Abstract: AIM: To determine the T(2) relaxation time of colorectal hepatic metastases and changes in T(2) relaxation times following chemotherapy. MATERIALS AND METHODS: 42 patients with 96 hepatic colorectal metastases underwent baseline MRI. Axial T(1), T(2) and multi-echo GRASE sequences were acquired. ROIs were drawn on T(2) relaxation maps, obtained from GRASE images, encompassing metastasis and normal liver to record T(2) relaxation time values. In 11 patients with 28 metastases, MRI was repeated using same protocol at 6 weeks following chemotherapy. The median pre-treatment T(2) values of metastases and normal liver were compared using the Mann-Whitney test. The pre- and post-treatment median T(2) values of metastases were compared using the Wilcoxon-Rank test for responding (n=16) and non-responding (n=12) lesions defined by RECIST criteria. The change in T(2) values (ÎT(2)) were compared and correlated with percentage change in lesion size. RESULTS: There was no difference in the pre-treatment median T(2) of metastases between responding (67.3±8.6) and non-responding metastases (71.4±16.5). At the end of chemotherapy, there was a decrease in the median T(2) of responding lesions (61.6±12.6) p=0.83, and increase in non-responding lesions (76.2±18.4) p=0.03, but these were not significantly different from the pre-treatment values. There was no significant difference in ÎT(2) of responding and non-responding lesions (p=0.18) and no correlation was seen between size change and ÎT(2) (coefficient=0.3). CONCLUSION: T(2) relaxation time does not appear to predict response of colorectal liver metastasis to chemotherapy.
Abstract: There is much debate about the optimal sedation strategy for transoesophageal echocardiography (TEE). Despite previous studies demonstrating the potential benefits of combining opiates and benzodiazepines for conscious sedation, and previous published national surveys and recommendations, sedation practice for TEE in clinical practice varies widely within the UK. All UK centres routinely use midazolam, but only 7% of centres use it in combination with an opiate: 14% of hospitals report no routine use of sedation for TEE. Thereis no British Society of Echocardiography (BSE) recommended TEE sedation protocol within the UK and even where guidelines exist locally, 82% of operators report being unaware of their details. Consequently, a wide range of sedative doses are used and many patients are reported to be over-sedated. We developed a new protocol for conscious sedation using intravenous pethidine and midazolam for TEE and have shown it to be safe and effective when implemented within an existing TEE service
Abstract: INTRODUCTION: Primary pulmonary mucinous cystadenocarcinoma is a rare variety of lung cancer. It is characterized pathologically by copious mucin production predominantly in the extracellular space. This tumour has a remarkably favorable prognosis. CASE PRESENTATION: We present imaging and histopathological findings of primary pulmonary mucinous cystadenocarcinoma presenting as a complex bronchocele in a 67-year-old Caucasian woman. CONCLUSION: Diagnosis of pulmonary mucinous cystadenocarcinoma should be considered in patients presenting with bronchocele that has suspicious imaging features, because the results of fine needle aspiration cytology and bronchoscopy are frequently inconclusive in these tumours. Positive emission tomography has an important role in helping to identify these tumours.
