Fine-needle aspiration of breast biopsy specimens: correlation of histologic and cytologic findings.

The accuracy of fine-needle aspiration (FNA) cytologic diagnosis of nonpalpable breast lesions and the prevalence of neoplasm occurring in areas unrelated to the radiologic abnormality were studied. Template-guided FNA cytologic examination was performed in 101 surgically excised breast specimens. The exact area of the mammographic abnormality was aspirated with radiographic control. Despite accurate placement of the needle for aspiration, seven of 101 aspirates (7%) yielded insufficient cytologic material. Ninety-four of the 101 aspirates (93%) were adequate for diagnosis. The cytologic diagnosis was benign in 58 (62%), atypical in seven (7%), suspicious for malignancy in four (4%), and malignant in 25 (27%). All cases diagnosed as suspicious or malignant and five of 58 cases diagnosed as benign at cytologic examination proved to be malignant at histologic examination. In three of these five the malignancy was in the area of the radiologic abnormality; in two it was not. FNA cytologic examination can be helpful in evaluating nonpalpable breast lesions, but it is not as accurate as histologic examination of surgically excised lesions.

The value of mammography after limited breast surgery and before definitive radiation therapy.

One hundred twenty consecutive patients who had breast-conserving surgery for cancer and were referred for definitive radiation therapy (RT) had a mammogram performed before starting RT. This was done to determine the presence of residual neoplasm or other abnormalities that may alter or delay the planned RT and are undetected by other means. It also was performed to provide a baseline for the diagnosis of postoperative changes and recurrence of disease on follow-up studies. In six (5%) patients, calcifications or masses were found that proved to be residual tumors. This led to reexcision in two, mastectomies in two, and a higher radiation booster dose to the tumor bed in two. Eight (6.6%) patients had postoperative hematomas larger than 4 cm in diameter, which delayed the start of RT by 2 to 3 weeks. In 39 (32%) patients, the pre-RT mammogram provided information considered to be helpful for the interpretation of post-RT mammograms. Such information may lead to a decrease in the number of diagnostic biopsies based on indeterminate mammographic findings. Therefore, a routine mammogram is recommended before RT is started.

Cryptosporidiosis of the biliary tract in AIDS.

Cryptosporidiosis of the biliary system was studied retrospectively in 13 patients with acquired immunodeficiency syndrome (AIDS). The diagnosis was made by means of histologic examination (n = 9) or imaging studies and the presence of intestinal cryptosporidiosis (n = 4). Imaging studies were done in 10 patients. Ultrasound (US) and computed tomography (CT) showed dilatation of the biliary ducts, some with wall thickening, thickening of the gallbladder wall and pericholecystic fluid. Cholangiograms showed attenuation and pruning of the intrahepatic bile ducts, some with beading and dilatation of the common bile duct. Three patients had papillary stenosis. Numerous Cryptosporidium organisms were found in three resected gallbladders and in the biliary ducts of seven patients in whom autopsy was performed, accompanied by an exuberant inflammatory response. Correlation of the radiologic and pathologic findings establishes a direct etiologic role of Cryptosporidium as one of the major infectious agents in cholangitis associated with AIDS.

Diagnostic quality of mammograms obtained with a new low-radiation-dose dual-screen and dual-emulsion film combination.

We evaluated the image quality of mammograms made by using a new dual-screen, dual-emulsion film combination (Kodak Min-R Fast screen, T-Mat Mll film) that permits reduction of radiation exposure by approximately 50% when compared with a standard single-screen, single-emulsion film system (Kodak Min-R screen, OM-1 film). This new film has been improved when compared with earlier T-Mat M film, including the introduction of an inert dye to reduce light crossover to essentially 0%. Mammogram pairs made with the dual-emulsion film combination and the standard single-emulsion film combination were obtained in 50 patients otherwise undergoing routine mammography. The image pairs were randomized and evaluated by three radiologists who used a three-point scale (better, same, or worse). Each pair was evaluated with regard to parenchymal contrast, sharpness, and latitude, as well as the number and sharpness of calcifications (n = 19) and sharpness of masses (n = 12) when present. All three observers found the dual-emulsion film combination to be better than or the same as the standard with regard to parenchymal sharpness (94-100%), the number and sharpness of calcifications (98-100%), and sharpness of masses (100%). Two observers found the dual-emulsion film combination to be significantly worse (p less than .05) than the standard with respect to parenchymal contrast (72%, 86%), and all three observers rated it significantly worse for film latitude (14 to 42%). Our results suggest that this new dual-emulsion film combination that allows mammography to be performed with less radiation exposure can be used without loss of image quality.

Smoke inhalation injury: evaluation of radiographic manifestations and pulmonary dysfunction.

