Roentgen Findings Research Articles

Malignant tumors of the paranasal sinuses

The detection of malignant disease of the paranasal sinuses in its early stages is largely in the province of roentgen examination, since physical signs and symptoms seldom reveal the presence of an underlying malignancy until it is advanced. Identifying the site of origin and the anatomic extent of the tumor also depends upon careful analysis of detailed roentgenograms. This analysis serves as the basis for treatment planning. From a review of 121 cases of primary malignant tumors of the paranasal sinuses and nasal cavity, the frequency of various roentgen findings has been tabulated, their significance discussed, and their appearance illustrated. A knowledge of head and neck anatomy and of the natural history and routes of spread of sinus cancer are essential in interpreting the roentgenograms. Many of the changes are subtle and require judicious interpretation. Others are quite straightforward and easily recognized if they have been seen before. Constant attention to detail and a willingness to obtain additional views to resolve a point in question are necessary if the maximum contribution to diagnosis, evaluation and management of these lesions is to be achieved.

Diagnosis: Roentgen findings of irritable colon syndrome

Diagnosis: Roentgen findings of irritable colon syndrome

Roentgen Findings in Cerebral Paragonimiasis

Paragonimiasis is a benign parasitic disease caused by ingestion of Crustacea contaminated by Paragonimus westermani. Although the lung is the primary site of infection, involvement of the brain, spinal cord, subcutaneous tissue, abdomen, eyes, and genital organs may be found. Among these, paragonimiasis of the brain occurs with the highest frequency (1). Paragonimiasis is endemic in Southeast Asia and the Far East, and cases have occurred in Africa and South America (2). Within the past two decades only 9 cases have been reported in the United States, and these occurred in military personnel who had been stationed in endemic areas (3, 4). It is anticipated, however, that more cases will be seen in this country as increasing numbers of Americans, both military and civilian, travel and live in areas where the disease is prevalent. Cerebral involvement is observed in 0.8 per cent of patients with active pulmonary paragonimiasis (5). It is believed that the larvae travel through the soft tissues surrounding the jugular vein to the brain (6) where they may produce arachnoiditis, abscess, or granuloma (7). In the acute stage the predominant symptoms are those of meningitis, while the chronic stage may be associated with organic mental syndrome, epilepsy, or “infarction” and “tumor” syndromes. Seizure, headache, visual disturbance, and motor and sensory disorders are the five most common symptoms, and mental deterioration, hemiplegia, hemihypesthesia, homonymous hemianopia, and optic atrophy are the five major signs (8). While a number of excellent studies have dealt with cerebral as well as pulmonary paragonimiasis, there is a paucity of material on roentgen findings in cerebral paragonimiasis. The purpose of this paper is to report the x-ray findings in 62 cases of the disease studied by means of skull roentgenography, angiography, and pneumoencephalography. Materials Between 1958 and 1964, 62 patients with cerebral paragonimiasis were seen at the Neurology Department of the National Medical Center, Seoul, Korea. In each case a diagnosis was made on the basis of fulfillment of all the following criteria: 1. A positive result of the intradermal Paragonimus westermani test 2. Detection of Paragonimus westermani ova in the sputum or stool or a positive complement fixation test in the serum 3. Evidence of cerebral paragonimiasis by (a) the positive complement fixation test in the spinal fluid, (b) characteristic lesions on microscopic examination of biopsy specimen of brain tissue, and (c) the detection of eosinophile, abnormal colloidal gold reaction, and/or abnormal routine spinal fluid findings in cases with major symptoms and signs (8). In these cases, other diseases were ruled out by pneumoencephalography, angiography, brain scan, and electroencephalography. There were 46 males and 16 females in the group, 75 per cent of whom were under twenty years of age. The average duration of symptoms was five and a half years with twenty-six years the longest.

