Effect of adjuvant tamoxifen therapy on thyroid function in postmenopausal women with breast cancer.

Serum thyroid-stimulating hormone (TSH), free thyroxine (FT4) and total tri-iodothyronine (TT3) concentrations were measured in 45 postmenopausal breast cancer patients before adjuvant treatment with tamoxifen and at 3- and 6-month intervals. A significant increase in TSH (p = 0.002) at the end of 3 months and a subsequent decrease at the end of 6 months was noted. There were no significant changes in TT3 and FT4. We concluded that tamoxifen therapy in postmenopausal women may result in a reversible increase in TSH after 3 months.

Appendiceal CT in 140 cases. Diagnostic criteria for acute and necrotizing appendicitis.

Computed tomography (CT) was performed in 140 patients with suspected acute appendicitis. Thin collimation (5 mm), intravenous contrast enhancement, 1-second scan times, and supplementary cecal air insufflation were emphasized. CT accuracy was 98% overall (137/140), and 99% in the 124 cases with early surgery. Necrotizing appendicitis was diagnosed by CT with 86% accuracy and 90% positive predictive value.

CT and US of the pancreas.

The diagnostic capabilities of pancreatic imaging continue to improve with technological advancements in computed tomography (CT), ultrasound (US), and magnetic resonance imaging (MRI). To update the practicing radiologist, this article summarizes the current literature on pancreatic imaging, with particular emphasis on CT and US. Pertinent clinical considerations of the disease entities are included, along with illustrative material from the authors' experience.

Recurrent renal cell carcinoma after 45 years.

Late recurrence of renal cell carcinoma (RCC), arbitrarily defined as > 10 years post nephrectomy, is rare. The longest known clinical disease-free interval of 36 years was reported by Walter and Gellespie in 1960. We report a case of recurrent RCC presenting 45 years after nephrectomy.

Sonographic diagnosis of cisternal subarachnoid hemorrhage in the premature infant.

PURPOSE: To evaluate sonographic criteria for the diagnosis of subarachnoid, and particularly cisternal, hemorrhage in the preterm infant. METHODS: The subarachnoid cisterns were studied on cadaveric anatomic sections and on postmortem ultrasonograms, as well as on in vivo ultrasonograms of healthy neonates. Based on the normal ultrasound appearances of these cisterns, criteria were developed for the recognition of abnormal cisternal fluid collections, which strongly suggest the presence of subarachnoid hemorrhage in the premature infant. These criteria were evaluated prospectively in a group of 63 preterm infants who underwent subsequent autopsy. RESULTS: In the 63 infants with neuropathologic verification, increased echogenicity and/or increased echo-free content of the subarachnoid cisterns correctly predicted subarachnoid hemorrhage with an accuracy of 75%, sensitivity of 69%, and specificity of 93%. The positive and negative predictive values were 97% and 46%, respectively. In 47% of the cases, ultrasound correctly detected cisternal subarachnoid hemorrhage before intraventricular hemorrhage could be diagnosed. CONCLUSION: A highly specific, although somewhat insensitive, sonographic diagnosis of subarachnoid hemorrhage can be made from the appearance of the subarachnoid cisterns. The diagnosis of subarachnoid hemorrhage may predate the ultrasound diagnosis of intraventricular hemorrhage and may alert the neonatologist to the need for follow-up sonograms in the absence of ultrasound evidence of intraventricular hemorrhage.

The use of deep inspiration preceding the Valsalva maneuver and rapid expiration in color Doppler imaging of the lower extremity veins.

Deep inspiration preceding Valsalva maneuver and rapid expiration immediately following it (DIVE) enhance venous blood flow on color Doppler flow imaging (CDI). The effect of DIVE was assessed in 115 consecutive lower extremity examinations. Of these, 95 or 115 (83%) had negative CDI sonograms, and 20 of 115 (17%) had partially (six of 115) or completely (14 of 115) occluding deep vein thrombosis. DIVE enhanced venous blood flow in 68% of the negative cases, resulting in transient venous distention, and/or more complete color filling, and/or greater spectral flow velocities. The 14 cases with completely occluding thrombi showed no response to DIVE. Six cases with partially occluding thrombi showed moderate to mild response to DIVE, with improved color delineation of the residual patent lumen around the thrombus. The authors conclude that DIVE facilitates deep venous CDI, especially when compression cannot be used to augment venous flow.

MR imaging of portal venous thrombosis: correlation with CT and sonography.

Fourteen patients with portal venous thrombosis (PVT) diagnosed by CT and/or sonography were studied with MR. Three of the 14 had portal hypertension. The MR findings were compared with those of eight patients with portal hypertension, but without CT or sonographic evidence of PVT. MR imaging showed portal venous thrombosis in all 14 PVT cases. Intraluminal thrombi of less than 5 weeks duration appeared markedly hyperintense relative to liver and muscle on both T1- and T2-weighted images. Older thrombi appeared hyperintense relative to liver and muscle in eight of 11 cases, but only on T2-weighted images. MR showed thrombi in 11% more portal vessels than did CT (MR = 30, CT = 27) and in 28% more vessels than did sonography (MR = 32, sonography = 25). MR also showed 24% more collateral vessels than did CT (MR = 31, CT = 25) and 50% more vessels than did sonography (MR = 33, sonography = 22). Third-echo images (echo time = 96 msec, repetition time = 1500-2150 msec) verified the presence of venous thrombi in 28 (93%) of 30 PVT vessels, and they differentiated flow-related intravascular signal from true thrombi in six (17%) of 36 portal hypertension vessels. We conclude that MR is a valuable tool for imaging portal vein thrombosis. MR is a good substitute for CT and can be more informative than sonography.

