Imaging of cystic echinococcosis.

This paper reviews various imaging techniques in different organs. Ultrasound is the most popular and readily available technique. Special emphasis is given to computerized tomography (CT) and magnetic resonance imaging (MRI) findings and their advantages for a confident diagnosis and treatment.

Fine needle aspiration biopsy of hydatid cysts.

Fine needle aspiration biopsy (FNAB) was performed in 31 patients with hydatid disease by 15 operators in 41 biopsy events during the period 1983-93. The FNABs were unintentionally done without prior clinical suspicion of hydatid cysts (HCs) in 18 patients and intentionally (with prior clinical suspicion of HC) in 13 patients for pathologic confirmation required for specific therapy. The FNABs were performed with the guidance of fluoroscopy (n = 7), CT (n = 14) or ultrasonography (n = 10). The material included both closed, open and ruptured HCs from different locations such as abdomen, thorax, spine and bone. Pathologic confirmation of HC was achieved by recovering and demonstrating parasitic material in the specimen. In only 7 of 31 patients were the specimens diagnostic at the initial interpretation. This emphasizes the importance of alerting the pathologist about the possibility of hydatid disease. In 25 of 31 patients (81%) no biopsy reactions occurred. In 5 patients minor allergic reactions occurred and 3 had filling of air into intrathoracic cysts not requiring therapy. One patient, with a FNAB of a liver HC, had a sudden severe drop in blood pressure, which required anti-shock therapy with subsequent recovery without sequelae. All complications occurred with non-intentional biopsy of HC. Suggestions for diagnostic and therapeutic management of patients with HC and advice to avoid or limit potential complications or spread of disease are given where a planned biopsy is necessary for appropriate and effective therapy.

CT-guided fine needle aspiration biopsy in the diagnosis of mediastinal tuberculosis.

Twenty-two patients with mediastinal tuberculosis were reviewed. The most common symptoms were chest pain, cough, fever, and weight loss. Results of the physical examination were unremarkable. The chest radiographs of all 22 patients showed abnormal mediastinum with no evidence of extramediastinal disease. Most (62%) had right-sided paratracheal lymphadenopathy. Mantoux skin test was positive (> 15 mm) in all patients, whereas sputum smears and cultures for acid-fast bacilli were negative. Computed tomographic (CT) guided fine needle aspiration biopsies (FNAB) were performed in 12 patients using 22- to 25-gauge needles. Ten patients had fiberoptic bronchoscopic (FOB) examination with brushings and biopsies. Mediastinoscopy (n = 8) or thoracotomy (n = 6) was performed in patients where either FNAB or FOB was not diagnostic or where lymphoma was suspected clinically. The rates of true-positive diagnoses were 20%, 66%, 75%, and 100% for FOB, FNAB, mediastinoscopy, and thoracotomy, respectively. The rate of false-negative for FNAB was 34%. Only one patient developed nonsignificant pneumothorax after FNAB. These findings suggest that CT-guided FNAB is a useful and safe procedure and should be considered in the initial evaluation of patients suspected of having mediastinal tuberculosis.

Case report 833: Primary spinal echinococcosis (Echinococcus granulosus) of lumbosacral spine with destruction of the left pedicles of L3-5 and extension of a large paraspinal cystic mass into the spinal canal.

CT is helpful in recognizing the occurrence of hydatid cysts. The increased spatial resolution allows better visualization of details of bone destruction and spinal canal involvement. Paraspinal cystic disease may also show typical and/or characteristic signs of hydatid disease even if serological findings are falsely negative or inconclusive. In the postoperative follow-up, CT may be helpful in assessing residual hydatid cysts and/or in detecting recurrence at an earlier stage.

Sarcoidosis in native Saudis.

Sarcoidosis is believed to be rare in Saudi Arabia. We report twenty cases of sarcoidosis among native Saudis followed-up at our tertiary care centre. The majority (55%) of these patients were referred as either tuberculosis or lymphoma. Twelve out of twenty patients had been or were being treated for pulmonary tuberculosis at the time of presentation. The clinical presentation of these patients was similar to the western pattern of disease with some differences such as severe constitutional symptoms (52%), relative frequent eye involvement (35%) and common occurrence of stage II changes on chest film (70%). Mantoux skin test was negative in nineteen patients (95%). Histological evidence of non-caseating granulomata was obtained in 19 patients. A positive correlation (p < 0.034) between constitutional symptoms and Angiotensin Converting Enzyme (ACE) levels was noted. Thirteen patients (65%) were treated with oral steroids while topical ophthalmic steroids were used in seven patients (35%). Functional and radiographic deterioration was observed in four patients (20%). Three patients went into respiratory failure including a patient who developed Hodgkin's lymphoma six years after the diagnosis of sarcoidosis. The epidemiology of sarcoidosis among native Saudis requires further studies.