Radiation Therapy in Esophageal Cancer

Carcinoma of the esophagus still has placed in a poor result in the field of cancer. However, the advances in radiation therapy-the use of rotation or multiple perithoracic ports and supervoltage radiation-made possible the introduction of sufficiently high and homogeneous doses such as are considered necessary for the sterilization of esophageal cancer, and therefore some treated cases can be expected to survive more than five years.Both surgery and radiation therapy are local therapy and are no significant difference in either therapy, for this reason, it is possible to do the radial therapy by irradiation alone. Howevere the healing process of radiation therapy is quite different from surgery, therefore, in an attempt to find more definite guides for the selection of patients for either surgery or radiation therapy, it should be carefully considered. In choosing indication, the length and type of a filling defect by barium swallow radiographic study of the esophageal cancer are most important factors.Esophageal cancer tends to infiltrate in upward and downward through the esophageal wall and spread frequently into the mediastinal structures. These form of involveme nt are usually accurately provided on the basis of roentgen study of the esophageal cancer with many types, it is likely that a small filling defect is well controlled and prognosis is better than that exceeding 5 cm in length.In general, there are two types in growing form of the esophageal cancer; one is the exophytic and comparatively localized type, another is the endophytic and infiltrative type. These type of growth also correlate with patients prognosis, so they can be available for classification on the roentgen findings. Our classification by roentgen findings is as follows:1) Early stage type2) Non-ulcerated type: Polypoid type, Cauliflower type, Hill-like type3) Superficial ulcerted type: Saw type4) Ulcerated type: One sided ulcer type, spiral type5) Sclerotic typeIt appeares that the type of Polypoid, Cauliflower and Saw are suitable for the radiation therapy, on the other hand, Ulcerated type should be tried the combined therapy with surgery and radiation therapy.

Pursuit of shadows.

Retrospection, retrospective analysis of a single case or of a group of cases of a single entity, offers much in the way of potential information. Thus, we want to know the surgeon's or pathologist's findings in order that we may re-evaluate what we saw on the films and find what we failed to see initially. We must constantly check our visual acuity and validate the accuracy of our interpretation. It seems rather obvious that we are right when we make a diagnosis, for example, of a duodenal ulcer, and the patient subsequently proves to have an ulcer. It ought to be equally obvious, but it is not, that we may have been right for the wrong reason. If we find a deformed bulb in a young male patient who presents with melena, the likelihood is great that the bleeding is coming from an open crater, but how sure can we be that the barium pocket we de- scribed as a crater was truly that? The surgeon may tell us that he found a crater at operation, but how often does he remove the bulb? If he does, can we re-examine the specimen under precisely the same physiologic and projectional conditions that existed in vivo? We have developed a large body of literature on the roentgen findings in benign gastric ulcer and swear by the statistical accuracy of this or that sign. We tend to ignore the fact that we are gross, shadow morphologists and that any gastric ulcer without coexisting mass is benign in well over 90 per cent of the cases and that consequently any sign of benignity we use, short of the absence of a mass, must of necessity have a high degree of validity. We are, I think, too firmly convinced of the descriptive correctness of the surgeon's findings, especially when he fails to take tissue. The patient is jaundiced, the gastrointestinal series shows a pancreatic mass, the surgeon finds the situation hopeless because of widespread neoplasm and performs a bypass procedure. He does not take a biopsy of the pancreas because this is difficult, and the nodes he removes show reactive hyperplasia and inflammation. He is convinced, nonetheless, that this is a case of malignant tumor and carries his conviction over to us. We then demonstrate the case at conference and expound on the difference between the pressure and adhesive changes in duodenal mucosa in inflammatory and neoplastic diseases of the pancreas. Do we remember to correct our error when the patient returns for some other reason several years later? Too often we succumb to the infallibility of microscopy. We painfully learn that all mitoses are not due to malignant tumors and that many colon polypi are benign now and forever. Gastric glandular epithelium may make its way into muscular depths during repair processes without indicating neoplastic invasion. We are proud of our therapeutic success with primary lymphomas of the gastrointestinal tract but pseudolymphomas do exist.

Dural arteriovenous malformation in the posterior fossa.

