Prospective Diagnosis Research Articles

Hemangiosarcoma of the adrenal glands: CT findings in two cases

Hemangiosarcomas of the adrenal gland, both benign and malignant, are exceedingly rare; only a dozen of them have been reported in literature to our knowledge. We describe herein the findings at CT of 2 primary hemangiosarcomas of the adrenal glands. We also discuss their etiology, incidence, and differential diagnosis, particularly in relation to more frequent primary adrenal lesions, such as adrenal adenomas and carcinomas. CT will generally show a heterogeneous mass with frequent necrosis, contrast-enhancement, and occasional calcifications. A prospective diagnosis cannot be made by imaging alone, and pathology represents the discriminating method for a correct diagnosis.

Hepatocellular carcinoma and dysplastic nodules in patients with cirrhosis: prospective diagnosis with MR imaging and explantation correlation.

To determine the sensitivity and specificity of magnetic resonance (MR) imaging for detection of hepatocellular carcinoma (HCC) and dysplastic nodules (DNs) by using explantation correlation in patients with cirrhosis and no known HCC. Seventy-one patients without a known history of HCC who underwent MR imaging and subsequent transplantation within 90 days were examined. Breath-hold turbo short inversion time inversion-recovery and/or T2-weighted turbo spin-echo MR images were obtained. Dynamic two- or three-dimensional gadolinium-enhanced gradient-echo MR images were obtained in the hepatic arterial, portal venous, and equilibrium phases. Prospective MR image interpretations were compared directly with explanted liver pathologic results. Eleven (15%) of 71 patients had hepatic malignancies; MR imaging enabled diagnosis of tumor in six (54%) of 11 patients. On a lesion-by-lesion basis, MR imaging depicted 11 of 20 hepatic neoplasms, for an overall sensitivity of 55%. MR imaging depicted four (80%) of five lesions larger than 2 cm, six (50%) of 12 lesions 1-2 cm, and one (33%) of three lesions smaller than 1 cm. MR imaging depicted only nine (15%) of 59 DNS: The specificities of MR imaging for detection of HCC and DNs on a per patient basis were 60 (86%) of 70 patients and 53 (85%) of 62 patients, respectively. MR imaging is insensitive for the diagnosis of small (<2-cm) HCCs and DNS:

Retrospective prenatal diagnosis of scimitar syndrome aided by three‐dimensional power Doppler imaging

Scimitar syndrome is a rare malformation of the arterial supply and venous drainage of the lung. We report the case of a fetus that presented with cardiac asymmetry and malposition of the fetal heart. Postnatally, scimitar syndrome was confirmed at cardiac catheterization. Retrospective reconstruction of three-dimensional power Doppler volumes, obtained during fetal life, allowed direct visualization of the abnormal aortopulmonary collateral vessel. This had not been seen on conventional scans. This case demonstrates many of the strengths of three-dimensional sonographic techniques for the delineation of complex vascular anatomy. It confirms that a prospective diagnosis of scimitar syndrome should be possible during fetal life.

The “Prodromal” Patient: Both Symptomatic and At-Risk

This article discusses conceptual issues relevant to the prospective diagnosis of the schizophrenic prodrome. Recent efforts to diagnose these patients with operational criteria based on current symptoms are reviewed. Symptomatic patients so identified appear to be treatment-seeking and to have mild cognitive impairments. In addition to being currently symptomatic, these patients are imminently at risk for progression of illness and development of schizophrenia. Data from three international centers suggest that this risk is approximately 40% over the next year of follow-up if untreated. The implications of the reviewed data for the appropriateness of the term "prodromal" and for treatment/prevention research for these patients are discussed.

A Department of Social Work Uses Data to Prove Its Case (88-99B)

ABSTRACT The introductions of managed care with its emphasis on cost containment has led a Department of Social Work Services at a large urban teaching center to better document and justify its roles. A concrete result was the saving of social work positions during budget cutbacks and downsizing. There is also information in these data to help clarify the differential roles of social workers and utilization review nurses in the hospital case management/discharge planning processes. The system came about because of concerns around cost containment, the need for more systematic discharge planning and the advent of the Prospective Payment System and Diagnosis Related Groups (DRG's) as a means of reimbursement to hospitals.

Bowel obstruction following liver transplantation: clinical and ct findings in 48 cases with emphasis on internal hernia.