Hydatid disease of the urinary tract.

Hydatid disease of the urinary tract is uncommon, accounting for only 2 to 3% of all such cases. We report 2 cases of urinary tract hydatidosis, of which 1 was associated with disseminated disease and 1 with isolated renal hydatid disease. We describe the variety in presentation, manifestations and symptoms of the disease, and discuss radiological evaluation and findings.

Hydatid disease of the spleen. Ultrasonography, CT and MR imaging.

Seven patients with hydatid disease of the spleen were examined by radiography, ultrasound, CT, and in one case MR imaging. The observations were confirmed by patho-anatomic findings except in 2 patients where high indirect hemagglutination tests confirmed the diagnosis. In one patient primary, and in the others secondary, echinococcosis of the spleen was assumed to be present. Secondary hydatid disease of the spleen was caused by rupture of liver cysts with abdominal and pelvic dissemination. Ultrasound and CT findings of the cysts and cystic calcifications are described. In one patient MR imaging indicated prolapse of a splenic hydatid cyst into the left hemithorax, confirmed by patho-anatomic examination.

New diagnostic signs in hydatid disease; radiography, ultrasound, CT and MRI correlated to pathology.

Seventeen of 70 patients with hydatid disease had verified Echinococcus granulosus infection of the chest. In 14 patients (20%), the primary location was the lung parenchyma. Two patients had primary and one secondary mediastinal hydatid cysts, and one patient a primary hydatid cyst of the chest wall. In three above-mentioned patients, secondary pleural involvement occurred, of which two were due to ruptured pulmonary cysts and one due to an hydatid cyst arising in the liver and having prolapsed into the chest. In all cases, clinical findings, radiography, ultrasound (US), computed tomography (CT) and/or magnetic resonance imaging (MRI) were correlated to macroscopic and microscopic pathology. Characteristic signs made recognition of hydatid disease possible, sometimes even when serologic tests had been non-conclusive. Assessment of other cysts throughout the body with or without involvement of neighbouring organs or tissues allowed appropriate therapeutic management. CT and MRI also played a key role in recognizing complications (e.g., rupture, infection of cysts).

Ultrasound, CT and MRI of ruptured and disseminated hydatid cysts.

Three cases of echinococcus granulosus with rupture of hydatid cysts and widespread abdominal, pelvic or pleural dissemination are described. Ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI) allowed recognition of ruptured hydatid cysts. This assisted to come to an appropriate therapy and exclusion or confirmation of hydatid cysts elsewhere in the body. Ultrasound, CT and MRI are also important for follow-up, evaluation of therapeutic response and/or early diagnosis of recurrence.

Mediastinal hydatid disease: report of three cases.

We report three patients who had mediastinal echinococcosis and then review the literature. The first patient had a primary anterior mediastinal echinococcal cyst, the second a mediastinal hydatid cyst, secondarily involving the mediastinum and mimicking Hodgkin's disease, and the third had a primary cardiac and pericardial hydatid cyst. In two patients computed tomography (CT) was helpful in making a preoperative diagnosis before any complication could arise. In the third CT was not done and the diagnosis of cardiac echinococcosis at surgery was a surprise. Two large echinococcal cysts compressing the ventricles, which on echography and cardioangiography had the appearance of endomyocardial fibrosis, were removed by total excision. The disease in each patient was correlated with clinical and radiologic findings and was confirmed by tissue microscopy.

Magnetic resonance imaging of thoracic hydatid disease. Correlation with clinical findings, radiography, ultrasonography, CT and pathology.

Two patients with thoracic manifestations of hydatid disease (HD) are discussed; one patient had recurrent HD of the chest wall and the other, intrapulmonary HD after rupture and intrathoracic extension of an infradiaphragmatic cyst. At magnetic resonance (MR) imaging the manifestations of HD in the thorax are similar to previously reported MR findings in HD in the liver. The presence of a low signal intensity rim on T2 weighted images representing the cyst wall was confirmed. On T1 weighted images cysts with heterogeneous low and intermediate signal intensity contents and a relatively high signal intensity wall were seen. 'Folded parasitic membranes' previously not described on MR were noted. Daughter cysts may have a low or high signal intensity depending on contents. Reactive changes in the lung may be quite marked compared with the liver, due to reaction to the parasite or simply because the lung is more easily compressed leading to secondary atelectasis.