Arteriovenous malformations that involve the dura of the posterior fossa are rare, and they are therefore seldom considered in the differential diagnosis of posterior fossa lesions. Such malformations may involve the tentorium and the dura that covers the remainder of the posterior fossa. Their presence and extent can be evaluated accurately only by angiography. The purpose of this report is to present the clinical and angiographic features of 16 patients with dural arteriovenous malformations of the posterior fossa. These patients were studied either at the University of California Medical Center at San Francisco or Los Angeles or at the Karolinska Hospital in Stockholm, Sweden. Clinical Features The clinical features of the 9 males and 7 females are summarized in Table I. The ages ranged from one to sixty-eight years. In 11 patients a pulse-synchronous bruit was audible either at the vertex or over the mastoid region. Of these patients, 7 complained of hearing a pulsatile buzzing sound. Both the bruit and the subjective buzzing sound could usually be stopped or markedly diminished by compression of the carotid artery. The arteriovenous malformation was manifested externally in 5 patients. These external findings included dilated scalp and facial veins in 2 patients, pulsatile masses behind the ear in 2 others, and an enlarged head in the fifth. In addition, 2 of these patients had unilateral proptosis. Neurologic abnormalities were observed in 8 patients. Three complained of headaches, and 1 gave a history of convulsions. Visual complaints, visual field defects, or both were noted in 3 patients and papilledema in another 3. Motor and sensory deficits were present in 3 patients. Subarachnoid hemorrhage was a presenting sign in only 2. An asymptomatic small dural arteriovenous malformation was an incidental finding in 1 patient studied because of suspected cerebrovascular insufficiency. Roentgen Findings Plain roentgenograms of the skull showed evidence of increased vascular markings in 5 patients (Cases I, IV–VI, and IX) and localized bony thinning in one of these (Case IV). The angiographic features are summarized in Table II. In each patient we noted enlargement of one or more of the meningeal arteries that supplied the arteriovenous malformation. Enlarged tentorial branches of the internal carotid artery supplied a portion of the malformation in 11 patients (Figs. 1, A-C, 2, A, 3, A, and 4, A and B). The posterior branches of the middle meningeal artery were involved in 9 patients. In 2 of these, both the right and left middle meningeal arteries were enlarged (Figs. 1, D and E, and 2, B and D). Hypertrophy of the meningeal branches of the occipital artery was noted in 13 patients (Figs. 3, B, 5, A and C, and 6, A) and enlargement of the posterior meningeal branches of the vertebral artery in 5 (Fig. 1, F).

Lipoatrophic diabetes mellitus (generalized lipodystrophy): roentgen findings in two brothers with congenital disease.

LIPOATROPHIC DIABETES MELLITUS (GENERALIZED LIPODYSTROPHY): ROENTGEN FINDINGS IN TWO BROTHERS WITH CONGENITAL DISEASERICHARD H. GOLD, M.D. and HOWARD L. STEINBACH, M.D.Audio Available | Share

The use of rapid sequence mannitol pyelography in the diagnosis of renovascular hypertension.

Ever since the association between renal vascular lesions and hypertension has been known, better tests have been sought to determine whether or not morphologically demonstrable lesions are in fact functionally significant (11, 12). Taken as a group, the rapid sequence intravenous pyelogram, the Stamey test, the Howard test, the radioactive renogram, the renal venous washout time, the renal venous renin level, and the closed renal biopsy have been fairly accurate in predicting functionally significant lesions (8–11). However, many of these tests are not simple, require special equipment, and are not readily available in the community hospital. It would seem, then, that there is great need for a safe, simple, accurate screening procedure for preliminary evaluation of patients with suspected renovascular hypertension. Presently rapid sequence intravenous pyelography and/or urea washout pyelography are widely employed as primary screening tests in the evaluation of such patients. While these methods can distinguish gross differences in renal size, subtle discrepancies in renal function are often difficult, if not impossible, to evaluate (3, 5, 6). It occurred to us that the mannitol pyelogram originally described as a modification and simplification of the drip infusion technic might have some use in screening suspected cases of renovascular hypertension since it is in fact a modified Stamey test, the only essential difference being the addition of contrast medium to the intravenous injection of osmotic diuretic and vasopressin (7). This approach seemed to offer a way of performing split renal function studies with evaluation of the roentgen findings rather than relying on occluding ureteral catheters and timed urine samples. The following case report is presented to illustrate the presumed value of the mannitol pyelogram in the evaluation of functionally significant renal vascular hypertension. Case Report A 21-year-old white male was admitted to the hospital on Nov. 27, 1966, with a chief complaint of high blood pressure. The present illness dated to December 1965, when he was first informed that he had hypertension at an Armed Forces preinduction physical examination. Since that time his blood pressure has been continually elevated. Headaches have been an occasional complaint. There was no history of renal disease, shortness of breath, or paroxysmal nocturnal dyspnea. His mother, father, and older sister all have hypertension. Physical examination revealed an alert, well developed male. The pulse was 80 and regular; the temperature 99°. The blood pressure was: sitting, right arm 165/120 and left arm 170/110; prone, right arm 160/120, left arm 170/110, and right leg 230/160. No other abnormalities were noted. Laboratory studies disclosed normal hemogram and urogram, a blood urea nitrogen of 19 mg per 100 cc, sodium 138 mEq/l, potassium 4.0 mEq/1. On Nov. 29, 1966, a modified Howard test was performed.

