Lobular carcinoma in situ of the breast: mammographic features

Lobular carcinoma in situ (lobular neoplasia; LCIS) of the breast is most commonly an incidental microscopic finding in breast tissue removed for some other reason. The authors reviewed the clinical and mammographic features and surgical findings in 26 cases of LCIS not associated with other breast abnormalities. In 16 instances, needle localization was performed before removal of the tissue, which yielded LCIS on histologic examination. Calcifications were the most common reason for biopsy, although there were no distinctive mammographic features of LCIS.

Computed tomography of isolated osteoblastic colon metastases in the bony pelvis

Skeletal metastases from colorectal carcinoma are unusual and osteoblastic metastases are quite rare. Three cases are described in which an isolated recurrence of a previous colorectal carcinoma occurred within the pelvic bones, without evidence of skeletal metastases elsewhere so that local spread via portocaval anastomoses in the pelvis is postulated. In all three cases, proliferative calcification and new bone formation occurred within an expansile, destructive lesion, suggesting the occurrence of a synergistic effect between the underlying bone and a malignant neoplasm which has a propensity to calcify.

The acromioclavicular joint: normal variation and the diagnosis of dislocation

Acromioclavicular separation is a common traumatic injury. Diagnosis rests on clinical and radiographic findings. However, normal variation in the alignment of the acromioclavicular joint may make the roentgen diagnosis more difficult. We stress the variations of normal alignment at the acromioclavicular joint and offer suggestions for avoiding pitfalls in this clinical situation.

Nontraumatic avulsion of the lesser trochanter: a pathognomonic sign of metastatic disease?

Isolated avulsion fractures of the lesser trochanter resulting from trauma are most commonly seen in adolescent athletes and are rare in adults. Standard therapy is nonsurgical with bedrest and immobilization of the leg. However, when this lesion is seen in the adult without significant trauma, it should be regarded as secondary to metastatic neoplasm until proven otherwise. Treatment should be surgical with prophylactic internal fixation of the hip to help prevent the commonly associated subtrochanteric pathologic fracture. In a patient without a known primary malignancy, biopsy should be carried out before therapy. We describe four patients with isolated avulsion fracture of the lesser trochanter due to metastatic carcinoma. Radiologists should be aware of this lesion because its presence has a decisive effect on therapy.

Intravasation during hysterosalpingography using oil-base contrast medium--a second look

Hysterosalpingography is a study performed commonly to assess the upper reproductive tract in infertile women. A risk with hysterosalpingography is either lymphatic and/or venous intravasation with or without embolization. Of 593 consecutive hysterosalpingograms performed with a low-viscosity oil-base medium, intravasation occurred in 41 cases (6.9%). Embolization was documented in six patients. There were no recognized adverse sequelae from either intravasation or embolization. Intravasation was frequently associated with pathology of the upper genital tract, and suspected tubal occlusion was the most common abnormality detected. Proper timing of the procedure and avoidance of excessive instillation pressure will diminish the incidence of this complication. The use of both a low-viscosity oil-base medium and high-resolution fluoroscopic image intensification may increase the detection of intravasation.

The variable nature of the mediastinal contour lines: CT/chest radiography correlation

Interfacing of the lung with the mediastinum produces a number of mediastinal lines including those due to the innominate veins, left subclavian artery, paratracheal stripe, both anterior and posterior junction lines, the azygo-esophageal recess, descending aorta and paraspinal lines. Displacement or absence of one or more of these lines may be due to an abnormality of mediastinal contour or may indicate a mediastinal mass, but can occur in normal subjects. Correlative findings between chest radiography and chest computed tomography in 50 normal subjects illustrate the variable nature of these lines.

Idiopathic synovial chondromatosis in two unusual sites: inferior radioulnar joint and ischial bursa

Synovial chondromatosis is a rare disorder of unknown cause characterized by multiple calcific bodies in the vicinity of the affected joint. It is most commonly seen in the knee, hip, elbow, and shoulder. We describe three cases of synovial chondromatosis in two extremely uncommon sites, the inferior radioulnar joint and the ischial bursa, and review the literature on the subject. The characteristic radiographic appearance, even if in an uncommon location, should prompt the radiologist to suggest the correct diagnosis preoperatively.

