Preoperative CT Findings Research Articles

Accelerated hyperfractionated radiotherapy in supratentorial malignant astrocytomas

Purpose: To determine the safety and effectiveness of accelerated hyperfractionated radiotherapy in the treatment of supratentorial malignant astrocytomas. Materials and methods: Between June 1995–July 1997, 75 patients were enrolled to a prospective phase II study. A total dose of 60 Gy was delivered in 2 Gy b.i.d. fractions with an interval of 6–8 h, 5 days per week, in an overall time of 3 weeks. The treatment protocol was planned to give 40 Gy to a treatment volume covering the contrast-enhancing lesion and oedema (+ 3-cm margin) and additional 20 Gy to the volume encompassing the contrast-enhancing lesion alone with a 1-cm margin based on preoperative magnetic resonance imaging and/or CT findings. The patients had a median age of 46 years and a median Karnofsky performance status score of 80. Histology consisted of anaplastic astrocytoma (AA) in 16 (21%) and glioblastoma multiforme (GBM) in 59 (79%) patients. Results: Median survival was 11 months for all patients; 10 months for GBM patients and 40 months for AA patients. Survival rates at 1 and 3 years were 41%, 11% for all patients; 62, 37% for AA patients and 35, 6% for GBM patients, respectively. Multivariate analysis revealed significant impact of age, histology and neurological functional class on survival. The incidence of grade 3 or worse late neurological toxicity was 5.3%. Conclusions: Although accelerated hyperfractionated radiotherapy showed no significant advantage on survival, it shortened the treatment period from 6 to 3 weeks. Radiotherapy was well tolerated and the incidence of late toxicity is acceptable.

Early recurring hepatocellular carcinoma after partial hepatic resection: preoperative CT findings.

ObjectiveThe purpose of this study was to determine the utility of preoperative CT in predicting early recurrence of hepatocellular carcinoma after partial hepatic resection.Materials and MethodsPreoperative three-phase helical CT scans in 53 patients with hepatocellular carcinoma were retrospectively reviewed by two radiologists. In 27 patients (group I), HCC had recurred within six months, while 26 (group II) had remained disease free for at least two years. In each group, preoperative CT findings were evaluated in each group for the tumor size and number, the presence or absence of capsule, distinctness of tumor margin, perinodular extension, and the presence or absence of portal vein thrombosis.ResultsIn group I, a tumor capsule of tumor was seen in five of 27 patients (19%), and in group II, in 16 of 26 (62%) (p = .001). The tumor margin was distinct in eight patients (30%) in group I and in 20 (77%) in group II (p = .001). Multiple tumors, perinodular extension, and portal vein thrombosis were more frequently seen in group I but the differences were not statistically significant (p > .05). Tumor size was similar in each group (p > .05).ConclusionPreoperative CT findings that may help predict the early recurrence of hepatocellular carcinoma after surgical resection are an absence of capsule of tumors and an indistinct margin. Reference to these findings during preoperative CT can guide clinicians in their choice of treatment.

Bile Duct Dilatation after Subtotal Gastrectomy in Stomach Cancer: Comparison with Gastroduodenostmy (BillothI) and Gastro Jejunosto my (Billoth II)