Elevated serum gonadotrophins in Silver's syndrome.

IN 1953 Silver et al 1 reported cases of two children having a syndrome characterized by low birth weight after full-term gestation, shortness of stature, hemihypertrophy, and elevated urinary gonadotrophins. Subsequently, Silver and various other authors have reported cases of numerous children with similar manifestations. 2-5 In 1964 Silver summarized the findings in 29 examples of the syndrome. 6 Reister and Scherz 7 described cases of two additional patients and suggested the eponym, Silver's syndrome. In 1966 Moseley et al 8 discussed the roentgen findings in these cases. Other clinical manifestations encountered in the syndrome are as follows: variations in sexual development; short, incurved fifth fingers; triangular shaped facies; cafe au lait spots; and syndactyly. One case was associated with congenital heart disease. The purpose of the present paper is to discuss the clinical and laboratory findings in a case of Silver's syndrome occurring in a very young child. The

Pseudocysts of the pancreas.

1. Twenty-one patients with pseudocysts of the pancreas have been reviewed.2. Most patients will have a history of alcoholism or abdominal trauma.3. The most common presenting findings are pain and abdominal mass.4. The roentgen findings are reviewed, stressing the varied locations in which this lesion may present and the not infrequent appearance of an intramural or invasive mass.

Pulmonary Roentgen Findings Following Renal Transplantations

Transplantation of vital organs in other than identical twins calls forth the normal body rejection mechanism. Steroids and other immunosuppressive agents have been used in an attempt to preserve the organ graft, but the protection afforded against graft rejection also leads to susceptibility to infection. Organisms which ordinarily are saprophytic become capable of producing severe disease. These organisms are often difficult to identify. For example, no good diagnostic test short of lung biopsy exists for Pneumocystis carinii. Fungal cultures take one to two weeks to isolate the organism. A need exists for some rapid means of identification of these organisms so that appropriate therapy may be instituted early. With this goal in mind, the roentgenograms of a series of renal transplant patients who died were reviewed. Methods And Materials One hundred and eleven patients were treated by renal transplant from the beginning of the program in November 1962 through December 1965. Immunosuppressive therapy wa...

Solitary pulmonary lesions. Computer-aided differential diagnosis and evaluation of mathematical methods.

The Roentgenographic differential diagnosis of solitary lung nodules is a difficult problem (3). In a significant group of patients the roentgen findings are virtually nonspecific, while in other cases the radiologist feels confident in making a specific diagnosis. Thus, the radiologist faces a twofold dilemma. Not only must he decide what disease process is most likely responsible for the roentgenographic findings, but he must also determine how confident he can be about his diagnosis in each case. To resolve the type of diagnostic problem discussed above, Ledley and Lusted (4) proposed a mathematical approach based on Bayes' theorem of prior probabilities. With the aid of the digital computer, this method has been applied to the differential diagnosis of many disease groups, including congenital heart lesions (9), primary bone tumors (6), thyroid dysfunctions (2), and gastric ulcers (10). All of these studies have employed not only Bayes' theorem but also the assumption that the signs and symptoms used to make a diagnosis may be treated as independent variables. This assumption has been shown to be poorly justified and to result in unreliable diagnostic probabilities, at least in certain circumstances (9). Therefore, a modified approach, which allows for linear relationships between variables, has been developed (1). In this paper roentgenographic data collected from 242 histologically proved cases of solitary lung lesions are presented. These data are then analyzed both by the“standard” method assuming independence of roentgenographic findings and by the“new” linear method. The diagnostic results obtained by these two methods are discussed and compared with respect to their accuracy and reliability. The applicability of statistical methods to roentgenographic diagnosis of solitary lung nodules is discussed in the light of these findings. Material and Methods The following nine solitary lung lesions have been evaluated: nonspecific granuloma, primary adenocarcinoma, epidermoid carcinoma, undifferentiated carcinoma, abscess, infarction, hamartoma, chronic pneumonitis, and histoplasmoma. The patient's age, sex, and smoking history were recorded on a work sheet, using information taken from the patient's chart. Pos-tero-anterior and lateral chest roentgenograms exposed within forty-eight hours of definitive biopsy, surgery, or autopsy were evaluated in all patients. Eighteen roentgenographic findings were initially evaluated for each of the 242 cases. After the roentgenographic information had been recorded on the work sheet, the information was transferred to data punch cards, from which a frequency distribution table and a prior probability matrix were compiled by the computer.