Computed tomography and magnetic resonance imaging of a superior gluteal artery pseudoaneurysm.

The magnetic resonance and computed tomography appearances of a superior gluteal artery pseudoaneurysm are described, with emphasis on the relative advantages and disadvantages of these two imaging procedures.

Perirenal spaces: CT evidence for communication across the midline.

The perirenal spaces may communicate across the midline, anterior to the lower aorta and vena cava. The connecting channel has a relatively narrow anteroposterior dimension on computed tomographic (CT) scans, both in vivo and in injected cadavers. It may therefore be difficult to visualize on abdominal radiographs and may be mistaken for unopacified bowel on CT scans. The midline extension of perirenal fluid is usually contiguous to the lower abdominal great vessels anteriorly but does not surround them completely, possibly because of fibrous septa within the perivascular fat. Hematomas from ruptured aortic aneurysms extend mainly into the perirenal spaces. Thus, the lower abdominal great vessels are located, in effect, within the midline extension of these spaces. Superiorly, the perirenal spaces extend to the diaphragm, abutting the lateral and anterior margins of the psoas and quadratus lumborum muscles and the bare area of the liver. Inferiorly, perirenal collections appear to diverge into the pelvis, along the psoas muscles, ureters, and iliac vessels.

Computed tomography appearance of adrenal vein thrombosis.

The computed tomography appearance of adrenal hemorrhage secondary to adrenal vein thrombosis is illustrated. The lesion appeared radiolucent, with a small focal calcification, mimicking an adrenal adenoma. Hypercoagulopathy was an underlying factor in this patient with myelofibrosis and chronic myelogenous leukemia.

Computed tomography of renal aspergillosis.

The CT and sonographic findings of a case of localized, invasive aspergillosis of the kidney are presented.

CT of fibrous tissues and tumors with sonographic correlation.

Fibrous tissues and tumors may appear hyperdense relative to muscles and solid viscera on CT both before and after IV contrast injection. In addition, fibrous tissues generally have a homogeneously hypoechoic sonographic appearance. The diagnostic value of these criteria is illustrated in a group of 21 fibrous tissue abnormalities that includes retroperitoneal, mediastinal, and perigraft fibrosis, sclerosing pseudotumor of the orbit, generalized fibromatosis, desmoids, malignant fibrous histiocytoma, and normal tendons and ligaments. It is concluded that while hyperdensity on CT and echopenia on sonography are not pathognomonic of fibrous tissue, they occur with sufficient frequency that their presence raises the possibility of a fibrous lesion.

Intraperitoneal paravesical spaces: CT delineation with US correlation.

The urinary bladder, obliterated umbilical arteries, and inferior epigastric vessels located within the extraperitoneal space of the anterior abdominal wall indent the anterior parietal peritoneum, forming intraperitoneal paravesical fossae. These are the supravesical space and the medial and lateral inguinal fossae. More posteriorly, the peritoneum covering the bladder is reflected onto the rectum to form the rectovesical space, which is divided by the uterus into an anterior vesicouterine recess and a posterior rectouterine pouch, or cul-de-sac. The cul-de-sac is continuous with the pararectal and ovarian fossae and is bounded posterolaterally by the rectouterine (sacrogenital) folds. These peritoneal compartments form a large potential space for the accumulation of ascites and are separated from the equally large extraperitoneal paravesical spaces by only a thin layer of peritoneum or peritoneum and umbilicovesical fascia. The computed tomographic scans of 100 patients with ascites were reviewed, with particular attention to the differentiation between intraperitoneal and extraperitoneal paravesical collections. The scans of intraperitoneal collections were found to have certain characteristic appearances, including inferior displacement of the distended urinary bladder, visualization of the umbilical folds, and preservation of the preperitoneal fat.

Extraperitoneal paravesical spaces: CT delineation with US correlation.

The extraperitoneal space around the urinary bladder is lamellate, just like the retroperitoneal space around the kidneys. The bladder, urachus, and obliterated umbilical arteries lie within the perivesical space, surrounded by umbilicovesical fascia, analogous to the perinephric space within the renal fascia. A much larger prevesical space, analogous to the anterior pararenal space, lies anterior and lateral to the umbilicovesical fascia. Posterior to the urinary bladder, the lower uterine segment or seminal vesicles lie within the perivesical space, rather than in a separate compartment, corresponding to the posterior pararenal space. The cul-de-sac, and the inferolateral extension of its peritoneal layers as the rectovaginal or rectovesical septum, separate the posterior perivesical space from the rectum. The sectional anatomy of these spaces, and particularly their computed tomographic and ultrasound appearances, were noted in normal anatomic sections, patients with extraperitoneal fluid collections, and a cadaver into which fluid was injected.

Percutaneous needle biopsy of deep pelvic masses: a posterior approach.

The classical approach for the fine-needle aspiration biopsy of deep pelvic masses has been through the lower anterior abdominal wall. With this approach, and using either CT or sonographic guidance, bowel or bladder may be unavoidably traversed to reach the mass. We have been using a posterior approach through the sciatic notch, which is a safe and simple procedure, with good results. The biopsy is done with the patient in a prone position, using a 22-gauge biopsy needle. With this technique we have successfully biopsied various neoplastic pelvic entities.