Purpose : To evaluate the incidence and degree of bile duct dilatation after partial gastrectomy due togastric cancer and to determine any differences between gastroduodenostomy (Billoth I) and gastrojejunostomy(Billoth II). Materials and Methods : We retrospectively analyzed the follow up abdominal CT findings in 113patients who had undergone partial gastrectomy without truncal vagotomy or cholecystectomy. In all cases,preoperative abdminal CT findings showed no evidence of bile duct dilatation. Among 113 patients, 41 underwentBilloth I surgery, and 72 underwent Billoth II. No case showed clinical or radiological evidence of obstructivecauses of bile duct dilatation. Among these patients, we decided the criteria for dilatation when this was noted.The grade was either mild (3 -4 mm), moderate (5 -8mm), or severe (over 9mm), as measured at the centralintra-hepatic duct. Extra-hepatic duct dilatation was graded as mild (6 -8mm), moderate (9 -12mm) or severe (over13 mm). We analyzed serum bilrirubin and alkaline phosphatase levels. Results : When the central intrahepatic ductwas measured, 78 of 113 patients(69 %) showed bile duct dilata-tion; 24 of 41 cases(58.5 %) were in the billoth Igroup and 54 of 72 (75 %) were the in Billoth II group. After measurement of the extra hepatic duct, 22 of41cases(53.6%) in the Billoth I group and 54 of 72 (75 %) in the Billoth II group were found to be dilated. Theresults showed a slightly increased incidence of bile duct dilatation in the Billoth, II group but this was notstatistically significant(p>0.05). In the laboratory, total, direct, and indirect bilirubin, as well as alkalinephosphatase levels, were measured. Higher levels were found in Billoth II than in Billoth I but all findings werewithin normal limits. Conclusion : Mild dilatation of the bile duct after partial gastrectomy was a not uncommonfinding, and there was no significant difference of incidence or degree of dilatation according to the procedureperformed. If a patient has no clinical symptoms, it appears that clinical it appears that clinical evaluationdoes not require fur-ther study.

Congenital cystic adenomatoid malformation of the lung: CT-pathologic correlation.

The purpose of this study was to correlate CT findings of congenital cystic adenomatoid malformation (CCAM) of the lung with pathologic findings. CT scans of CCAM from 21 consecutive patients were analyzed retrospectively by two chest radiologists who achieved consensus. Pathologic findings were assessed by an experienced pulmonary pathologist. Preoperative CT findings were correlated with pathologic findings. Areas with small cysts (< 2 cm in diameter) were seen on CT scans in 19 (90%) of 21 patients, whereas areas with a large cyst (> 2 cm in diameter) were observed in 18 patients (86%). Areas of consolidation (n = 9; 43%) with heterogeneous attenuation on enhanced scans and areas of low attenuation (lower than normal lung) around cystic lesions (n = 6; 29%) were also seen on CT scans. The diameter of the largest cyst seen on CT scans in each patient ranged from 1.0 to 8.0 cm (median, 4.5 cm). Cysts that CT showed to be filled with air, fluid, or both correlated completely with the pathologic findings. Areas of consolidation corresponded histologically to areas of glandular or bronchiolar structures with or without areas of endogenous lipoid or organizing pneumonia or mucus plugs. Areas of low attenuation corresponded to areas of microcysts blended with normal lung parenchyma. CT scans show the variable internal characteristics of CCAM and can suggest the underlying pathology of such lesions.

術後性上顎嚢胞に対する鼻内手術について 過去４年間の手術例の検討

Surgical treatments for postoperative maxillary cysts include the peroral method (trans-maxillary sinus method) in which the cyst wall is totally removed or conserved, and opened to the nasal cavity by incising from the gingiva, and the endonasal method in which the cyst wall is opened to the nasal cavity by the nasal approach. Recently, the endonasal method is more widely used because CT and endoscopy can be applied. Forty-two patients (56 sides) who underwent surgery for postoperative maxillary cysts in Nanyo City Hospital over the last four years were reviewed. Preoperative CT findings, surgical methods, operative findings and prognosis were analyzed. Forty-one sides were monocystic and 15 sides were multicystic. Forty-two sides were of the medial type, 4 sides were of the lateral type and 10 sides were of the mixed type. Twenty sides (35.7%), which were both monocystic and medial, were operated on by the endonasal method, while the transmaxillay sinus method was used for the remaining sicks. Though one of endonasal patients experienced a relapse of the maxillary cyst, the endonasal method was associated with less suffering and a shorter operative time than the trans-maxillary sinus method. Therefore, the endonasal method is recommended, if the postoperative maxillary cyst is both monocystic and medial.

