Assessment of the spine with CT and MRI prior to interspinous/interlaminar spinal procedures: a pictorial review.

Imaging of the spine is increasingly available, whether as dedicated spine examinations or as studies that include the spine in the images obtained (e.g. CT abdomen). This pictorial review discusses imaging of the spine with CT and MRI and how prior review of this imaging can be helpful with potentially difficult spinal procedures. Pathologies illustrated include osteoarthritis, scoliosis, inflammatory spondyloarthropathies and post-operative spines.

Breast surgical specimen radiographs: how reliable are they?

Radiography of the excised surgical specimen following wire guided localisation of impalpable breast lesions is standard surgical practice. The aims of the study were to establish the reliability of the breast specimen radiograph (SR) in determining lesion excision and to determine whether the radiographic margin correlated with the histological margin. The clinical, imaging, SR and pathological details of 106 patients with a pre-operative diagnosis of breast cancer were retrospectively reviewed. The reliability of orientation was estimated and the appearance and distance from the mammographic abnormality to each radial margin were measured and correlated with surgical histological findings. The overall accuracy of the specimen radiograph in determining whether the mammographic lesion was present was 99%. The SR could be orientated "very reliably" or "reliably" in 80% of patients however in only 48% of patients did the closest margin on the SR correspond with the same nearest margin at final histology. A maximum measurement of 11 mm or more from the lesion to the specimen edge was associated with a 77% likelihood of having a clear final histological margin (taken as 5mm or more) and if <11 mm a 58% chance of having involved final histological margins. There was however a wide overlap in the results with patients having an apparently wide SR margin but histologically involved margins and vice versa. The SR is reliable at determining whether the target lesion has been removed. The correlation of SR margin orientation and measurement with final histological measurement is however far less reliable.

Comparison of endoscopic and robotic thyroidectomy.

BACKGROUND: Endoscopic thyroidectomy is a technically challenging procedure. Robot-assisted thyroidectomy has been recently introduced and offers improved visualization and dexterity. The present study compared conventional endoscopic and robotic thyroidectomy for thyroid cancer patients in terms of perioperative outcomes and learning curve. All operations were performed by the same surgeon. MATERIALS AND METHODS: Between April 2007 and March 2010, 96 patients underwent endoscopic thyroidectomy (endoscopy group) and 163 patients underwent robotic thyroidectomy (robot group). A gasless transaxillary approach was used in both groups. The 2 groups were compared in terms of patient characteristics, perioperative clinical results, complications, and pathologic details. Learning curves for the 2 procedures were compared based on the number of cases required to reach a consistent operation time. RESULTS: Patient characteristics were similar for both groups. The mean total operation time for thyroidectomy with central compartment neck dissection was 142.7 ± 52.1 min in the endoscopy group and 110.1 ± 50.7 min in the robot group (P = .041). Both patient groups were similar in terms of pathological features including TNM stage, intraoperative blood loss, length of hospital stay, and complication rate. However, the mean number of retrieved central lymph nodes was 2.4 ± 1.9 for the endoscopy group and 4.5 ± 1.5 for the robot group (P = .004). The learning curve was 55-60 cases for endoscopic thyroidectomy and 35-40 cases for robotic thyroidectomy. CONCLUSION: Robotic thyroidectomy was found to be superior to endoscopic thyroidectomy in terms of operation time, lymph node retrieval, and learning curve. Complication rates and postoperative hospital stay were similar for the 2 procedures.

Incidence and clinical behavior of papillary thyroid carcinoma in renal allograft recipients: a single center experience.