To review the incidence, cause, and radiologic findings of bowel obstruction in patients who have undergone orthotopic liver transplantation (OLT). Retrospective review of 4,001 cases of OLT revealed 48 cases of bowel obstruction in 44 patients. Seventeen computed tomographic (CT) scans and seven barium-enhanced radiographs were reviewed to determine level and cause. Surgical proof was available in 45 cases, while three had characteristic clinical and radiographic features. Adhesions caused the obstruction in 19 cases in 16 patients; three had bowel ischemia. Internal hernias caused obstruction in 18 patients; all obstructions were transmesenteric or retroanastomotic and occurred with choledochoenteric anastomosis. Seven patients had volvulus; four had bowel ischemia. CT signs of internal hernia included mesenteric vascular abnormalities and clusters of dilated small-bowel segments that displaced the colon away from the abdominal wall. Prospective diagnosis of internal hernia was made in only one case. Incisional or inguinal hernia caused obstruction in seven patients; CT was used just once. Four patients had neoplastic bowel obstruction, three due to posttransplantation lymphoproliferative disorder and one due to colon carcinoma. Liver transplantation was complicated by bowel obstruction in 48 (1.2%) of 4,001 cases. While adhesions and incisional hernias are common and well recognized, other causes are more challenging to diagnose. The CT findings reported here may allow more accurate diagnosis of internal hernia.

Performance of CT in detection of bowel injury.

The objective of our study was to identify relevant and reliable CT signs of bowel injury, to determine the overall performance of CT in detection of bowel injuries, and to establish the effect of the training level of radiologists on this performance. Abdominal CT scans of 112 patients with blunt abdominal trauma were prospectively and retrospectively reviewed. Fifty patients had proven bowel injuries (with or without other visceral injuries), whereas 62 patients had no bowel injury and comprised the comparison or control group. Thirty-one of the 62 patients in the comparison group had surgical proof of abdominal but not bowel or mesenteric injuries. The retrospective review of the 112 CT scans was performed randomly and individually by nine radiologists unaware of the diagnosis, including three faculty abdominal radiologists, three senior residents in training, and three junior residents in training. Individual performance and group performance were evaluated by receiver operating characteristic analysis, and interobserver agreement was tested. Individual CT signs as relevant predictors of bowel injury were identified by logistic regression. Relevant predictors of bowel injury included mesenteric infiltration, bowel wall thickening, extravasation of vascular or enteric contrast agent, and the presence free air. In the retrospective blinded review, CT showed good to excellent interobserver reliability for individual CT signs as well as for diagnosis of bowel and visceral injuries. Faculty radiologists tended to diagnose injuries with greater accuracy and confidence, but they showed significantly better performance than residents only in diagnosing duodenal perforation. For the prospective CT diagnosis of bowel injury, CT had a sensitivity of 64%, an accuracy of 82%, and a specificity of 97%. Bowel injuries are challenging to diagnose on CT. Radiologists with various levels of experience and expertise can achieve accurate and reproducible results using a variety of CT criteria.

Prospective ultrasound diagnosis of Pallister‐Killian syndrome in the second trimester of pregnancy: the importance of the fetal facial profile

The Pallister-Killian syndrome (PKS) represents a rare polymalformative complex characterized by a tissue-specific mosaic distribution of an additional isochromosome 12p and characterized by diaphragmatic hernia, rhizomelic limb shortening, facial anomalies and, rarely, acral hypoplasia. Since diaphragmatic hernia and acral hypoplasia can be also found in Fryns syndrome, the differential diagnosis between the two conditions depends on the demonstration of the 12p isochromosome by FISH. Prenatal diagnosis of PKS has been reported in cases submitted to karyotyping due to advanced maternal age or congenital anomalies detected on second trimester ultrasound. Among the ultrasound-detected malformations, little attention has been paid to facial anomalies. We describe a case in which PKS was prospectively suspected on the basis of the various anomalies detected at ultrasound, namely diaphragmatic hernia, rhizomelic limb shortening, and abnormal facial profile. The diagnosis was then confirmed by FISH on amniocytes and peripheral lymphocytes. In the present case, the disclosure of typical facial abnormalities significantly contributed to the differentiation between PKS and Fryns syndrome. Copyright © 2000 John Wiley & Sons, Ltd.

Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation.