4. Surgical approaches in special situations

The optimal extent of a combined resection in patients with lung cancer invading the chest wall remains controversial. To assess whether specific preoperative findings could lead to the precise evaluation of the depth of chest wall invasion and evade en-bloc resection of the chest wall in cases of tumor invasion limited to the parietal pleura, 132 patients with resected lung cancer involving the chest wall were retrospectively surveyed for the preoperative findings, surgical procedures, pathological results, and survival. A pathological examination of the resected specimens showed that 58 tumors had invaded only to the parietal pleura (shallow invasion) and 74 had involved the soft tissue or ribs (deep invasion). A multivariate analysis showed that preoperative CT findings of obvious tumor invasion beyond the parietal pleura (p = 0.005) and complaints of chest pain (p = 0.015) were independent indicators of deep invasion. In patients with lung cancer involving the chest wall, chest pain and/or invading on chest CT suggested that an en-bloc resection was a suitable surgical procedure, because 79% of those patients had deep invasion. On the other hand, in patients without chest pain and invasion on chest CT, an extrapleural approach was recommended at first based on the fact that 63% of them had shallow invasion. In practice, an extrapleural resection was performed in 40 cases and an en-bloc resection in 10 patients with shallow invasion. There was no significant difference in the survival between the two surgical procedures. Therefore, the CT findings of obvious tumor invasion beyond the parietal pleura and/or the presence of chest pain indicate the need to perform an en-bloc resection in patients with lung cancer involving the chest wall. However, in patients without these findings, an extrapleural approach could be initially attempted for chest wall resection, because an en-bloc resection had no survival benefit for patients with shallow invasion.

頸動脈内膜剥離術における合併症の検討

We experienced 63 cases with carotid endarterectomy (CEA). After CEA, 54 cases (86%) showed clinical improvement or no change, 6 cases (9%) showed transient complications and 3 cases (5%) suffered sutained complications. Complications consisted of 2 subcutaneous hemorrhages, 5 lower cranial nerve palsies, 2 myocardial infarctions, 2 convulsions and hemiparesis, 2 slight impairments of consciousness and one secondary glaucoma.Among 6 patients with complications such as myocardial infarction, glaucoma, convulsion and declined consciousness except for the ones due to surgical maneuvour, we analyzed the risk factors such as age, preoperative ischemic condition, CT and MRI findings, multiple operations and the degree of stenosis of ipsilateral carotid artery on the operative side. Severe carotid stenosis over 90% was the most significant risk factor in carotid endarterectomy. It correlated with hyperperfusion syndrome, myocardial infarction and mental impairment. One patient with severe carotid stenosis presenting ischemic ocular syndrome had glaucoma in spite of improvement of ophthalmic circulation after CEA. These data suggested that in CEA for severe carotid stenosis over 90%, the patients should be more intensively cared for during the postoperative period.

Emergency CT in Blunt Abdominal Trauma of Multiple Injury Patients

Multiple injury patients with blunt abdominal trauma (n = 110) were examined by abdominal CT. An i.v., but not peroral, contrast medium was used, thereby eliminating the delay caused by administering peroral contrast medium and any subsequent delay in making the diagnoses and beginning operative treatment. Eighteen patients underwent emergency laparotomy after the initial CT examination. The preoperative CT findings were compared to the laparotomy findings. CT revealed all but one of the severe parenchymal organ lesions requiring surgery. The one liver laceration that went undetected had caused hemoperitoneum, which was diagnosed by CT. The bowel and mesenteric lesions presented as intra-abdominal blood, and the hemoperitoneum was discovered in every patient with these lesions. Fourteen patients also initially had positive abdominal CT findings; 10 of them underwent an additional abdominal CT within 3 days, but the repeat studies did not reveal any lesions in need of surgery. Omission of the oral contrast medium did not jeopardize making the essential diagnoses, but it did save time.