Transthoracic Needle Biopsy

By Sven Dahlgren, M.D., Department of Pathology, and Björn Nordenström, M.D., Director, Department of Thoracic Radiology, Karolinska Institutet, Stockholm, Sweden. Cloth, $12.50. Pp. 132, with 70 figures. Chicago, Yr. Bk. Pub'rs., 1966. This very good monograph reports in detail on a large clinical experience with transthoracic needle biopsy. The material is well organized, clearly presented, reads easily, and will be a useful basic reference work for all those interested in initiating this technic. The authors have shown quite conclusively that needle biopsy of pulmonary lesions under roentgen television control has been sufficiently developed to become a clinically valuable diagnostic tool. It provides the opportunity for obtaining specific diagnostic information in those lesions that otherwise would not be obtainable except through open thoracotomy and excisional biopsy. Although needle biopsy of pulmonary lesions is not a new procedure, it was never generally accepted as a safe and accurate diagnostic method. The recent ability to monitor the puncture procedure by roentgen television viewing has been chiefly responsible for the ease and accuracy with which the examination can now be performed. It is also an important factor in minimizing the risk inherent in all diagnostic needle puncture technics. The importance of close co-operation between the radiologist and the pathologist and the need for systematic training of personnel in the various aspects of this diagnostic procedure in obtaining good results is emphasized. The lack of any serious complication in the first 900 biopsies performed is reassuring and is a reflection of the organized approach used in the study of candidates for transthoracic needle biopsy. The illustrative material is well selected, and there are in most of the case reports a correlation of the roentgen findings with the histology of the specimens obtained. Some of the illustrations chosen to depict the roentgen character or differential appearance of malignant and benign infiltrates are not specific enough to permit appreciation of this difference. The clinical material consists of 574 needle biopsies in 408 patients with an age range of nine to eighty-three years. Presently, this diagnostic service is averaging 25 patients a month. Patients are punctured on an average of 1.4 times and occasionally as many as 5 times each. The technic is particularly suitable for the diagnosis of tumors. Inflammatory processes provide greater diagnostic difficulty. In the latter problem, obtaining bacteriologic studies in suspected inflammatory lesions was found helpful in establishing a correct diagnosis. In 13 per cent of the total material, it was not possible to obtain satisfactory cell material. It must be pointed out, however, that in a significant number of patients in this group the lesions were small.

Unusual symptomatic arch anomalies.