Inhalation injury is a frequent complication in burned patients. Upper airway injury is reliably diagnosed endoscopically, but early diagnosis of pulmonary parenchymal injury is less reliable. Radiographic diagnosis in such cases is inconsistent. This study correlated degree of chest X-ray (CXR) change with pulmonary function in 29 adult patients during the first 5 days after inhalation injury. Daily CXRs were graded: 0 (normal), 1+ (peribronchial cuffing or perivascular edema), 2+ (edema involving one third of the lung field), 3+ (edema involving two thirds of the lung field), and 4+ (edema involving the entire lung field). Extravascular lung water volume (EVLW) was measured in vivo with the thermal/green dye double indicator technique. Twenty-five of the 29 patients were intubated on admission. Of these patients with serious inhalation injury, 84% showed some abnormality on CXR within 48 hours after injury. When abnormalities were present on CXR, pulmonary dysfunction (increases EVLW, increases Qs/Qt, decreases compliance) was clinically important. These data suggest that this grading scale may have utility in reports of CXR findings in inhalation injury.

Echinococcal hepatic disease: magnetic resonance appearance.

The magnetic resonance (MR) appearance of an echinococcal hepatic cyst is described. A previous report has suggested that a low-intensity rim surrounding the cyst may be useful in differentiating hydatid cysts from other hepatic lesions. No such rim was identified in our case; however, MR was found to be superior to other modalities in delineating the internal contents of the hydatid cyst.

Appendicitis with bladder involvement: CT appearance.

A case of appendicitis presenting with microscopic hematuria and a suprapubic mass involving the bladder is described. Computed tomography (CT) is a valuable aid in the diagnosis of atypical or otherwise unsuspected appendicitis. Besides first suggesting the diagnosis of appendicitis, CT was also able to demonstrate the full extent of the inflammatory process preoperatively in this case.

Cytomegalovirus infection of the alimentary canal: radiologic findings with pathologic correlation.

A spectrum of radiologic findings in cytomegalovirus (CMV) infection of the alimentary canal seen in 14 patients and correlated with pathologic examinations is described. Twelve patients had acquired immunodeficiency syndrome and two had no identified immunosuppression. Autopsies were performed on 12. Diffuse CMV colitis was present in eight patients, enteritis in seven, esophagitis in four, gastritis in two, cholangitis in one, and acute pancreatitis in one. Of 11 patients with enteritis and/or colitis seven had significant lower gastrointestinal bleeding and five died as a result of it. Radiologic findings in the gastrointestinal tract included superficial or deep mucosal ulcerations, perforation or fistula formation, luminal narrowing, rigidity and thickening of the intestinal wall, and inflammatory infiltration of the mesentery. These were seen on barium examinations and computed tomographic (CT) scans. Findings of pancreatitis were seen on CT scans in one patient. In another, a cholangiogram showed abnormal bile ducts caused by CMV cholangitis. The radiologist should be aware of the diverse manifestations of the disease and its likely occurrence in immunosuppressed individuals.

Pulmonary complications in burn patients.

In recent years, pulmonary complications have become a major cause of death in burn victims. Familiarity with the spectrum of these complications leads to an earlier and more specific diagnosis based on chest radiographs. We reviewed the medical records and chest radiographs of 239 patients admitted to our burn unit over a one-year period. Pulmonary complications were categorized on the basis of their anatomic location in the respiratory tract and on whether they were the result of direct chemical injury from smoke inhalation, or were secondary to inhalation injury with or without cutaneous burns. Tracheobronchitis, chemical pulmonary edema, and adult respiratory distress syndrome (ARDS) resulted from direct injury. Pneumonia, ARDS, pulmonary congestion, atelectasis and pulmonary emboli were the main complications secondary to the injury. Pulmonary complications developed in 76 patients (31.8%) and, of these, 57 died (75%). Patients involved in a closed space fire and those who had a burn involving 50% or more of their surface area seem to be at the greatest risk of developing pulmonary complications.

Smoke inhalation: radiologic manifestations.

The medical records and radiographs of 62 patients admitted for smoke inhalation were reviewed to determine the value of the plain chest radiograph in the early detection of inhalation injury. Pulmonary edema resulting from the inhalation injury often leads to pulmonary insufficiency, and its early diagnosis is crucial to the management of patients with this condition. In addition to the usual presentation of pulmonary edema, subtle radiographic findings of interstitial edema such as perivascular fuzziness and peribronchial "cuffing" were observed. Of 56 patients with significant inhalation injury, 35 (62.5%) had radiographic findings attributed only to smoke inhalation. These abnormalities often had a characteristic distribution in the lungs, and in the majority of patients they appeared in the first 24 hours after the injury. The radiologic diagnosis of inhalation injury may be made at a time when findings of other diagnostic tests are still equivocal or mildly abnormal, thus alerting the clinician to impending pulmonary failure.

Atypical pulmonary malaria.