Abstract: ABSTRACT: BACKGROUND: Shoulder dysfunction is common and pathology of the rotator cuff tendons and subacromial bursa are considered to be a major cause of pain and morbidity. Although many hypotheses exist there is no definitive understanding as to the origin of the pain arising from these structures. Research investigations from other tendons have placed intra-tendinous neovascularity as a potential mechanism of pain production. The prevalence of neovascularity in patients with a clinical diagnosis of rotator cuff tendinopathy is unknown. As such the primary aim of this pilot study was to investigate if neovascularity could be identified and to determine the prevalence of neovascularity in the rotator cuff tendons and subacromial bursa in subjects with unilateral shoulder pain clinically assessed to be rotator cuff tendinopathy. The secondary aims were to investigate the association between the presence of neovascularity and pain, duration of symptoms, and, neovascularity and shoulder function. METHODS: Patients with a clinical diagnosis of unilateral rotator cuff tendinopathy referred for a routine diagnostic ultrasound (US) scan in a major London teaching hospital formed the study population. At referral patients were provided with an information document. On the day of the scan (on average, at least one week later) the patients agreeing to participate were taken through the consent process and underwent an additional clinical examination prior to undergoing a bilateral grey scale and colour Doppler US examination (symptomatic and asymptomatic shoulder) using a Philips HDI 5000 Sono CT US machine. The ultrasound scans were performed by one of two radiologists who recorded their findings and the final assessment was made by a third radiologist blinded both to the clinical examination and the ultrasound examination. The findings of the radiologists who performed the scans and the blinded radiologist were compared and any disagreements were resolved by consensus. RESULTS: Twenty-six patients agreed to participate and formed the study population. Of these, 6 subjects were not included in the final assessment following the pre-scan clinical investigation. This is because one subject had complete cessation of symptoms between the time of the referral and entry into the trial. Another five had developed bilateral shoulder pain during the same period. The mean age of the 20 subjects forming the study population was 50.2 (range 32-69) years (SD= 10.9) and the mean duration of symptoms was 22.6 (range .75 to 132) months (SD= 40.1). Of the 20 subjects included in the formal analysis, 13 subjects (65%) demonstrated neovascularity in the symptomatic shoulder and 5 subjects (25%) demonstrated neovascularity in the asymptomatic shoulder. The subject withdrawn due to complete cessation of symptoms was not found to have neovascularity in either shoulder and of the 5 withdrawn due to bilateral symptoms; two subjects were found to have signs of bilateral neovascularity, one subject demonstrated neovascularity in one shoulder and two subjects in neither shoulder. CONCLUSIONS: This study demonstrated that neovascularity does occur in subjects with a clinical diagnosis of rotator cuff tendinopathy and to a lesser extent in asymptomatic shoulders. In addition, the findings of this investigation did not identify an association between the presence of neovascularity; and pain, duration of symptoms or shoulder function. Future research is required to determine the relevance of these findings.
Abstract: INTRODUCTION: Cystic hygroma is a benign congenital neoplasm that mostly presents as a soft-tissue mass in the posterior triangle of the neck. Pure mediastinal lesions are uncommon; the vast majority are asymptomatic and are an incidental finding in adulthood. The diagnosis is often made intra- or postoperatively. Prenatal identification is exceptional and post-natal diagnosis also proves challenging. CASE PRESENTATION: We report one such case that was mistaken for other entities in both the prenatal and immediate post-natal period. Initial and follow-up antenatal ultrasound scans demonstrated a multicystic lesion in the left chest, and the mother was counselled about the possibility of her baby having a congenital diaphragmatic hernia. Initial post-natal chest radiographs were reported as normal. An echocardiogram and thoracic computed tomography scan confirmed a complex multiloculated cystic mediastinal mass. The working diagnoses were of a mediastinal teratoma or congenital cystic adenomatous malformation. At operation, the lesion was compressed by the left lung and was found to be close to the left phrenic nerve, which was carefully identified and preserved. After excision, histopathological examination of the mass confirmed the diagnosis of cystic hygroma. Postoperative dyspnoea was observed secondary to paradoxical movement of the left hemidiaphragm and probable left phrenic neuropraxia. This settled conservatively with excellent recovery. CONCLUSION: Despite the fact that isolated intrathoracic cystic hygroma is a rare entity, it needs to be considered in the differential diagnosis of foetal and neonatal mediastinal masses, particularly for juxtadiaphragmatic lesions. The phrenic nerve is not identifiable on prenatal ultrasound imaging, and it is therefore understandable that a mass close to the diaphragm may be mistaken for a congenital diaphragmatic hernia because of the location, morphology and potential phrenic nerve compression. Post-natal diagnosis may also be misleading as many mediastinal cystic masses have similar appearances on imaging. Therefore, as well as cystic architecture, special consideration needs to be given to the anatomical location and effect on local structures.
