Preoperative Imaging Evaluation Research Articles

Preoperative imaging evaluation of head and neck cancer: Comparison of 2D spin-echo and 3D THRIVE MRI techniques with resected tumours

To evaluate the usefulness of contrast-enhanced three-dimensional (3D) T1-weighted high-resolution isotropic volume examination (THRIVE) for the preoperative assessment of head and neck cancer, by comparison with spin-echo (SE) T1-weighted sequences and the pathology specimen. Thirty-seven consecutive patients who were diagnosed with oral cavity, oropharyngeal, and hypopharyngeal cancer and received surgical excision with preoperative magnetic resonance imaging (MRI) using both SE and 3D THRIVE sequences after gadolinium injection were studied. Tumour conspicuity, motion- and flow-related artefacts were evaluated, and the tumour size was measured based on both sequences, which were correlated with the surgical specimen. The population correlation coefficient (r(g)(2)) and Bland-Altman plots were used to assess measurement agreement. There was no statistical difference between SE and THRIVE in terms of tumour conspicuity and motion-related artefacts, however, flow-related artefacts significantly decreased with THRIVE. The measurement agreement of tumour size estimated on both SE and THRIVE was good (r(g)(2) = 0.87 for SE and 0.93 for THRIVE), and the difference was statistically significant. The 3D THRIVE sequence provided satisfactory image quality for the accurate measurement of tumour size with fewer artefacts and could be an acceptable alternative for SE T1-weighted images for preoperative staging in patients with head and neck cancer.

Endoscopic anatomy of sellar region

The transsphenoidal approach is the preferred access used in surgical treatment of most sellar region pathologies. The use of endoscopy is advantageous, and it is considered a good alternative to the traditional microsurgical technique. The purpose of this study is to recognize and describe anatomical variations of the sphenoid sinus and the sellar region, mainly describing the anatomy of the posterior wall of the sphenoid sinus and analyzing intercarotid distances in 3 regions. Thirty sphenoid blocks treated with formaldehyde were injected and dissected. Using endoscopy, anatomical variations were studied and the intercarotid distances were measured at the tuberculum sellae, sellar floor and clivus. The types of sphenoid sinus found were: conchal in 1 (4.76%), pré-sellar in 2 (9.52%) and sellar in 19 (85.7%) specimens. The mean distance found from the sphenoid sinus ostium to the sella turcica was 19mm (±6.5)mm. The mean intercarotid distances found at the tuberculum sellae, sellar floor and clivus were respectively 13.32, 18.00 and 18.90mm. Endoscopy, with its magnification and lighting provide a panoramic view of deep fields. The anatomical variations described in this study support the need for a careful evaluation of preoperative images in each case.

Treatment of Inverted Nipple with Subareolar Abscess: Usefulness of High-Resolution MRI for Preoperative Evaluation

Background. Inverted nipples with subareolar abscesses can recur due to insufficient resection. It is important to provide reliable curative treatment after determination of the extent of resection by preoperative imaging evaluation. Methods. Ten patients were treated for inverted nipples with subareolar abscess. Sonography and high-resolution MRI were used as preoperative imaging modalities. The endpoints of preoperative imaging evaluation were defined as the identification of the abscess site, isolated fistula site, and extent of inflammation. Results. In all patients, sonography confirmed the presence of abscesses but their locations could not be identified. Sonography could not confirm the presence of isolated fistula or inflammation. In contrast, high-resolution MRI not only confirmed the presence of abscesses but also revealed their positional relationships with the nipples. In addition, high-resolution MRI confirmed the presence of isolated fistulas and inflammation as well as revealed their positional relationships with the nipples. In all patients, no recurrence was observed, and satisfactory surgical results were obtained. Conclusion. High-resolution MRI is useful in determination of the extent of resection of subareolar abscess associated with inverted nipple.

Giant Left Atrial Appendage Aneurysm in a Neonate

Giant aneurysm of the left atrial appendage (LAA) is a rare condition typically presenting in adulthood. This case report describes the investigations and surgical management of a giant LAA aneurysm in a neonate, emphasizing the role of echocardiography and cardiovascular magnetic resonance imaging in preoperative evaluation as well as challenges in surgical repair of this defect.