The chronic use of immunosuppressive therapy in transplant recipients increases the long-term risk for carcinoma. However, there is insufficient knowledge regarding the incidence and biological behavior of papillary thyroid carcinomas (PTC) in renal allograft recipients. In the present study we examined the incidence and biological behavior of PTCs among 1739 patients transplanted between January 1986 and December 1999 who had been followed for a mean period of 137 months (range, 84-238 months). During the follow-up, 129 (7.4%) recipients were identified to display posttransplantation malignancies, including 12 (0.7%) with PTCs. The 6 male and 6 female patients had a mean age of 41 years (range, 23-57 years). Nine cases (incidentalomas) were diagnosed based on ultrasonographic (US) screening. Eight of those 9 were TNM stage I, 2 of the 3 clinical carcinomas were TNM stage IVa. During a mean follow-up of 94 months (range, 18-159 months), 2 (16.7%) PTC patients developed locoregional recurrence, but no patients showed distant metastases. These data showed that recipients had a higher incidence of PTC compared with the general Korean population (0.7% vs 0.02%). Posttransplantation PTC tended to show no difference in gender distribution, and was often associated with aggressive lymphatic metastasis. However, most incidentalomas showed favorable treatment outcomes. In conclusion, routine surveillance of the thyroid gland using US screening is recommended to ensure early detection, treatment, and favorable prognosis of PTC.

MR-guided direct arthrography of the glenohumeral joint.

AIM: To evaluate the feasibility of magnetic resonance (MR)-guided direct arthrography of the glenohumeral joint with a 1.5 T MR system, performing the entire procedure in a single MR examination. MATERIALS AND METHODS: MR-guided direct arthrography was performed on 11 patients. MR imaging guidance and interactive MR fluoroscopy, with in-room control and display system, were used for needle placement and contrast medium injection. The outcome measures were success or failure of joint puncture, the time taken for introduction of contrast medium, and the diagnostic quality of the subsequent MR arthrography images. RESULTS: Contrast medium was successfully instilled into the joint and diagnostic quality MR arthrography images were obtained in all cases. The median time from initial placement of the skin marker to introduction of the contrast medium was 17 min (range 11-29 min). There were no immediate post-procedure complications. CONCLUSION: Accurate needle placement is feasible in a single MR examination on a commercial 1.5 T closed-bore MR system, using an in-room control and display system together with interactive fluoroscopic imaging, and this was used to provide direct MR arthrography in this study.

Cyclooxygenase-2 expression in human thyroid disease.

OBJECTIVES: Cyclooxygenase (COX)-2, which is the inducible form of the COX enzyme for prostaglandin synthesis and a key mediator of epithelial cell growth, has been shown to be up-regulated in gastrointestinal cancers. Additionally, regular intake of other non-steroidal anti-inflammatory drugs (NSAID) is known to decrease the incidence of these cancers. Therefore, the goals of the present study were to determine the possible involvement of COX-2 in human thyroid diseases. METHODS: We used immunohistochemical staining and Western blot analysis to characterize the expression of COX-2 proteins in thyroid tissues from 64 patients with thyroiditis, benign tumors, and malignant tumors with or without metastasis. Immunoreactivity scores were calculated by multiplication of the determined grades. RESULTS: COX-2 proteins were not expressed in normal thyroid tissues. However, each type of tumor tissue showed intense bands of COX-2 protein expression in Western blot analyses, and the immunoreactivity scores were 7.67+/-1.17 (SD) for thyroiditis, 7.87+/-0.9 for benign tumors, 7.53+/-1.53 for follicular cancer, 7.63+/-1.11 for papillary cancer without metastasis, and 7.17+/-1.55 for papillary cancer with metastasis. No significant differences were found in the levels of COX-2 expression between different tumor tissue types. CONCLUSION: No significant correlations were observed between clinical and/or pathological characteristics of thyroid tumors and the intensity of COX-2 protein expression. In addition, we found no difference in COX-2 protein expression between thyroiditis and thyroid tumors. Thus, up-regulation of COX-2 protein synthesis in human thyroid diseases does not appear to be of clinical significance.

Magnetic resonance imaging findings of tamoxifen-associated uterine Müllerian adenosarcoma: a case report.

Müllerian adenosarcoma of the uterus is a rare biphasic tumor, which was first described in 1974. Recent studies have suggested an association with tamoxifen therapy, but there have been few reports with detailed imaging findings. We present a case with magnetic resonance imaging (MRI) findings of this rare tumor in a woman who received long-term tamoxifen therapy for breast cancer. In addition, myometrial invasion was detected more accurately with MRI compared to ultrasound in this one single case.

Prophylactic antiemetic efficacy of granisetron or ramosetron in patients undergoing thyroidectomy.