Anomalies of the aortic arch are not uncommon. Quite often they may be suspected from the standard four chest films, with barium in the esophagus, and definitively demonstrated by angiocardiography. Those anomalies forming vascular rings, e.g., the double aortic arch, have been well documented in the literature. The purpose of this report is to illustrate three anomalies of the aortic arch and its brachiocephalic branches: anomalous innominate artery, the cervical aortic arch, and congenital stenosis of one or more of the brachiocephalic vessels. The second and third of these have not been previously documented in the radiologic literature. Most vascular rings and malformations of the aortic arch can be related to either a persistence or abnormal regression of one or more of the six original paired primitive aortic arches. The caudal descent of the heart occurs as the first two arches regress and disappear. Edwards (1, 2), in his simplified classification, uses the basic embryologic pattern of two arches, a dorsal and ventral aorta, and a ductus between to explain most of the anomalies by persistence or regression at multiple locations in this system. The three aortic-arch anomalies of this communication may not be recognized on conventional radiography. The symptoms and signs of the first two types relate to compression of the esophagus and/or tracheobronchial tree, usually evident shortly after birth. They may be so severe as to be life-threatening or they may be minor and never clinically significant. The following events may be included in the clinical picture; coughing, choking, stridor, “apneic spells,” and aspiration and recurrent pneumonia (3). The third type of anomaly may not cause significant clinical distress but be confusing and annoying because of murmurs and pulse abnormalities. It may be mistaken for a congenital heart defect, as in our Case III below. Anomalous Innominate Artery Case I: This male infant was the product of a 9-month full-term pregnancy. The child was apneic during the newborn period, but this condition improved, and physical signs did not again appear until respiratory distress occurred at one month of age. Subsequently, he was hospitalized on four separate occasions for respiratory distress. Each time improvement followed symptomatic therapy. On his fifth hospital admission, at the age of thirteen months, the child again presented with stridor, rhonchi, and subcostal retractions. The respiratory rate was 36 per minute. There was no cyanosis. No significant laboratory abnormalities were found. The lungs were clear on auscultation. Cultures of the nose and throat grew alpha Streptococcus and 1+ Staphylococcus aureus. The blood culture showed no growth. Oral fluids and Ampicillin were administered, and the child was placed in a croupette with oxygen and mist. On the sixth hospital day, he became afebrile without respiratory distress. The roentgen findings on this admission are shown in Figures 1–3.

The roentgenology of silicosis

1. A description of the roentgen patterns of silicosis has been presented. 2. It is to be emphasized that the proper evaluation of a patient with silicosis requires the combined efforts of physicians interested in the clinical and physiological aspects of the disease as well as in the roentgen findings. 3. There is need for continued investigation of earlier means of detecting silicosis and ways of differentiating its complications from other diseases.

Massive Herniation of the Bladder: “The Roentgen Findings”

Massive Herniation of the Bladder: “The Roentgen Findings”

Pleuropulmonary pseudotumors in childhood.

Four cases of pediatric pleuropulmonary inflammatory disease are reported with emphasis on the roentgen findings. Three children with acute pneumonia demonstrated a rounded, retrocardiac and paravertebral density which could not be differentiated from a posterior mediastinal tumor. Clinical and laboratory findings suggested the correct diagnosis. The fourth patient underwent extensive diagnostic studies for evaluation of a rounded postenor mediastinal mass. The history, clinical course and roentgenographic findings indicated that this was probably an encapsulated paramediastinal pleural effusion secondary to tuberculosis.

Fracture of the medial margin of the patella, a finding diagnostic of lateral dislocation.

Afracture or cortical irregularity of the medial articular margin of the patella was noted in a number of patients admitted to The Hospital for Special Surgery, New York, with the diagnosis of recurrent lateral dislocation of the patella. We regard this roentgen finding as pathognomonic evidence of previous lateral dislocation of the patella. In a few instances, we have been able to diagnose this previous dislocation from the x-ray examination without knowledge of the patient's history or clinical findings. The purpose of this presentation is to discuss and illustrate the roentgen abnormalities which follow lateral dislocation of the patella and to point out the importance of the tangential view of the patella in the examination of the knee. Presentation of Material Records of 150 patients admitted to the hospital with a diagnosis of lateral dislocation of the patella were obtained, and their roentgen examinations and charts reviewed. In 16 cases, 12 females and 4 males, the fracture of the medial articular margin of the patella was demonstrated. Not all the 150 patients had a complete roentgen examination, including tangential views, and therefore the exact statistical occurrence of the marginal fracture could not be established. A concurrent finding also previously described (1–4), the compression fracture or irregularity of the lateral margin of the lateral femoral condyle, was seen in only a few cases. It appears to be less common and more difficult to evaluate than the patellar rim fracture. In none of the 16 cases was any congenital abnormality of the patella such as hypoplasia demonstrated. A history of previous trauma was obtained in 12. Mechanism of Injury The laterally dislocated patella locks itself over the lateral margin of the lateral femoral condyle; then, upon contraction of the quadriceps, the patella is pulled back into its normal position. The impingement of the medial margin of the patella upon the lateral condyle causes a compression defect in the condyle and a fracture of the medial margin of the patella either by compression or by shearing as the patella slides back, pulled by the contracting quadriceps. This process produces a predominantly chondral fracture at the margin of the articular surface, which becomes radio-graphically visible only when a sufficient portion of subchondral bone is involved. Discussion Of the 16 patients in whom the medial marginal fracture of the patella was demonstrated, the youngest was twelve years of age. We assume that the fracture also occurs in younger children but is not radio-graphically detectable because the articular cartilage is thick and the ossification center proportionally small. Here the fracture is purely chondral in nature and therefore invisible. A dislocating patella in a patient eight years of age is demonstrated in Figure 1. No marginal fracture is visible.