Intramural Aortic Abscess Mimicking Chronic Aortic Dissection

A 77-year-old patient was referred for progressive fatigue and dyspnea on exertion. Preoperative imaging evaluations including transthoracic echocardiography and computed tomography were suggestive of a chronic ascending aortic dissection with an intramural hematoma. Intraoperatively, the intramural structure was identified as an abscess cavity.

Multi-Visceral Resection of Malignant Tumors with Left-Sided Portal Hypertension

Left-sided portal hypertension (LSPH) is an uncommon clinical syndrome which may lead to bleeding from isolated gastric varices and pancreatitis is the most common etiology. Despite the particular rare incidence of LPSH caused by malignant tumor, the optimal management remains undefined. From January 2006 to December 2009, a total of 8 patients of left-sided portal hypertension caused by malignancies were admitted into the department of surgery of our hospital. Medical records of those patients were retrieved and analyzed, including etiologies, clinical presentations, diagnostic methods and surgical approaches. Of current series, pancreatic tumors (5/8) and retroperitoneal tumors (3/8) were the primary etiologies. Those patients mainly presented with upper gastrointestinal bleeding or irregular left upper abdominal pain and isolated gastric varices became important clinical evidence. All those patients were performed multi-visceral resection. No recurrent upper gastrointestinal bleeding occurred during the follow-up period and three patients died 6, 18 and 21 months postoperatively. Although LSPH caused by malignant tumor is uncommon and difficult to deal with, deliberate evaluation of preoperative CT images will ensure the success of an aggressive multi-visceral resection and the prognoses in those patients are relatively promising.

Modern Approach to Surgical Intervention of the Thyroid and Parathyroid Glands

Operative intervention on the parathyroid and thyroid glands has become more minimally invasive and selective over the past decade. This requires high-quality preoperative imaging evaluation for better knowledge of the relevant anatomical considerations and potential localization. Minimally invasive parathyroidectomy has become the operation of choice for most patients presenting with sporadic primary hyperparathyroidism (when the suspected parathyroid tumor is localized preoperatively). Preoperative imaging helps guide the surgeon as to which patients with thyroid pathology require intervention and the extent of resection. The imaging modalities reviewed include ultrasonography, technetium-99m sestamibi imaging, and four-dimensional computed tomography. Imaging modalities are discussed within the categories of benign and neoplastic parathyroid and thyroid pathology.

P5-12-05: (In-)Efficiencies in the Preoperative Imaging Evaluation of the Medicare Breast Cancer Patient.

Abstract Introduction: Breast cancer evaluation requires a combination of physical examination and imaging for preoperative diagnosis and assessment of surgical treatment options. While imaging remains a critical component of that assessment, the burden of patient (pt) return visits for imaging is unknown. Methods: Medicare claims linked to Surveillance Epidemiology End Results data were reviewed for women developing breast cancer between 1992 and 2005. The preoperative interval was defined as the period from the first physician encounter for a breast-related diagnosis until therapeutic surgery. Pts without ≥6 mos of data prior to that interval, those having DCIS or Stage IV disease, and those having preoperative chemotherapy or radiotherapy were excluded. Imaging modality counts exclude image-guidance claims for biopsies. Results: Among 353,265 Medicare pts developing breast cancer between 1992 and 2005, 67,751 women >65 y of age had invasive, nonmetastatic breast cancer, and simultaneous breast surgery (lumpectomy or mastectomy) with lymph node staging. Median age was 75 y and preoperative interval length was 27 d. In the 6 mos before the preoperative interval, mammograms (MMGs), breast ultrasounds (USs), and breast MRIs were performed exclusive of the preoperative interval in 34,192 (50.5%), 16,936 (25.0%), and 180 (0.3%) pts respectively, while during the preoperative interval, MMGs, USs, and MRIs were performed in an additional 30,414 (44.9%), 17,983 (26.5%), and 1,409 (2.1%) respective pts. Imaging was performed on ≥2 separate dates during the preoperative interval in 4.9% of pts in 1992, rising to 19.4% in 2005 (trend, p<0.0001). During that interval, there were ≥2 encounter dates for MMGs in 7.0% of pts, rising from 3.9% in 1992 to 8.8% in 2005 (trend, p<0.0001); for US, 3.6% overall, rising from 0.2% in 1992 to 6.6% in 2005 (trend, p<0.0001). Multiple MRI encounters were rare, occurring in 0.2% overall, and increasing to 0.6% in 2005 (trend, p<0.0001), while single MRI use increased from <0.1% in 1994 to 8.3% in 2005 (trend, p<0.0001). In the preoperative interval, use of more than one imaging modality on any given date increased from 4.3% in 1992, to 27.1% in 2005. Among those with imaging, there was low correlation between number of imaging dates and number of modalities on any given date (rs= 0.13, p<0.0001). MMGs accounted for 71.9% of the days where one modality was performed alone, but MRI was performed alone 94.1% of the time. The total number of imaging dates in the preoperative interval was inversely related to age (p<0.0001). Differences in the mean number of imaging dates by race and stage were minor and all <0.3 days. Conclusion: Preoperative Medicare breast imaging claims on multiple dates have been increasing substantially since 1992, suggesting that the patient's time burden for such evaluation is increasing. This trend is present despite the fact that multiple imaging modalities are being performed more frequently on the same date. Efforts to further consolidate preoperative breast imaging visits to lower that burden should be undertaken where possible in the Medicare population, for whom advanced age, in itself, may provide its own challenges. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-12-05.