OBJECTIVE: Thyroidectomy is associated with a high incidence of postoperative nausea and vomiting (PONV), ranging from 60% to 84%. We conducted this study to compare the antiemetic effects and safety of granisetron 20 micro g/kg and ramosetron 4 micro g/kg in patients undergoing elective thyroidectomy under standard anaesthetic technique. METHODS: One hundred and thirteen patients were randomized to receive placebo (n = 41), granisetron 20 nug/kg (n = 36) or ramosetron 4 micro g/kg (n = 36) intravenously over 2-5 minutes immediately before the induction of anaesthesia. The incidence of PONV, nausea severity score (NSS), adverse events and the need for rescue antiemetics were assessed during the first 1 hour (0-1 h) and following 23 hours (1-24 h) after anaesthesia. RESULTS: During the first hour after anaesthesia, the incidence of PONV was 36.6% for placebo, 11.1% for granisetron (p = 0.012 vs placebo) and 25.0% for ramosetron. During 1 hour to 23 hours after anaesthesia, the incidence of PONV was 51.2% for placebo, 30.6% for granisetron and 41.7% for ramosetron. There were no significant differences between the three groups. Overall (0-24 h), the corresponding incidence of PONV were 61.0%, 30.6% and 50.0%, respectively, showing a significantly lower value in the granisetron group than in the placebo group (p = 0.008). The incidence of vomiting and rescue antiemetic requirement during the first 24 hours after anaesthesia was significantly lower with the granisetron group than with placebo (p = 0.021 and 0.030, respectively). The most common adverse events in the three groups were headache and dizziness. CONCLUSION: Only granisetron 20 micro g/kg was superior to placebo for the prevention of PONV after thyroidectomy.

Neutralizing vascular endothelial growth factor activity inhibits thyroid cancer growth in vivo.

BACKGROUND: Without angiogenesis, tumor growth is limited to a few millimeters, the limit of diffusion. Vascular endothelial growth factor (VEGF) is an endothelial-specific mitogen and a major regulator of angiogenesis. METHODS: To investigate the relationship between VEGF and thyroid tumor angiogenesis, we xenografted human dermal matrix inoculated with FTC-133 cells into nude mice or directly injected FTC-133 cells subcutaneously. To block the function of VEGF, the neutralizing anti-VEGF monoclonal antibody A.4.6.1 (mAb A.4.6.1) was injected intraperitoneally twice weekly. As control, an antibody of the same isotype (Ab 5B6) or phosphate buffer saline solution (PBS) was used. To evaluate the dermal matrix as a model for angiogenesis studies, recombinant human VEGF was inoculated into the dermal matrix pocket and xenografted into mice. RESULTS: In the dermal matrix angiogenesis model, the number of blood vessels paralleled the concentration of recombinant human VEGF and was highest at 100 ng/mL. Mice that were treated with the mAb A4.6.1 developed fewer blood vessels (mean, 6.6 per HPF) than control mice (18 per HPF in Ab 5B6 and 22 per HPF in PBS; P <.01). Tumors from mice that were treated with mAb A.4.6.1 were much smaller (mean +/- SD, 0.09 +/- 0.02 gm) at 5 weeks, compared with the tumors treated with Ab 5B6 (5.38 +/- 1.15 gm) or PBS (4.0 +/- 0.72 gm; P <.001). CONCLUSIONS: VEGF is produced by the follicular thyroid cancer cell line and stimulates angiogenesis and growth of thyroid cancer. This stimulation can be blocked by mAb A.4.6.1.

Does leptin exhibit cytokine-like properties in tissues of pregnancy?