Assessment AT CT of the Rheumatoid Shoulder with Surgical Correlation

Eleven shoulders in 10 patients with rheumatoid arthritis were examined by conventional radiography and CT prior to cup hemiarthroplasty of the humeral head and the results were compared with the surgical findings. There was good agreement between preoperative CT and surgical findings. Humeral head cavities and erosions, with cortical boundaries, could be seen more accurately at CT than at conventional radiography. The HU of their contents corresponded to those of soft tissue, being granulomatous in nature at surgery. In 8 humeral heads CT disclosed large areas of fatty degeneration of bone marrow with HU between − 10 HU and − 76 HU that were not visible on the conventional radiographs. These “fatty cysts” had no cortical boundaries, unlike inflammatory granulomas, but both lesions may influence the surgical approach to hemiarthroplasty.

Emergency CT in Blunt Abdominal Trauma of Multiple Injury Patients

Multiple injury patients with blunt abdominal trauma (n = 110) were examined by abdominal CT. An i.v., but not peroral, contrast medium was used, thereby eliminating the delay caused by administering peroral contrast medium and any subsequent delay in making the diagnoses and beginning operative treatment. Eighteen patients underwent emergency laparotomy after the initial CT examination. The preoperative CT findings were compared to the laparotomy findings. CT revealed all but one of the severe parenchymal organ lesions requiring surgery. The one liver laceration that went undetected had caused hemoperitoneum, which was diagnosed by CT. The bowel and mesenteric lesions presented as intra-abdominal blood, and the hemoperitoneum was discovered in every patient with these lesions. Fourteen patients also initially had positive abdominal CT findings; 10 of them underwent an additional abdominal CT within 3 days, but the repeat studies did not reveal any lesions in need of surgery. Omission of the oral contrast medium did not jeopardize making the essential diagnoses, but it did save time.

INFLUENCE OF SPLENOMEGALY ON PATIENTS UNDERGOING HEPATIC RESECTION FOR HEPATOCELLULAR CARCINOMA

This study is designed to study the influence of splenomegaly on the risk and outcome following hepatectomy in 75 patients with hepatocellular carcinoma (HCC). Spleen volume was measured by preoperative CT findings and divided into 3 groups, i.e., group A: less than 120cm3, group B: between 120 and 300cm3 and group C: more than 300cm3. In order of group A, B, and C, the frequency of association of liver cirrhosis or esophageal varix increased, but the platelet count decreased. There was no significant difference among three groups in preoperative ICGR15 value. Intraoperative bleeding volume in group C tended to be larger than other two groups, without significant difference. There were no significant differences in mobidity rate among 3 groups, 52.0% in group A, 41.7% in group B and 57.0% in group C. The 5-year cumulative survival rates were 49%, 54%, and 68% in group A, B, and C, respectively. There was no significant difference among these rates, but it tended to increase with the volume of the spleen. It is thought that the influence of spleen volume on the morbidity rate and surgical outcome can be negligible in patients undergoing hepatectomy for HCC.

Hepatic extramedullary plasmocytoma: imaging findings

The case of a 72-year-old man with a solitary hepatic extramedullary plasmocytoma (EMP) is presented. Preoperative MRI and CT findings showed a homogeneous solitary unspecific lesion with an early brief enhancement after IV contrast administration. Differential diagnoses are reviewed and discussed. Imaging findings were not specific but could be observed in a hypervascular hepatic metastasis. However associated with IgG monoclonal spike, without bone marrow involvement, EMP should be suspected.