Diagnostic significance of magnetic resonance imaging in preoperative evaluation of patients with laryngeal tumors

To evaluate the diagnostic accuracy of pretreatment surgical magnetic resonance images (MRI) in the assessment of patients with laryngeal tumors. The prospective study included 34 patients (mean age 62.2 ± 5.1 years) with suspected tumors of the larynx who underwent laryngeal endoscopy, followed by MRI. The MRI images were evaluated for the invasion of anterior commissure, subglottis, paraglottic and preepiglotic space, cartilage invasion, extension to extralaryngeal tissue and lymph nodes, and were compared to pathological examination of surgical specimen. In 15 patients (44%) the tumor was glottic, in 10 patients (29%) supraglottic, in 9 (27%) patients tumor was transglottic. No statistical difference was seen in the number of patients with positive MRI findings in comparison to postsurgical pathohistology for extension to subglottic subside (29 vs. 38%), growth to the anterior commissure (48 vs. 48%), preepiglottic space (33 vs. 29%), and cartilage infiltration (19 vs. 14%), respectively. However, infiltration of the paraglottic spaces was observed more frequently on MRI (71 vs. 47%), p < 0.05. According to MR findings, 4 (12%) patients were classified as T2, 26 (76%) patients as T3 and 4 (12%) patients as T4, while on pathohystological specimens after surgery, 12 patients were classified as T2 (35%), 18 as T3 (53%), and 4 as T4 (12%). Based on MRI, 76% of the patients were correctly classified, which was shown to be statistically significant (ρ = 0.56, <0.05). Fifteen patients had metastases in regional lymph nodes and only two were detected on MRI. MRI has been shown to be a method that contributes to presurgical assessment of patients with tumor of the larynx.

Gauze Padding: A Simple Technique to Delineate Small Oral Cavity Tumors

Small oral cavity tumors are an imaging challenge. Intimate apposition of vestibular oral mucosa to the alveolar mucosa makes tumor assessment difficult. In CT imaging, the "puffed cheek" method has been used to separate surfaces, though this is not feasible with long MR imaging sequences. We implemented placement of 2 × 2 inch (6.45 cm) gauze into the oral vestibule before the MR imaging examination, to determine whether this might improve tumor visualization. MR imaging examinations of all T1 oral malignant tumors treated at University of California, San Francisco, by the Oral and Maxillofacial Department were reviewed by 2 neuroradiologists. Nine patients were included in the final analysis. Six patients were imaged by using a standard protocol. Three patients were imaged with gauze placement. The radiologists evaluated the MR images, assessing whether they could see the tumor and then fully delineate it and its thickness. Fisher exact analysis was performed on questions 1, 2, and 4 with the following results: P value = .048, Can you see the tumor? P value = .012, Can you fully delineate? P value of .012, How confident are you? MR imaging examinations with gauze clearly delineated the tumor with the tumor thickness measurable. MR imaging examinations without gauze did not clearly show the tumor or its thickness. Confidence of interpretation of the findings was also increased when gauze was used. A 2 × 2 inch (6.45 cm) rolled gauze in the oral vestibule significantly improved tumor localization and delineation at MR imaging. This technique is simple and provides superior preoperative imaging evaluation and treatment planning of small oral cavity tumors.