Osteochondroma represents the most common bone tumor and is a developmental lesion rather than a true neoplasm. It constitutes 20%-50% of all benign bone tumors and 10%-15% of all bone tumors. Its radiologic features are often pathognomonic and identically reflect its pathologic appearance. Osteochondromas are composed of cortical and medullary bone with an overlying hyaline cartilage cap and must demonstrate continuity with the underlying parent bone cortex and medullary canal. Osteochondromas may be solitary or multiple, the latter being associated with the autosomal dominant syndrome, hereditary multiple exostoses (HME). Complications associated with osteochondromas are more frequent with HME and include deformity (cosmetic and osseous), fracture, vascular compromise, neurologic sequelae, overlying bursa formation, and malignant transformation. Malignant transformation is seen in 1% of solitary osteochondromas and in 3%-5% of patients with HME. Continued lesion growth and a hyaline cartilage cap greater than 1.5 cm in thickness, after skeletal maturity, suggest malignant transformation. Variants of osteochondroma include subungual exostosis, dysplasia epiphysealis hemimelica, turret and traction exostoses, bizarre parosteal osteochondromatous proliferation, and florid reactive periostitis. Recognition of the radiologic spectrum of appearances of osteochondroma and its variants usually allows prospective diagnosis and differentiation of the numerous potential complications, thus helping guide therapy and improving patient management.

Adenomyosis: sonographic findings and diagnostic accuracy.

The purposes of this study were to evaluate the accuracy of pelvic sonography in identification of adenomyosis and to characterize the most commonly seen sonographic features. We identified all patients over a 10 year period in whom a prospective diagnosis of adenomyosis was suspected on the basis of sonographic findings and who had undergone hysterectomy at a single hospital. Patients were referred for sonography based on standard indications. Sonographic features used in the diagnosis of adenomyosis consisted of two or more of the following: a mottled inhomogeneous myometrial texture, globular appearing uterus, small cystic spaces within the myometrium, and a "shaggy" indistinct endometrial stripe. Correlation was made with the pathology report on the hysterectomy specimen. Fifty-one women met the study criteria. Forty-three of 51 (84.3%) patients sonographically suspected of having adenomyosis were confirmed as having adenomyosis by pathologic examination. All patients with adenomyosis had a mottled heterogeneous appearing uterus, 95% had a globular uterus, 82% had small myometrial lucent areas, and 82% had an indistinct endometrial stripe. Eight patients (15.6%) who had been suspected of having adenomyosis by pelvic sonography did not have adenomyosis reported in the pathology specimen. Six of these eight (75%) patients had multiple small fibroids, one had stage IV endometriosis, and one had a normal uterine specimen with no evidence of pathology. Pelvic sonography provides an accurate diagnosis of adenomyosis in the majority of cases.

Predictive value of galactographic patterns for benign and malignant neoplasms of the breast in patients with nipple discharge.

The purpose was to identify features of malignant and non-malignant neoplastic breast disease on galactography and to estimate their predictive value. This is the largest reported study correlating galactographic morphological patterns with histopathology and the only blinded study. The study included 351 consecutive galactograms and 161 breast biopsies performed in patients with nipple discharge over a 10-year period. Three radiologists, blinded to clinical data and histological results, re-evaluated 158 previously performed galactograms of patients who had undergone excision biopsy. Extravasation or incomplete filling precluded reading in 9.5% of examinations. Among the remaining 143 examinations there were 11 cancers (7.7%), 56 papillomas (39.2%), 19 cases of intraductal papillomatous proliferation (13.3%), 55 cases of fibrocystic or secretory disease (38.5%) and two normals. A "filling defect/cut-off" pattern (n = 90) was found in 6 cancers (6.7%) and 58 cases of papilloma or papillomatous proliferation (64.4%). A "leafless tree" pattern was found only in benign cases (n = 12; 8.4%). In 32 of 143 cases (22.4%) a "ductal ectasia" pattern was present, in one case of which (3.1%) cancer was found. Cancer was identified in two of four cases with an "architectural distortion" pattern. Cancer is rare in patients with nipple discharge. A tendency towards a lower incidence of cancer associated with the "ductal ectasia" and "leafless tree" patterns was found. No statistical evidence was found to indicate that galactography provides an effective prospective diagnosis of malignancy. However, an abnormal galactogram strongly correlated (p < 0.001) with the presence of a breast neoplasm when both benign and malignant tumours were considered. The most important role played by galactography is in the localization of breast neoplasms and in the choice of appropriate surgical therapy.