Three atypical cases of pulmonary malaria are presented and discussed. Radiologically, they were manifested by very subtle thickening of interlobular septae or by more overt interstitial edema and pleural effusion. They were all relatively mild and cleared completely on antimalarial drugs. This is in contrast to most reported cases which were severe and fatal. This resultant widening of the clinical and radiologic spectrum of pulmonary malaria leads to the conclusion that such a complication is likely more common than previously recognized. The radiologist can suggest the correct diagnosis by being aware of its many manifestations and by having a high index of suspicion.

The use of ultrasonography in the management of masses of the breast.

Contact B-mode ultrasonography of masses of the breast is a simple, safe and noninvasive technique which does not involve the use of ionizing radiation. It is highly accurate in differentiating cystic from solid mammary masses measuring 1 centimeter or larger. A biopsy of a sonographically solid mass should be done unless it has an unequivocally benign appearance on mammography. A biopsy of a purely cystic mass, if asymptomatic, need not be done for diagnostic purposes. Needle aspiration can be used as an alternate method for diagnosing a cyst, but failure of this method occurs more often than one is aware of. Sonography is the method of choice for such a diagnosis. Its accuracy in masses 1 centimeter or larger is 100 per cent. When propertly used and carefully correlated with clinical and mammographic findings, it can eliminate over one-third of all operations on the breast.

Idiopathic intestinal pseudo-obstruction in a family.

A patient with severe manifestations of idiopathic intestinal pseudo-obstruction is presented. Three members of his family suffer from similar symptoms but in a much milder form. The disease has a wide range of clinical and radiologic presentations and its diagnosis is dependent upon the exclusion of all known causes of intestinal pseudo-obstruction. A high incidence of associated megacystis in this family as well as in some reported cases in the literature lead us to conclude that idiopathic intestinal pseudo-obstruction is not a primary disease of the gastrointestinal tract. Its etiology remains obscure.

Combined mammographic-sonographic evaluation of breast masses.

Palpable breast masses which have a nondiagnostic appearance on the mammogram often require a biopsy to rule out malignancy. Contact B-scan ultrasonography of such masses were performed in an effort to improve the diagnostic accuracy of mammography and reduce the number of unnecessary biopsies. A total of 200 patients with breast masses of 1-8 cm were examined by both methods. The results of this combined evaluation were compared to those of mammography alone. Of 115 pathologically proven lesions, 44 were fluid-filled cysts. Sonography correctly diagnosed all 44 cysts, while mammography was equivocal in 27 (61%) of them. Of the remaining 71 solid masses, 38 were benign and 33 malignant. Mammography alone correctly diagnosed 31 carcinomas (94%), whereas sonography correctly diagnosed 26 (78.8%). While the infiltrating carcinomas have a typical sonographic appearance, circumscribed carcinomas may have the same sonographic features as fibroadenomas; the value of sonography here was to establish whether the mass was solid. In other solid masses such as those produced by dysplasias, abscesses, and mastitis, sonography was helpful in differentiating between diffuse and discrete lesions. The combined mammographic-sonographic evaluation of breast masses was more accurate than either method alone.

Carcinoma of the gastric cardia and hiatal hernia.

Carcinoma of the cardia of the stomach in patients with sliding hiatal hernia is a disease of poor prognosis, since symptoms nearly always occur late in its course at an already incurable stage. Eleven cases are reviewed from the records of The New York Hospital-Cornell Medical Center from 1932 to 1975. Resectability of tumor appeared related to shorter interval between onset of symptoms and diagnosis. Barium studies combined with esophagoscopy led to correct preoperative diagnosis of malignancy in all cases.

The posterior tracheal band: a reflector of local superior mediastinal abnormality.

The posterior tracheal band (PTB) is a thin band of uniform width consisting primarily of the posterior tracheal wall which is observed almost constantly in a well-positioned and exposed lateral view of the chest. It is formed by two interfaces; and internal junction line between the inner tracheal wall and air in the lumen, and an external junction line between the adventitial surface of the right posterior wall (with paper-thin mediastinal covering) and aerated lung in the right retrotracheal recess. Any pathological process in the mediastinum, pleura or right upper lobe medially which affects the external interface causes an alteration or disappearance of the PTB. Anatomical studies explaining the formation of the PTB and clinical cases showing its alteration or disappearance are presented.

Metastatic carcinoma simulating inflammatory colitis.

Metastatic carcinoma to the colon may be mistaken for inflammatory colitis, particulary Crohn's disease, both clinically and roentgenologically. Characteristic changes include mucosal thickening, nodular masses, multiple and eccentric strictures, asymmetric involvement, pseudosacculations, and spiculations of contour. This report, based upon experience with 12 cases, establishes the distinctive roentgen features of metastatic disease to the colon from a variety of primary sites. It is shown that these changes are dependent upon pathways of spread, growth characteristics, and local tissue response. The clinical importance of making this differential diagnosis is two-fold. A patient with an occult or a known primary malignancy may present clinically with metastatic disease to the colon masquerading as inflammatory colitis. Recognition of the characteristic roentgenologic changes immediately either leads to a search for the primary neoplasm or establishes the diagnosis of widespread disease.