Subvalvular mitral insufficiency: roentgen aspects.

The characteristic roentgen appearance of rheumatic mitral insufficiency is dominated by the large left ventricle and the large left atrium (14). This appearance is generated by the slow development of mitral incompetence over a period of years. As the rheumatic process heals, the leaflets scar and the chordae tendineae shorten, allowing regurgitation into the left atrium and elevation of left atrial pressure with subsequent left atrial dilatation (6, 10, 15). In addition to the valvular insufficiency of rheumatic heart disease, however, mitral incompetence may result from disruption of the subvalvular apparatus. Each leaflet of the valve is anchored by a number of chordae tendineae. In turn each of the chordae inserts into one or the other of the papillary muscles. Rupture of the chordae tendineae or of the papillary muscle causes prolapse of the unsupported leaflet into the left atrium with consequent acute mitral insufficiency. This may occur in an otherwise competent valve or may aggravate pre-existing mitral incompetence from another cause (15). The purpose of this report is to present the roentgen findings in eight patients with subvalvular mitral incompetence studied at the University of Kentucky Medical Center, Lexington. The clinical and hemodynamic findings will be analyzed elsewhere. Table I summarizes the clinical course of our patients and Table II the radiographic evaluation. The roentgen appearance is illustrated in Figures 1 to 3. A number of roentgen findings were present in almost all of our patients. These include absence of mitral valve calcification, cardiac enlargement, evidence of pulmonary venous and capillary hypertension, systolic pulsation of the left atrium by fluoroscopy, and moderate-to-massive mitral regurgitation on the left ventriculogram. Left atrial size is variable, and on that basis the findings in these patients form a spectrum. It is our feeling that the size of the left atrium and the appearance of the roentgenogram are dependent upon the following factors: (a) the etiology of the subvalvular incompetence; (b) the duration of mitral incompetence; (c) the number of chordae involved; (d) the age of the patient; (e) associated heart disease. Etiology Rupture of the chordae tendineae has been attributed to trauma (3) and rheumatic heart diseases (2). Several papers have implicated bacterial endocarditis as the leading cause of ruptured chordae, even where there is little if any other evidence of endocarditis (8, 11, 13, 16). Some cases have no obvious cause and are listed as spontaneous (7, 9, 17–19). Myocardial infarction is the cause of rupture or dysfunction of a papillary muscle in almost all instances (1,4). In patients in whom the acute subval-vular incompetence is not preceded by previous valvular heart disease, the left atrium is not enlarged radiographically but exhibits vigorous systolic pulsations by fluoroscopy (15,16).

A-mode ultrasound differentiation of soft-tissue masses.

Roentgenography is currently the principal diagnostic method available for the detection of suspected masses within the thorax, abdomen, and retroperitoneal space. Differentiation of these masses, however, is frequently difficult, despite the roentgen findings and the associated clinical data. A-mode ultrasound is a relatively simple technic that can differentiate cystic from solid masses. By utilizing this information in conjunction with the x-ray studies, the radiologist can offer a more accurate differential diagnosis. A-mode has been used successfully for differentiating breast lesions (1) and localizing liver cysts, which are referred to as “fluid flat segments” (2). The method has also been employed to study mediastinal and abdominal masses (3, 4) and to differentiate echinococcal cysts of the lung from solid tumors (5). In this country, ultrasound research has been directed mainly toward the more complex type of ultrasound, known as B-scan, in which cross-section images of organs and tumors are pro...