First-trimester diagnosis of Morquio disease type A

Since the introduction in 1990 of a novel fluorogenic substrate for galactose-6-sulphate sulphatase we have used this substrate for prospective prenatal diagnosis in 10 pregnancies at risk for Morquio disease type A. Chorionic villi were analysed in five cases. The results indicated an affected fetus in one pregnancy which represents the first case of first-trimester diagnosis of this disorder; heterozygosity was demonstrated in two cases. Following amniocentesis, two affected fetuses and one heterozygote were diagnosed. The results of the present prospective prenatal analyses confirm our previous retrospective studies and demonstrate the reliability and convenience of the 4-methylumbelliferyl substrate.

Osteoid osteoma: MR imaging revisited

To assess and compare with computed tomography (CT) the performance of magnetic resonance (MR) imaging in the detection of osteoid osteoma, and determine the features of this lesion on MR imaging. The prospective MR imaging and CT diagnosis of osteoid osteoma was determined from original radiology reports. MR images were assessed retrospectively with regard to the location and signal intensity of the nidus and surrounding bone marrow and soft tissue edema. These findings were correlated with the age of the patient, duration of symptoms, and drug therapy. Ten patients with histologically proven osteoid osteoma who underwent MR imaging were reviewed. All 10 lesions were correctly diagnosed at the time of MR imaging. None of the lesions was intracortical. Nine lesions were intra-articular. Two out of five patients with extracortical lesions had false negative CT preceding the MR study. Signal intensity of the nidus, marrow, and soft tissue edema on MR imaging were variable. Perinidal edema was most pronounced in younger patients and had no apparent relation to drug therapy. MR imaging reliably demonstrates the nidus of an osteoid osteoma, which has a variable appearance related to its position relative to the cortex of the bone. A predominance of cancellous osteoid osteomas are encountered in patients referred for MR imaging. Marrow edema in the vicinity of the lesion improves the conspicuity of the nidus. CT may fail to diagnose osteoid osteoma when the nidus is in a cancellous location, due to the lack of perinidal density alteration.

Prospective ultrasound diagnosis of Pallister-Killian syndrome in the second trimester of pregnancy: the importance of the fetal facial profile

The Pallister-Killian syndrome (PKS) represents a rare polymalformative complex characterized by a tissue-specific mosaic distribution of an additional isochromosome 12p and characterized by diaphragmatic hernia, rhizomelic limb shortening, facial anomalies and, rarely, acral hypoplasia. Since diaphragmatic hernia and acral hypoplasia can be also found in Fryns syndrome, the differential diagnosis between the two conditions depends on the demonstration of the 12p isochromosome by FISH. Prenatal diagnosis of PKS has been reported in cases submitted to karyotyping due to advanced maternal age or congenital anomalies detected on second trimester ultrasound. Among the ultrasound-detected malformations, little attention has been paid to facial anomalies. We describe a case in which PKS was prospectively suspected on the basis of the various anomalies detected at ultrasound, namely diaphragmatic hernia, rhizomelic limb shortening, and abnormal facial profile. The diagnosis was then confirmed by FISH on amniocytes and peripheral lymphocytes. In the present case, the disclosure of typical facial abnormalities significantly contributed to the differentiation between PKS and Fryns syndrome.

Antenatal ultrasonographic diagnosis of rhizomelic chondrodysplasia punctata.

Rhizomelic chondrodysplasia punctata is an autosomal recessive disorder characterized by stippled epiphyses and rhizomelic shortening of the long bones. Most fetuses with the disorder die in utero or shortly thereafter, and the few that survive suffer severe debility and profound mental retardation. Death ensues in the first decade of life. Relatively few reports discuss antenatal ultrasonographic diagnosis of rhizomelic chondrodysplasia punctata. We describe the prospective antenatal diagnosis of rhizomelic chondrodysplasia punctata in a fetus with no family history of the disorder, based on the sonographic findings of severe rhizomelic limb shortening in combination with premature ossification and stippling of multiple epiphyses. The ultrasonographic features and differential diagnosis of rhizomelic chondrodysplasia punctata are elaborated.

From the archives of the AFIP. Imaging of musculoskeletal neurogenic tumors: radiologic-pathologic correlation.