18F‐FDG–PET/CT in the assessment of pancreatic cancer: Is the contrast or a better‐designed trial needed?

See article in J. Gastroenterol. Hepatol. 2011; 26: 657–662.

Cochlear implantation in the congenitally malformed ear

Approximately 20%-35% of patients with profound congenital sensorineural hearing loss have radiographic evidence of anatomic inner ear abnormalities. 1 Jackler R.K. Luxford W.M. House W.F. Congenital malformations of the inner ear: A classification based on embryogenesis. Laryngoscope. 1987; 97: 2-14 Crossref PubMed Scopus (622) Google Scholar , 2 Parry D.A. Booth T. Roland P.S. Advantages of magnetic resonance imaging over computed tomography in preoperative evaluation of pediatric cochlear implant candidates. Otol Neurotol. 2005; 26: 976-982 Crossref PubMed Scopus (114) Google Scholar , 3 McClay J.E. Tandy R. Grundfast K. et al. Major and minor temporal bone abnormalities in children with and without congenital sensorineural hearing loss. Arch Otolaryngol Head Neck Surg. 2002; 128: 664-671 Crossref PubMed Scopus (92) Google Scholar , 4 Papsin B.C. Cochlear implantation in children with anomalous cochleovestibular anatomy. Laryngoscope. 2005; 115: 1-26 Crossref PubMed Scopus (262) Google Scholar In the past, congenital malformations of the inner ear were considered by some to be a contraindication to cochlear implantation due to surgical concerns over electrode placement as well as expected poor audiologic performance. 5 Phelps P.D. Cochlear implants for congenital deformities. Jour Laryn Oto. 1992; 106: 967-970 Crossref Scopus (38) Google Scholar With the advent of improved imaging modalities as well as refined surgical techniques, implantation of the malformed inner ear is now performed frequently. In addition, recent studies continue to demonstrate a significant hearing benefit from cochlear implants in patients with inner ear dysplasia. 6 Buchman C.A. Copeland B.J. Yu K.K. et al. Cochlear implantation in children with congenital inner ear malformations. Laryngoscope. 2004; 114: 309-316 Crossref PubMed Scopus (117) Google Scholar , 7 Hoffman R.A. Downey L.L. Waltzman S.B. et al. Cochlear implantation in children with cochlear malformations. Am J Otol. 1997; 18: 184-187 PubMed Google Scholar These hearing results, however, tend to correlate with the severity of the inner ear malformation.

Septal Vein Symmetry: Implications for Endoscopic Septum Pellucidotomy

Endosopic septum pellucidotomy is used for treating patients with unilateral and specific types of bilateral hydrocephalus. The ideal location for septostomy is controversial; however, an avascular region is preferred. As the septal veins (SVs) are viewed only from one side, we studied the symmetry of the SVs in an attempt to define a safe area for septostomy. Sixteen cadaver brains were dissected. The septum pellucidum was exposed bilaterally and divided into 3 regions. SVs of both sides were evaluated according to number, size, distribution, and location relative to common markers on both sides. Each side included 1 to 7 large veins (mean ± standard deviation, 2.3 ± 1.4), 0 to 3 small veins (2.05 ± 1.73), and a total of 2 to 7 veins (4.35 ± 1.53). Of the large veins, 88% were located in the anterior septal region (anterior to the foramen of Monro). Among the 10 brains that were extensively dissected, 90% had asymmetric SVs (either in the number of large veins or in the existence of any veins) in at least 1 of the septal regions, and 50% of brains had asymmetric SVs in the anterior region. Distribution of the SVs is asymmetric in most cases. We recommend septostomy be performed at the anterior area of the middle septal region, at the level of the foramen of Monro, mid-height between the corpus callosum and fornix. Careful evaluation of preoperative images and thorough coagulation at the septostomy site are essential to avoid injury to a contralateral large SV.