Abstract: Imaging to guide percutaneous closure of patent foramen ovale (PFO) and atrial septal defect (ASD) has traditionally required transoesophageal echocardiography (TOE) with general anaesthesia. The development of intracardiac echocardiography (ICE) allows these procedures to be performed under local anaesthesia, obviating the need for endotracheal intubation and general anaesthesia. We set out to prospectively evaluate the effect of ICE on the success and efficiency of PFO and ASD closure. Data on all adult patients undergoing percutaneous PFO and ASD closure were collected prospectively between 2003 and 2008. Allocation to echocardiographic technique was non-random and determined by availability of anaesthetic and cardiology staff, initial ICE probe availability and relative contraindication to general anaesthesia. Procedure time, fluoroscopy time, radiation dose, device deployment success rate, procedural complications, hospital stay length, and interatrial communication closure at 3 months were compared between the two imaging modalities. 210 consecutive patients underwent percutaneous interatrial defect closure over the study period, 55 (26%) with TOE and 155 (74%) using ICE. Baseline characteristics of the TOE and ICE groups were similar (age 45.3±15.5 vs 47.9±13.6 years, p=0.415; male 36% vs 42%, p=0.524; body surface area 1.81±0.27 vs 1.90±0.26 m2, p=0.110; interatrial defect size (for ASD) 19.8±8.9 vs 18.2±7.9 mm, p=0.458). Procedural time (not including induction and recovery from general anaesthesia; 50±21 vs 42±18 minutes, p=0.007), fluoroscopy time (8.0±6.0 vs 5.4±4.0 minutes, p<0.0001), radiation dose (1350±1626 vs 714±1017 cGy/cm2, p<0.0001), and inpatient stay 1.8±0.9 vs 1.0±3.3 days, p<0.0001) were significantly reduced using ICE. There were no differences in the device deployment success rate (94% vs 95%, p<0.724) and interatrial communication closure at 3 months (96% vs 93%, p=0.722). During percutaneous closure of interatrial defects, ICE avoids the risks and inconvenience of general anaesthesia and is associated with significantly reduced procedure times, radiation doses, and inpatient stay compared to TOE, without compromising procedure success.
Abstract: Objectives: Echocardiographic imaging to guide percutaneous closure of a
patent foramen ovale (PFO) or atrial septal defect (ASD) has traditionally been
performed using transoesophageal approach (TOE) and general anaesthesia.
The development of intracardiac echocardiography (ICE) now allows the procedures
to be performed using only local anaesthesia, obviating the need for endotracheal
intubation and general anaesthesia. Following commencement of the
ICE programme in Oxford in 2003, we set out to evaluate the effect of this new
imaging modality on the success and efficiency of PFO and ASD closure.
Methods: Data were prospectively collected for all adult patients undergoing
percutaneous PFO or ASD closure. Allocation to echocardiographic technique
was non-random and based on availability of anaesthetic staff, initial ICE probe
availability and relative contraindications to general anaesthesia. Baseline patient
characteristics, procedure time, fluoroscopic screening time, total radiation dose,
device deployment success rate, hospital stay length, and interatrial communication
closure at 3 months were compared between the two imaging modalities.
Results: 94 consecutive adult patients underwent percutaneous interatrial defect
closure over the study period, 44 (47%) with TOE guidance and general
anaesthesia and 50 (53%) using ICE and local anaesthetic. There were approximately
equal numbers of ASDs and PFOs closed (55% vs 45%). The majority
of ASDs (78%) were closed using an Amplatzer device, whilst the remainder of
the ASDs and all of the PFOs were closed using a Helex device. Baseline characteristics
of the TOE and ICE groupswere similar (age 47.7±12.0 vs 47.4±14.5
years, p=0.862; male 33% vs 48%, p=0.398; body surface area 1.84±0.28 vs
1.90±0.27 m2, p=0.411; and interatrial defect size 20.4±9.8 vs 23.5±6.9mm,
p=0.215). Procedure time (52±23 vs 47±17 minutes, p=0.476), not including induction
and recovery from general anaesthesia; and screening time (8±6 vs 6±3
minutes, p=0.155) were not significantly different. Radiation dose (1472±1765
vs 1015±1354 cGy/cm2,p=0.038) and inpatient stay (2.0±0.7 vs 1.2±1.1 days,
p<0.001) were reduced using ICE. There were no significant differences in the
device deployment success rate (95% vs 96%, p=1) and interatrial communication
closure at 3 months (95% vs 89%, p=0.419).
Conclusions: The use of ICE for imaging PFO and ASD closure is associated
with reduced patient radiation exposure and inpatient stay without compromising
procedure success, and avoids the risks and inconvenience of general anaesthesia.