Numerous neurogenic tumors can affect the musculoskeletal system, including traumatic neuroma, Morton neuroma, neural fibrolipoma, nerve sheath ganglion, neurilemoma, neurofibroma, and malignant peripheral nerve sheath tumors (PNSTs). The diagnosis of neurogenic tumors can be suggested from their imaging appearances, including lesion shape and intrinsic imaging characteristics. It is also important to establish lesion location along a typical nerve distribution (eg, plantar digital nerve in Morton neuroma, median nerve in neural fibrolipoma, large nerve trunk in benign and malignant PNSTs). Traumatic and Morton neuromas are commonly related to an amputation stump or are located in the intermetatarsal space, respectively. Neural fibrolipomas show fat interspersed between nerve fascicles and are often associated with macrodactyly. Nerve sheath ganglion has a cystic appearance and commonly occurs about the knee. Radiologic characteristics of neurilemoma, neurofibroma, and malignant PNST at computed tomography (CT), ultrasonography, and magnetic resonance imaging include fusiform shape, identification of entering and exiting nerve, low attenuation at CT, target sign, fascicular sign, split-fat sign, and associated muscle atrophy. Although differentiation of neurilemoma from neurofibroma and of benign from malignant PNST is problematic, recognition of the radiologic appearances of neurogenic tumors often allows prospective diagnosis and improves clinical management of patients.

Prospective diagnosis of alveolar capillary dysplasia in infants with congenital heart disease

Alveolar capillary dysplasia (ACD) is a lethal pulmonary disorder found in newborns that is characterized by severe pulmonary hypertension and hypoxemia. We report on the clinical behavior of this disorder in a series of patients and its association with congenital heart disease, especially left heart obstructive disease; we also report a prospective diagnosis of ACD by lung biopsy in a newborn with congenital heart disease, which prevented futile and prolonged medical intervention.

Incomplete Intertrochanteric Fractures: Imaging Features and Clinical Management

To present the imaging findings and treatment options for incomplete intertrochanteric fractures. Among 31 patients with the magnetic resonance (MR) imaging diagnosis of incomplete intertrochanteric fracture, 30 also underwent radiography. MR and radiographic findings were compared. Note was made of fracture length and extent as depicted on the coronal and axial MR images, treatment (surgical vs conservative), and follow-up. Correlation between radiographic and MR findings was poor. Incomplete intertrochanteric fracture was the prospective radiographic diagnosis in only one case. Fracture in 18 patients was treated surgically and in 13 was managed conservatively. In both groups, the average age of the patients and length of the fractures and the percentage of separate fractures involving the greater trochanter and crossing the midline of the femur in the axial plane were the same. Fractures crossed the midline in the coronal plane in 50% of the surgical group but in only 23% of the nonsurgical group. Average time from injury to ambulation was 2 days less in the surgical group, but no difference in functional status was found subjectively between the two groups at clinical follow-up. Incomplete intertrochanteric fractures are a previously unrecognized subset of intertrochanteric fractures that are diagnosed unequivocally only with MR imaging.

Symbolic representation and visual querying of left ventricular image sequences.

In the evaluation of regional left ventricular function, relevant cardiac disorders manifest themselves not only in static features, such as shape descriptors and motion excursion in end-diastolic and end-systolic frames, but also in their temporal evolution. In common diagnostic practice, such dynamic patterns are analysed by direct inspection of frame sequences through the use of a moviola. This permits only a subjective and poorly defined evaluation of functional parameters, and definitely prevents a systematic and reproducible analysis of large sets of reports. Retrieval by contents techniques may overcome this limitation by permitting the automatic comparison of the reports in a database against queries expressing descriptive properties related to significant pathological conditions. A system is presented which is aimed at investigating the potential of this approach by supporting retrieval by contents from a database of cineangiographic or echocardiographic images. The system relies on a symbolic description of both geometrical and temporal properties of left ventricular contours. This is derived automatically by an image processing and interpretation module and associated with the report at its storage time. In the retrieval stage, queries are expressed by means of an iconic visual language which describes searched content properties over a computer screen. The system automatically interprets iconic statements and compares them against concrete descriptions in the database. This enables medical users to interact with the system to search for motion and shape abnormalities on a regional basis, in single or homogeneous groups of reports, so as to enable both prospective and retrospective diagnosis.

Bilateral elastofibroma dorsi: Two case reports

Elastofibroma dorsi is a benign fibroproliferative lesion of unknown pathogenesis. It is most commonly found in the periscapular region in elderly women. The majority of patients are asymptomatic. The lesions have a characteristic location and a specific magnetic resonance imaging (MRI) appearance allowing accurate prospective diagnosis. The importance of recognizing the benign nature of this lesion to avoid an unnecessary operation is apparent. We describe two cases of bilateral elastofibroma dorsi with characteristic findings on MRI and typical histological appearances.