Update in Müllerian anomalies: diagnosis, management, and outcomes

Müllerian anomalies include a fascinating constellation of congenital malformations. There is significant diversity in anatomic variants and their respective long-term sexual and reproductive outcomes. We review the current controversies in classification and management of vaginal, uterine, and fallopian tube anomalies. Comparative trials of preoperative magnetic resonance imaging (MRI) and laparoscopic intraoperative evaluation have demonstrated a moderately well correlated prediction of anatomic description. Three-dimensional ultrasound technology appears to be equivalent to MRI in detecting uterine anomalies; however MRI is a consistently superior method of evaluating the vaginal and cervical anatomy. Despite advances in both modalities, care at an experienced center is most highly associated with an accurate preoperative diagnosis and a decrease in the number of inappropriate surgical procedures.Large case series continue to be the main vehicle by which treatment and surgical management of these unique anomalies are described and recommended. Case reports continue to provide information on novel approaches to improve operative techniques. In the absence of prospective studies, these series provide the only emerging information on the long-term sexual and reproductive function of women with vaginal and uterine anomalies. Recent developments in three-dimensional ultrasonography and MRI improve our ability to accurately describe and diagnose female reproductive tract anomalies. With the description of new complex malformations, which do not fall into the recognized American Society of Reproductive Medicine, formerly American Fertility Society (AFS) classification system, questions arise regarding embryologic development upon which this classification system is based and support attempts to devise a new, comprehensive classification. Advances in surgical correction have expanded the options for the reconstructive surgeon when approaching a patient with an anomaly of the reproductive tract.

Preoperative evaluation of hepatic malignant disease using imaging investigation

Malignant liver lesions are a common disease entity requiring preoperative imaging evaluation to assess the patient’s eligibility for surgery.

Double-contrast Magnetic Resonance Imaging in Preoperative Evaluation of Rectal Cancer: Use of Aqueous Jelly as Luminal Contrast

Carcinoma of the rectum is one of the most common malignant tumours in the Western world. Preoperative knowledge of the local spread of rectal cancer is essential in the determination of the therapeutic strategy for this disease. Magnetic resonance imaging (MRI) has been described as being accurate in the detection of the extent of rectal cancer for staging. In particular, double-contrast material enhanced MRI of the rectum has been reported to better delineate tumours against the lumen and the normal mucosa [1]. Tissue characterization is excellent with MRI and can be improved further for staging of rectal cancer by enhancement of the mucosa with intravenously administered gadoliniumbased contrast combined with intraluminal contrast material to distend the bowel. Tumour detection and assessment of penetration through the rectal wall is important information for the surgeon [2]. Piippo et al [3] concluded that tumour detection may be problematic in an undistended bowel and may result in extended examination time and inadequate imaging planes that are not perpendicular to the tumour to allow accurate analysis. Several investigators have advocated the use of rectal contrast medium for improving the delineation of tumour and to estimate its extent within the rectum [3e7]. Contrast agents that have been used are superparamagnetic iron oxide solutions, methylcellulose, and barium suspensions [5]. Herein, we describe our experience with aqueous gel as intraluminal contrast material for preoperative staging of rectal cancer.

Cochlear Implantation in Postmeningitic Deafness

To propose guidelines in the management of a profound bilateral sensorineural hearing loss after bacterial meningitis. Retrospective chart review. All 40 postmeningitic cochlear implantation surgeries performed between August 1987 and April 2007. Descriptive analysis of data on the cause of meningitis, preoperative imaging evaluation, age at implantation, time elapsed between meningitis and implantation, and relevant surgical findings. Twenty-seven children and 13 adults with postmeningitic deafness were implanted. Mean age was 3 years 8 months for the children and 44 years and 10 months for the adults. The mean time delay between meningitis and surgery was 2 years 1 month for children and 28 years for adults. Eighteen children (67%) were implanted within a year. Labyrinthitis ossificans was evidenced at surgery in 62% of patients. Intraoperative cochlear ossification was classified according to the scale described by Smullen and Balkany (2005). Stage II ossification was seen in 3 patients within 49 days, with 1 of them as soon as 21 days. There was a partial insertion in 9 patients secondary to ossification. Open-set speech discrimination was achieved by 37% of the children (10 of 27) and 23% of the adults (3 of 13). We recommend early cochlear implantation for patients with bilateral profound deafness secondary to meningitis.