PROBLEM: To determine whether leptin exhibits cytokine-like properties in gestational tissues in light of its homologies with the class I family of cytokines. METHOD OF STUDY: WISH and JEG3 cells, and amnion and choriodecidua explants, were treated inflammatory modulators (interleukin-1beta [IL-1beta], tumor necrosis factor-alpha [TNF-alpha] and bacterial lipopolysaccharide [LPS]) and leptin production was measured by immunoassay. Other agents known to regulate adipocyte leptin production were also tested for comparative purposes. In addition, WISH cells, JAR cells and placental explants were treated with leptin to assess its effects on production of IL-8, IL-6 and prostaglandin E2 (PGE2). RESULTS: Leptin production by all cells and tissues studied was unaffected by treatment with IL-1beta (2.5 ng/mL), TNF-alpha (25 ng/mL) and LPS (2.5 microg/mL). Dexamethasone stimulated leptin production over two-fold by WISH and JEG3 cells, whereas insulin also stimulated a two-fold increase in leptin production in JEG3 cells. IL-6 production by JAR cells and placental explants was stimulated (two- to three-fold) by leptin (300 ng/mL). PGE2 production was unaffected. CONCLUSIONS: Leptin derived from gestational tissues is unlikely to play a role in inflammatory reactions within the placenta, but may regulate placental cytokine production. The physiological significance of amnion-derived leptin remains to be established.

Upper genital schistosomiasis mimicking an ovarian tumour.

Schistosomiasis is a widely prevalent disease in the world and usually involves the gastro-intestinal and urinary tract. The involvement of the female genital tract has been well-established in S. haematobium infections and is rare with S. japonicum infections. This case involves a Filipino female who was admitted to the University Hospital Kuala Lumpur for right iliac fossa pain and was diagnosed initially as acute appendicitis. Ultrasound showed a multi-septated pelvic cyst leading to a provisional diagnosis of ovarian torsion. Intraoperatively a right parovarian cyst was detected and removed. Histology revealed a congested cyst wall with areas of haemorrhage with several viable and calcified eggs of S. japonicum measuring 85 microns x 62 microns. Within the cystic cavity blood admixed with eggs were seen. Confirmation was carried out by using the indirect haemagglutination (IHA) test. This is a first report of upper genital schistosomiasis mimicking an ovarian tumour.

An unusual cause of antepartum haemorrhage.

This is a rare case of antepartum haemorrhage arising from the nonpregnant uterus in a woman with uterine didelphys. The bleeding and subsequent passage of a decidual cast did not have any adverse effect on the ongoing pregnancy.

Desensitization in normal and neoplastic human thyroid cell lines.

Because some papillary thyroid cancers continue to grow when thyroid-stimulating hormone (TSH) levels are suppressed, we questioned whether desensitization (i.e., a decreased cAMP response to repeat stimulation with TSH) occurs in normal and neoplastic thyroid tissue. If desensitization does occur, is it similar or different in these human thyroid cells? Normal and papillary thyroid cancer cells from the same patient were cultured as we have previously described. Normal and neoplastic thyroid tissues responded to TSH (0.01-10.0 mU/ml) by increasing cAMP production and growth in a dose-dependent manner. In normal cells there was an 11-fold mean increase in cAMP production at 4 hours, and all thyroid cultures responded. In neoplastic cells cAMP production increased from 1.5-fold to 3.0-fold with a mean 2.0-fold increase at 4 hours. In normal thyroid cells the cAMP response to a second TSH stimulus (desensitization) decreased up to 75% (range 25-75%), and desensitization occurred in all normal thyroid cell cultures. In neoplastic thyroid cells, however, the cAMP response to a second TSH stimulus decreased up to 17% (range 0-17%); and desensitization occurred in only two of the five neoplastic thyroid cell cultures. Thus when normal thyroid and neoplastic cells from the same patients were studied, greater desensitization occurred in the normal cells (75% vs. 17%). These studies document that there is greater desensitization in normal tissue than in neoplastic thyroid tissue, which may account for the increased growth of thyroid neoplasms in the presence of ever-changing low levels of TSH.

Fetal supraventricular tachycardia--a case report.

A gravid patient with fetal supraventricular tachycardia is presented. A review of this rare condition and the present recommended mode of therapy are discussed.

Vascular endothelial growth factor expression is higher in differentiated thyroid cancer than in normal or benign thyroid.

