100% overall response (OR). The lymph metastases in twenty-one cases with positive node achieved a 62% CR and a 100% OR. Good, local control of supraglottic and hypopharyngeal cancers were found to be an advantageous factor considered from the standpoint of the "quality of life". The cumulative survival rate, using Kaplan-Meier's method, was 82% for the first year, and 62% for the second year. No severe side effects were observed.

[Recanalization of long segment occlusion of superficial femoral artery by percutaneous transluminal laser angioplasty--report of a case].

Percutaneous Transluminal Laser Angioplasty (PTLA) for 46 cm complete occlusion of right superficial femoral and popliteal artery was successfully carried out. Intravenous digital subtraction angiography five months after the procedure showed almost complete recanalization of the arteries, and good flow of the contrast medium through the femoral and popliteal artery. Only Percutaneous Transluminal Angioplasty (PTA) was previously done for the stenosis of right popliteal artery, but restenosis of the artery took place. On this occasion PTLA was carried out to treat stenosis of the popliteal artery as well as the femoral artery lesions. It is speculated that one of the major causes of reocclusion of the femoral and popliteal artery is due to recurrence of a few portions of severe stenosis of superficial femoral and popliteal arteries. This case will illustrate the long term effect of PTLA, because stenotic segments treated only with balloon dilatation recurred, but those stenoses treated with laser did not recur.

[Hepatocellular carcinoma treated by continuous hepatic arterial infusion of etoposide, CDDP and 5-FU].

Fifteen patients with advanced hepatocellular carcinoma were treated by hepatic arterial infusion (HAI). Treatment consisted of a 24-hour continuous HAI of etoposide (60 mg/day, day 1-5), CDDP (30 mg/day, day 1-5) and 5-fluorouracil (250 mg/day, day 1-26). Three patients had two series of infusions. Five patients were treated by transcatheter arterial embolization following HAI. Among 13 evaluable patients, one showed a complete remission and five patients had a partial response. We obtained a response rate of 46.2%. Toxicity included hematologic toxicity, alopecia, nausea and vomiting. The major toxicity was myelosuppression, but it was well tolerated. These results indicate that continuous HAI of etoposide, CDDP and 5-FU is effective for advanced hepatocellular carcinoma.

[A case of hepatocellular carcinoma effectively treated by intraarterial infusion of CDDP and other agents].

It is very common for intraarterial infusion therapy of some anticancer agent to be effective against hepatocellular carcinoma. In this case, the patient was a 74-year-old man who suffered from very advanced hepatocellular carcinoma with tumor thrombus of the intrahepatic portal vein and IVC. He was treated with intraarterial infusion of CDDP, Etoposide, 5-FU, through a catheter placed in the proper hepatic artery. CDDP (30 mg/day) and Etoposide (60 mg/day) were given once every 5 days, and then 5-FU(250 mg/day) was infused daily for 26 days. The patient underwent this protocol study twice in 3 months. After the intraarterial infusion, transarterial embolization using CDDP (100 mg) powder added to lipiodol and aluminum stearate as suspension was done a month later. The tumor regression rate was 84% after intraarterial infusion of CDDP, Etoposide and 5-FU. The tumor thrombus in the intrahepatic portal vein and IVC had completely disappeared. We could not find lipiodol accumulated in the tumor after TAE. Thus, we assumed that the remaining tumor was a necrotic scar and that a complete response was obtained in the patient. There were some side effects, such as nausea, vomiting, pancytopenia and gastritis but no severe complication occurred.

[A case report of hepatoma with a giant splenic aneurysm both treated by TAE therapy].

A case of a 49-year-old woman who was found to have a giant splenic aneurysm during the course of TAE therapy for hepatoma and who was given TAE therapy using 47 steel coils is reported. The splenic arterial embolization therapy using steel coils proved effective for preventing the rupture of an aneurysm and for inhibiting hypersplenism. In addition, no serious adverse effect was observed.

[New technique of intra-arterial catheterization via the branch of left axillary artery for continuous infusion chemotherapy].

A new technique of intra-arterial catheterization via the branch of left axillary artery is described. This provides relatively swift and safe insertion and long-term placement of an infusion catheter through the left thoracoacrominal artery without exposure of the left axillary artery, that was required by conventional methods. With our technique, the tip of the catheter tends to enter the distal axillary artery because of oblique angulation of the trunk of the thoracoacrominal artery. Therefore, the tip of the catheter in the axillary artery must be deflected using a deflecting guidewire, so that it will advance into the subclavian artery and then down to the descending aorta. The deflection guidewire can also be of help when the catheter tip migrates into either celiac or SMA. The selective catheterization has been successful in all twenty seven patients without preliminary selective left subclavian arteriography.

[MR-angiography with intravenous administration of Gd-DTPA].

We carried out phase contrast MR-angiography of the lower extremities with intravenous administration of Gd-DTPA. Five healthy male volunteers, 25 to 40 years of age, were examined with a 0.5T MRI unit. We used fast scen (gradient echo) technique and it took about 8 minutes for whole procedure. Images were obtained before and after intravenous injection of Gd-DTPA. Injection dose was 0.1 mmol/kg. In two cases, we got images with variable flip angles. However angles of 30 or 40 degrees were thought to be best on the scan with Gd-DTPA. In three cases, we repeated short time procedures for about 4 minutes each time and continued to check the signal intensities of vessels for as long as one hour. The signal intensities greatly increased soon after administration of Gd-DTPA, and then they gradually decreased, but for as long as 60 minutes after administration they remained much higher than those before administration of Gd-DTPA. MR-angiography with Gd-DTPA was found very useful to demonstrate the peripheral femoral vessels clearly. No significant side effect was noticed in any case. Therefore, this method was thought to be very useful clinically.