Triple fine-needle biopsy of Kulchitsky cell carcinomas I, II (bronchial adenomas).

All bronchial adenomas (BA) or Kulchitsky cell tumours I, II, are classified by WHO as low-grade malignomas. In some cases with an established benign clinical course and stability over a period of years, the pre-operative diagnosis of a typical carcinoid (KCCI) may justify a wait-and-see approach. If surgery is indicated, local resection is feasible in place of lobectomy or pneumonectomy. In a consecutive series of thirty-two patients KCCI, II or BA were diagnosed pre-operatively by fine-needle biopsies (FNB). Samples from three different sites were obtained, permitting appropriate diagnostic management and treatment. The thirty-two BA comprised 22 typical carcinoids, five atypical carcinoids, and five cylindromas. Twenty-eight patients presented with a "benign" cytohistological and/or clinical appearance. In four out of thirty-two patients, signs of malignancy with or without metastases were present. No major complication occurred. In a five-year follow-up, 25 out of 32 patients remained alive. One patient was alive but had metastases. Three out of 32 patients with cytohistologic malignant features had died of their disease. In four out of 32 patients the cause of death was not attributed to neoplastic disease.

Importance and value of a preoperative diagnosis in oat cell carcinoma by radiography and its verification by fine needle biopsy (FNB).

Surgical resection currently offers the best hope of cure in Non Small Cell Lung Cancer (NSCLC), while chemotherapy and/or radiotherapy is the primary choice for Small Cell Lung Cancer (SCLC). The preoperative diagnosis of small cell anaplastic carcinoma (oat cell carcinoma) therefore is extremely important for adequate patient management treatment and prognosis. The patients history, clinical findings and radiographic patterns are all important for the differential diagnosis of SCLC (oat cell cancer) constituting a clinical, radiological and histopathological entity. FNB is a minor, fast, safe, inexpensive procedure, which is easy to perform, not uncomfortable for the patient and which, due to high accuracy may confirm or exclude SCLC (oat cell cancer). Major surgery with its inherent risk of morbidity/mortality may such be avoided allowing to choose the optimal and most appropriate form of alternative treatment permitting a high quality of life during the course of the disease. In a series of 2726 patients with 5300 FNB, of which 1264 (46%) showed evidence of malignancy SCLC (oat cell carcinoma) was cytologically diagnosed in 54 cases (6%). No serious complication occurred.

Directed fine needle biopsy of anterior and middle mediastinal masses.

Mediastinal masses are seldom detected early by conventional radiography since density differences between mediastinal tissues often are inconspicuous. With CT mediastinal masses may be recognized more easily and their localization and relationship to other organs as well as their site of origin and extension is revealed. Sometimes clues to the type of tissue, of which they consist, may be obtained, but their specific histology often remains unclear. Definitive therapy depends on accurate tissue diagnosis of both benign and malignant masses. Fine needle biopsy (FNB) satisfies all the requests for accurate patient management and therapy. A presentation of 76 cases of a wide variety of anterior and middle mediastinal masses diagnosed by FNB, using different approaches, is given. The technique, results and complications are discussed.

The direct approach to posterior mediastinal masses by fine-needle biopsy.

Fine-needle biopsy (FNB) is helpful in establishing an accurate cyto-histopathologic diagnosis of posterior mediastinal masses, which, on conventional radiography and with other imaging methods, may remain unclear. By doing so it initiates adequate patient management and therapy in the interest of improved prospects of cure. FNB was carried out in 55 patients with a wide variety of posterior mediastinal masses. The technique included percutaneous transthoracic FNB by a direct approach as well as FNB by the paravertebral approach with or without previous mediastinography. In 28 of 55 patients a neurogenic tumor could be diagnosed; 8 of these tumors (30%) proved to be malignant. In 14 patients, cystic lesions were detected, and in 13 patients a spectrum of other changes was found. Complications were minor and not essentially different as compared to the total material of 2,726 patients with 5,300 FNBs, with the exception that fewer pneumothoraces occurred (10 vs. 27%). In 2 patients, treatment was necessary (one suction by needle and one chest drainage). In the rest of the patients, observation during the post-biopsy period was utilized and the clinical follow-up was unremarkable.