Assessment at CT of the rheumatoid shoulder with surgical correlation

Eleven shoulders in 10 patients with rheumatoid arthritis were examined by conventional radiography and CT prior to cup hemiarthroplasty of the humeral head and the results were compared with the surgical findings. There was good agreement between preoperative CT and surgical findings. Humeral head cavities and erosions, with cortical boundaries, could be seen more accurately at CT than at conventional radiography. The HU of their contents corresponded to those of soft tissue, being granulomatous in nature at surgery. In 8 humeral heads CT disclosed large areas of fatty degeneration of bone marrow with HU between -10 HU and -76 HU that were not visible on the conventional radiographs. These "fatty cysts" had no cortical boundaries, unlike inflammatory granulomas, but both lesions may influence the surgical approach to hemiarthroplasty.

Relation between preoperative CT findings in rectal cancer and local recurrence rate. A pilot study.

To identify predictive factors of local recurrence possible to use as criteria for preoperative radiotherapy, we reviewed the CT scans of 51 patients undergoing curative resection for rectal cancer. Seven patients developed local recurrence. The presence of the CT images of spicular structures or a fibrous soft tissue layer around the rectum was related to extrarectal spread with a positive predictive value of 88% (30/34) when compared with the pathology. Six out of 34 cases with these CT findings developed recurrence, compared to only one out of 17 cases without such findings. The recurrence rate was especially high, (4/14), in patients where the abnormal tissue as judged by CT was attached to the perirectal fascia or extended beyond it. CT may be a useful tool for predicting local recurrence by using the perirectal fascia as a diagnostic marker.

CT and MR evaluation of pericardial constriction: a new diagnostic and therapeutic concept.

Eighty patients with pericardial constriction confirmed by catheter data were studied by CT (n = 79), MR imaging (n = 24), or both. To determine the validity of these imaging methods for subsequent treatment, 30 patients' studies were evaluated retrospectively (1980-1984) and 50 (1985-1991) prospectively. Twenty patients from the first group and 30 patients from the second group underwent pericardiectomy. By systematic analysis of CT scans and MR images it was possible to characterize the morphology of pericardial constriction (n = 80); to identify global (n = 27), right-sided (n = 46), left-sided (n = 2), annular (n = 2), effusive (n = 2), and epicardial (n = 1) forms of pericardial constriction; and to define parameters of myocardial atrophy and fibrosis (n = 17). Seventeen patients had myocardial atrophy, fibrosis, or both. Seven of them underwent pericardiectomy; all died of acute myocardial failure (100%). Four (9.3%) of 43 patients without myocardial atrophy or fibrosis died as a consequence of other complications. The method of thoracotomy and periepicardiectomy was continuously adjusted to the preoperative CT and MR findings. Thus, the clinical use of CT and MR imaging in patients with known or suspected pericardial constriction is based on (a) exclusion of patients with restrictive hemodynamics from diagnostic thoracotomy, (b) preoperative determination of the method of thoracotomy and extent of pericardiectomy, and (c) exclusion of patients with myocardial atrophy or fibrosis from pericardiectomy.

Rupture of the bowel after blunt abdominal trauma: diagnosis with CT.

The accuracy of CT in the detection of injuries of the solid viscera after blunt trauma is well established, but the value of CT in diagnosing bowel rupture resulting from blunt trauma is controversial. This study was conducted to determine the sensitivity of CT in diagnosing posttraumatic bowel rupture. During a 51-month period, 17 preoperative CT scans were obtained in 16 patients who subsequently had bowel ruptures verified surgically. Both preoperative (prospective) and retrospective CT findings were analyzed in these patients. Retrospective interpretation was made by consensus of two radiologists. Surgically confirmed bowel ruptures occurred in the duodenum (five), ileum (four), jejunum (four), colon (four), and stomach (two). CT findings considered diagnostic of bowel perforation were detected prospectively on 10 (59%) of 17 scans; these included pneumoperitoneum without prior peritoneal lavage (six), mesenteric, intramural, or retroperitoneal free air (six), or direct visualization of discontinuity of the bowel wall or extravasation of luminal contents (four). Prospective CT findings considered suggestive of bowel rupture were present on five (29%) of the 17 scans; these included intraperitoneal fluid of unknown source (three), thickened (> 4-5 mm) bowel wall (two), gross anterior pararenal fluid without a recognized source (one), and a mesenteric-bowel wall hematoma (one). On two of 17 scans, findings were seen in retrospect only; these included free intraperitoneal blood without a source (findings on a second CT scan were diagnostic) and pneumoperitoneum. CT findings diagnostic or suggestive of bowel injury were detected prospectively on 15 (88%) of 17 scans and were noted in all retrospectively. CT is sensitive for the diagnosis of bowel rupture resulting from blunt trauma, but careful inspection and technique are required to detect often subtle findings.