Fibromatous Uterus in a 16-Year-Old Girl: A Case Report

Although uterine leiomyomas are the most common neoplasms of the female genital tract, this is not the case when referring to women under the age of 20. Only a few cases of uterus leiomyomas have been reported in this age. Preoperative imaging evaluation is mandatory in adolescent women for the accurate detection, localization, and characterization of uterus leiomyomas. We report a case of a 16-year-old girl admitted to our hospital for pain and abdominal distention. The patient underwent multidetector CT examination of the abdomen and MR examination of the pelvis. Both imaging modalities revealed uterine enlargement and the presence of innumerable variably sized leiomyomas. Histopathologic examination following exploratory laparotomy confirmed the presence of uterus leiomyomas. The patient underwent laparoscopic myomectomy two years after the first operation, following MR examination of the pelvis.

Preoperative and pathological staging of NSCLC: retrospective analysis of 291 cases

The objective of this study was to evaluate the accuracy of preoperative clinical staging with computed tomography in predicting the correct pathological stage. Medical records of non-small cell lung cancer (NSCLC) patients treated, from 1990 to 2005 were reviewed. Clinical stage was based on routine preoperative clinical and imaging evaluation. Positron emission tomography was not routinely performed. Suspected lesions, that would preclude a surgical resection, were pathologically confirmed. The pathological stage was based on final postoperative or biopsy pathological assessment. A correlation table between clinical and pathological stages was generated. Cohen's kappa index, sensitivity, specificity, positive and negative predictive values and accuracy were calculated. Records of 291 patients were reviewed. Clinical stages Ia, Ib, IIa, IIb, IIIa, IIIb and IV were found respectively in 8.9%, 31.9%, 0.3%, 18.6%, 25.4%, 11% and 3.8%. Pathological staging was different from clinical staging in 33% (15% were upstaged and 18% downstaged). Sensitivity, specificity, positive and negative predictive values and accuracy for clinical staging were 78%, 69%, 82%, 64% and 67%, respectively. Cohen's kappa index was 0.574 (P < 0.001). Preoperative clinical staging presents limited efficacy for the correct staging of NSCLC patients from this sample of Brazilian population.

Preoperative imaging evaluation of interventional therapy for patients with symptomatic intracranial artery stenosis

Objective To investigate the value of comprehensive preoperative imaging evaluation in determining indication of intervention for patients with symptomatic intracranial artery stenosis.Methods DSA,high-resolution MRI of plaque and computed tomography perfusion (CTP) or perfusion weighted imaging (PWI) were performed in 26 patients with symptomatic intracranial artery stenosis and the intracranial artery cavity,artery wall and cerebral perfusion were evaluated.For patients with atherosclerotic plaque,the plaque characterization was analyzed according to high-resolution MRI findings,and intervention was used for those with unstable plaque.However,medicine was used for patients with arteritis.All patients were followed up after therapy.Results Combining with DSA,the stenosis in 18 cases was thought to be associated with atherosclerotic plaque,which showed eccentric stenosis with mild or no enhancement on MRI;13 of them had symptomatic unstable plaques,1 case showed stable plaque but cerebral perfusion damaged severely,all of them were treated with interventional therapy;the other 4 cases had stable plaques and treated with medicine. The stenosis in 8 patients,which showed concentric hypertrophy of local endangium on MRI,was caused by arteritis and treated with medicine.No ischemic events occurred during the following 1-8 months [average (5.2±3.1) months]after therapy.Conclusion Comprehensive preoperative imaging evaluation for patients with symptomatic intracranial artery stenosis is of great value in guiding the therapy. Key words: Intracranial artery diseases; Magnetic resonance imaging; Tomography; X-ray computed