Vascular endothelial growth factor (VEGF) is an angiogenic factor, and its expression has been rarely demonstrated in thyroid tumors. We, therefore, investigated the expression of VEGF messenger RNA (mRNA) and production of VEGF protein in cell lines from human primary and metastatic follicular (FTC-133, FTC-236, and FTC-238), papillary (TPC-1), Hürthle cell (XTC-1), and medullary thyroid cancers (MTC-1.1 and MTC-2.2), and in human thyroid tissues (papillary, follicular, medullary, and Hürthle cell cancers, follicular adenomas, and Graves' thyroid tissue) by Northern blot, immunohistochemistry, and enzyme-linked immunosorbent assay (ELISA) studies. All thyroid cell lines expressed a 4.2-kilobase VEGF mRNA. The VEGF mRNA levels were higher in the thyroid cancer cell lines than in primary cultures of normal thyroid cells, and higher in thyroid cancers of follicular than those of parafollicular cell origin. The VEGF mRNA levels were similar in primary and metastatic thyroid tumors. Immunohistochemical staining and Northern blot analysis of the cell lines correlated positively, thus thyroid cancer cell lines stained more intensely than normal thyroid cells and follicular tumor cells more intensely than parafollicular tumor cells. Again, no difference was noted in VEGF staining between primary and metastatic thyroid tumors. Deparafinized sections of papillary, follicular, and Hürthle cell cancers also stained much stronger than those of medullary thyroid cancers, benign, or hyperplastic (Graves' disease) thyroid tissue. Thyroid cancer cell lines (XTC-1 > TPC-1 > FTC-133 > MTC-1.1) also secreted more VEGF protein as measured by ELISA than did normal thyroid cells. VEGF secretion of cell lines derived from primary and metastatic thyroid tumors were similar. VEGF mRNA is therefore expressed, and VEGF protein is secreted by normal, hyperplastic, and neoplastic thyroid tissues. The higher levels of VEGF expression in differentiated thyroid cancers of follicular cell origin suggests a role in oncogenesis.

Thyroid-stimulating hormone promotes the secretion of vascular endothelial growth factor in thyroid cancer cell lines.

BACKGROUND: Vascular endothelial growth factor (VEGF) is a vascular endothelial cell-specific mitogen secreted by some cancer cells and is a major regulator of angiogenesis. Because thyroid-stimulating hormone (TSH) promotes growth and progression of thyroid cancers, we postulated that TSH may increase the production and secretion of VEGF by thyroid cancer cells. METHODS: We examined primary cultures of normal human thyroid (NT 1.0), medullary thyroid cancer (MTC 1.1), and cell lines derived from the papillary (TPC-1), follicular (FTC-133), and Hürthle cell (XTC-1) thyroid cancer. We quantified the concentration of VEGF in conditioned medium by means of enzyme-linked immunosorbent assay. RESULTS: Cell lines derived from thyroid secrete VEGF. Basal VEGF secretion was similar in normal and thyroid cancer cells, except XTC-1, which has high basal secretion (p < 0.01). All thyroid cancer cells secrete significantly more VEGF than normal thyroid cells after TSH (10 mIU/ml) stimulation (p < 0.05). TSH stimulated secretion of VEGF in FTC-133 (8.2 ng/dl versus 18.8 ng/dl), TPC-1 (5.5 ng/dl versus 26.9 ng/dl), and MTC 1.1 (5.9 ng/dl versus 13.4 ng/dl) cell lines (p < 0.01), but not in NT 1.0 (8.4 ng/dl versus 9.9 ng/dl) and XTC-1 (25.4 ng/dl versus 31.2 ng/dl) cells. CONCLUSIONS: These results suggest that VEGF secretion is constitutively activated in some thyroid cancers and that VEGF secretion is stimulated by TSH; thus TSH may promote growth in some thyroid cancers by stimulating VEGF secretion and angiogenesis.

Surgical considerations and approach to thyroid cancer.

Patients with thyroid cancer can be safely treated by an experienced endocrine surgeon. More extensive initial surgery such as total or near-total thyroidectomy seems to decrease tumor recurrence and prolong life. When such operations can be done with minimal complications, we believe it is the treatment of choice because even low-risk patients have a 4% or 5% risk of eventually dying of thyroid cancer. If this risk of death from thyroid cancer can be decreased to 1% or 2% and the rate of serious complications is 1% or 2%, the authors believe total thyroidectomy is indicated. Most patients can be discharged within 1 day of total thyroidectomy.