虚血性脳血管障害に合併する無症候性脳動脈瘤に対する治療方針

This study is based on eighty-five cases of unruptured asymptomatic aneurysms associated with ischemic cerebrovascular disease. Sixty-one cases (73 aneurysms) were treated surgically and 24 cases were treated non-surgically. The post-operative course was uneventful in 50 out of 61 cases (82%) and unsatisfactory in 11 cases (18%). There was no significant relation of the surgical results to site of aneurysm, type of stroke, or pre-operative CT and angiographical findings. The results appeared to correlate with patients' age and surgical technique. In the 11 unsatisfactory cases, symptoms worsened due to an intracerebral hematoma (ICH), an enlargement of the infarcted area or a subarachnoid hemorrhage (SAH). The cause of death in five cases, three of which were patients over 70, was attributed to acute myocardial infarction in 2 cases, large post-operative ICH in 2 cases and SAH in 1 case.In the 24 cases without surgery, only one aneurysm ruptured during 1-7 years follow-up.Based on these results, surgery might be indicated for cases with complicated lesions to prevent future SAH due to rupture of aneurysm and stroke following TIA. However, surgery is associated with a high rate of post-operative complications, because ischemic brain tissue is very vulnerable to retraction pressure. Patients over 70 with these complicated lesions should be excluded from surgical indication.

Diagnosis of ossicular chain in the middle ear by high-resolution CT

This study was conducted to assess the usefulness and limitation of high-resolution CT for evaluating the condition of ossicular chain in the middle ear. Preoperative CT findings of the ossicular chain were compared with the operative findings of ossicles in 26 patients with chronic otitis media or congenital ossicular anomaly who underwent tympanoplasty. Total defect of head of the malleus, body of the incus and long process of the incus were completely detected by high-resolution CT. But the reliability in detecting the defect of handle of the malleus and superstructure of the stapes were 33.3% and 60%, respectively. Defect of the I-S joint (1 case) and partial defect of stapes crus (2 cases) could not be diagnosed correctly in the preoperative estimation. Although these findings demonstrate the limitations of high-resolution CT in the diagnosis of ossicular chain, it will be diminished by the advanced space resolution of CT in the future.

Diagnosis of the ossicular chain in the middle ear by high-resolution CT.

This study was conducted to assess the usefulness and limitations of high-resolution CT for diagnosing the ossicular chain in the middle ear. The CT images in this study were obtained in as much detail as possible and 2 direction images. Preoperative CT findings of the ossicular chain were compared with operative findings in 26 patients with ossicular defects. Preoperative detection of the complete defect of the malleus head and the body and long process of the incus by high-resolution CT was possible in all cases, while detection of the defect of the manubrium of the malleus and superstructure of the stapes could be made in 33.3 and 60%, respectively. The defect of the incudostapedial joint (1 case) and partial defect of the stapes crus (2 cases) could not be diagnosed correctly by preoperative estimation.

Correlation between CT and DNA contents in peripheral lung cancers

The DNA contents of 30 lung cancers were correlated with preoperative chest CT findings. Tumors with diameters less than 4 cm had lower DNA contents than larger ones, and tumors with spiculated margins had lower DNA than those with lobulated or smooth margins. As DNA contents are correlated with prognosis, the border configuration of peripheral lung cancers may be enough to predict prognosis.