Abstract: Congenital lung lesions are diagnosed antenatally in the majority of cases. Postnatal management includes chest radiography and CT-scanning, followed by either surgical resection or CT surveillance. Pre-operatively, lesions are often "labelled" as CCAM (and the Stocker classification incorrectly applied), sequestration, or lobar emphysema, and their frequent "hybrid" nature sometimes missed. The aim of our study was to correlate antenatal and postnatal radiological diagnoses and classification of congenital lung lesions with surgical and pathological outcome. Twenty-six consecutive cases of antenatally-diagnosed cystic lung lesions managed at our centre between January 2003 and April 2007 were reviewed. Diagnoses were: cystic adenomatoid malformations (CCAM) in 13 cases (50.0%), three bronchopulmonary sequestrations (11.5%), "hybrid" lesions in eight cases (30.8%), one isolated lobar emphysema (3.8%) and a normal lung segment with anomalous systemic supply (3.8%). Overall concordance rate between prenatal ultrasound and resection pathology was 61.5%, whereas CT findings correlated with pathology in 65.4% of cases. Incorrect radiological classification resulted in one morbidity, when an attempted thoracoscopic resection of a presumed CCAM had to be converted to an open procedure due to bleeding from an unsuspected anomalous vessel. The common embryological origin of these lesions, and the need for standardisation of reporting is discussed. We propose that lesions should be classified anatomically according to their nature, arterial supply and venous drainage in order to reduce discrepancies between radiological, intra-operative and pathological reporting.
Abstract: Background: Sedation practice for TOE varies widely. No sedation is associated with adverse patient experience, and high dose bolus midazolam regimes (5â10mg) with adverse events; particularly in the elderly. We evaluated prospectively the impact on procedure and patient of a low dose titrated sedation regime.
Methods: All patients undergoing TOE over an 8-week period were involved. Operator guidelines were to give 2mg midazolam initially (1mg in the elderly) with further 1mg boluses depending on response. The operator could also give 25mg pethidine initially with a further 25mg depending on response. During the procedure, an independent observer recorded sedation dose, sedation level, ease of intubation and patient compliance (graded up to 5 â good), patient haemodynamics, respiration and adverse events. Afterwards patients completed a questionnaire about their experience.
Results: Fifty-two patients (31 male, 21 female) took part. Median midazolam dose was 3mg (range 1â8mg) and pethidine 25mg (range 0â50mg). Of the patients, 40% received â¤2mg midazolam and 70% received pethidine. Sedation level was similar across final titrated doses. Overall patient compliance and intubation ease were good (compliance â 4.4/5; intubation ease â 4.3/5) and not reduced if patient received â¤2mg midazolam. Similarly, patient satisfaction was high, with no reduction with low dose midazolam (overall â 4.1/5, â¤2mg midazolam â 4.0/5, p=0.7). For the whole group, use of pethidine did not impact on intubation ease, patient compliance, patient experience or midazolam dose. However, in those who received â¤2mg midazolam use of pethidine was associated with significant improvements in intubation ease (3.8/5 vs 4.7/5, p=0.03), compliance (3.8/5 vs 4.9/5, p=0.007) and a trend for increased satisfaction (3.5/4 vs 4.3/4, p=0.1).
Discussion: Low dose sedation with up-titration according to response is acceptable to patients, has minimal adverse events and no impact on procedural ease. The regime mirrors that for other endoscopic procedures and could be adopted as standard guidelines for TOE.
Abstract: AIMS
To analyze angioplasty results in the setting of a teaching hospital with a range of operators.
Use of defined anatomical classification of vascular lesions by the TASC classification to compare results to published data.
MATERIALS AND METHODS
Retrospective, consecutive data were collected for a period of 1 year for all patients undergoing endovascular interventions. Radiology information system and notes were utilised and angiograms were reviewed in all cases. All cases were performed or supervised by 5 vascular interventional consultants assisted by fellows or registrars. Patients age, sex, indication for treatment, TASC classification of treated lesion, calcification, use of stent, technical success (residual stenosis <20% on completion angiography) and complications were all assessed.
RESULTS
A total of 262 lesions were treated.
Of the aortoiliac lesions (83), overall primary technical success rate was 91.6% (TASC A and B: 96.7%, TASC C and D: 77.3%). No recorded complications. 61 lesions were stented.
Of the femoropopliteal lesions (123), overall primary technical success rate was 91.9% (TASC A and B: 98.7%, TASC C and D: 80.9%). There were 9 minor complications in this group (perforation angioplastied and stented, several minor hematoma, distal embolisation, self limiting perforation). 2 patients were stented.
In the infrapopliteal group (56), overall primary technical success rate was 91.1% (TASC A and B: 96.3%, TASC C and D: 86.2%). There were 2 complications (small retroperitoneal hematoma, occlusion requiring reintervention) and no stents were used.
CONCLUSION
Use of the TASC classification of lesions allows an assessment of severity and enables comparison with published data. Our study has shown results that are comparable with most published series and a low complication rate.
Abstract: PURPOSE
To determine the accuracy of computed tomography (CT) in differentiating upper urinary tract transitional cell carcinoma (UTTCC) from centrally infiltrating renal cell carcinoma (CRCC) and to define the most useful diagnostic CT features.
METHOD AND MATERIALS
CT studies of 98 patients (M:F = 67:31; Age range = 35-92years) with pathologically proven centrally infiltrating malignant renal tumours (67 CRCCs and 31 UTTCCs) underwent blinded, independent review by five specialty-trained radiologists (with 5-15 years of uroradiology experience). Twenty different CT features were graded on a 4 point score. The sensitivity and specificity were calculated for each variable and compared using receiver âoperating-characteristic (ROC) curves. The inter-rater agreement (kappa) was also calculated for each variable.
RESULTS
The mean (range) tumour sizes were UTTCC = 4.4cm (0.8-12cm); CRCC = 7.1cm (1-14cm). All 5 readers recognised UTTCCs with a high specificity (sensitivity between 74-100%; specificity: 84-88% for global assessment). The area under ROC curve was 0.81-0.92 (figure) with good inter-rater agreement (kappa value 0.52-1.00). Five CT features were most diagnostically specific in identifying UTTCCs: tumour centered within the collecting system (sens: 61-97%; spec: 84-90%), preservation of renal shape (sens: 66-90%; spec: 70-86%), homogeneous tumour enhancement (sens: 59-84%; spec: 79-97%), absence of necrosis/cystic change (sens: 67-87%; spec: 66-92%) and focal filling defect in the pelvicalyceal system (sens: 51.6-100%; spec: 63-92% ). There was moderate to good agreement between the readers over all these 5 diagnostic features.
CONCLUSION
Careful scrutiny of CT studies can help differentiate UTTCC from CRCC with a specificity of 84-88%. The most useful differentiating features (specificity range 70- 92%) are the position of the tumour, renal shape, enhancement pattern, absence of necrosis and the finding of a focal filling defect in the pelvicalcyceal system.
Abstract: Purpose
To assess the value of cross-sectional imaging in patients undergoing DaTSCAN for Parkinsonian symptoms IDIOPATHIC PARKINSONâS DISEASE(Shaking Palsy) First noted by British physician James Parkinson in 1817 A progressive movement disorder charecterised bytremorsrigidityslow movements (bradykinesia)posture instabilityAffects 1% of the elderly population Disease course is progressive but unpredictable Early diagnosis is important to differentiate between idopathic...
Methods and Materials
THE DOPAMINE TRANSPORTER (DAT) This is a presynaptic membrane-spanning protein through which dopamine is removed from the synapses Recent onset PD or hemiparkinsonism results in;50% decrease in presynaptic transporters in the contralateral Putamen30% decrease in ipsilateral PutamenDAT loss in PD correlates with nigrostriatal dopaminergic neurons There is a correlation between DAT binding on SPECT imaging and disease duration DaTSCAN123-I IoflupaneAlso known as...
Results
WHAT DO THE RESULTS TELL US? 18 out of 26 (69%) of patients already had a CT or MRI at the time of DaTSCAN.The patient's diagnosis on DaTSCAN may be altered if there is a basal ganglia infarct. The scan may otherwise be incorrectly called idiopathic parkinson's disease. There is one definite case of this in our study and one possible case with no CT or MRI available for correlation. Potentially this may repesent 11% of patients with an...
Conclusion
Patients with a significant unilateral DaTSCAN abnormality should have cross-sectional imaging to exclude a structural aetiology, such as an infarct or tumour.Patients with a normal DaTSCAN and parkinsonian symptoms should have cross-sectional imaging to exclude functional vascular parkinsonism.