Carcinosarcoma of the breast: radiologic, ultrasonographic, and pathologic correlation

Carcinosarcoma of the breast is a rare neoplasm which has been reported less than 20 times. Comprised of both malignant epithelial and malignant connective tissue components, it may radiographically exhibit features of either cellular element. We report the first film-screen mammographic description of such a lesion in a breast. Osteoid matrix calcification demonstrated mammographically should, in retrospect, have suggested osteogenic elements preoperatively.

Annulus fibrosus calcification in the cervical spine: radiologic-pathologic correlation

Intervertebral disc calcification can be secondary to a variety of pathologic processes including some of the arthritides, metabolic diseases, and trauma. The annulus fibrosus is the most commonly calcified component and may mimic vertebral body fracture, limbus vertebra, or a persistent ring apophysis. We describe two young patients who developed calcification in the anterior annulus fibrosus and present radiologic-pathologic correlation in this condition in another case. This calcification may actually be secondary to subclinical or chronic stress on the involved intervertebral disc.

Dedifferentiated chondrosarcoma: radiographic features

Dedifferentiated chondrosarcomas, unlike ordinary chondrosarcomas, are highly aggressive tumors that frequently metastasize. The lesion is characterized by a lytic intraosseous or extraosseous soft-tissue mass that is devoid of the calcifications that are usually associated with a chondroid tumor. We describe the radiographic and pathologic features of five cases involving dedifferentiated chondrosarcoma.

The clinical outcome of needle aspirations of the lung when cancer is not diagnosed

One hundred thirty-two of 397 consecutive percutaneous fine needle aspirations done at the University of Virginia between January, 1979, and December, 1984, for pulmonary lesions showed no evidence of cancer on cytological examination. We reviewed the presenting symptoms, radiographic findings on the day of needle aspiration, and the descriptive cytological terms to determine if it was possible to distinguish benign from malignant disease in these 132 patients. We found a specific benign diagnosis in only 16 (12%) of the 132 patients, and 1 of them ultimately was found to have cancer. In the remaining 116 patients, analysis of age, sex, smoking history, presenting symptoms, radiographic findings at the time of needle aspiration, and cytological terms other than malignancy did not enable distinction of benign from malignant disease as the cause of the radiographic finding. In the group of 132 patients without suggestion of cancer on initial cytological study, 38 (29%) were subsequently found to have a malignant process.

Atypical carcinoid of the lung: radiographic features

Atypical carcinoid of the lung is a neuroendocrine neoplasm with cellular and clinical features intermediate between those of typical carcinoid and small cell undifferentiated carcinoma of the lung. These neoplasms exhibit a wide range of histologic appearances and are misdiagnosed in up to 50% of cases. The clinical records and radiographs of 32 patients with this diagnosis from the University of Virginia Medical Center and Wake Forest University Medical Center were reviewed. Sixteen of these cases had been misdiagnosed pathologically. While the most frequent radiographic finding was a round or avoid lobulated peripheral mass, other appearances included thin-walled cavities, poorly defined nonsegmental infiltrates, and mediastinal masses. Fifty percent of the patients in this study have died from their tumor, with a mean survival of 15.5 months. This contrasts with both typical carcinoid and small cell undifferentiated carcinoma, in which patients develop fatal metastatic disease in 5% and nearly 100%, respectively. Proper categorization of typical carcinoid, atypical carcinoid, and small cell undifferentiated carcinoma is necessary to determine appropriate therapy, prognosis, and reporting of end results.

Has monitoring of the contralateral breast improved the prognosis in patients treated for primary breast cancer?

Bilateral breast cancer has a cumulative incidence of about 7% in patients with primary operable breast cancer, and most of these lesions are metachronous. Most retrospective studies have shown that a majority of these patients have invasive cancer in the second breast, and varying percentages have nodal metastases, which may be of a higher stage than the first cancer. Physicians are now more aware of the importance of careful monitoring of the second breast after ipsilateral mastectomy, and improvements have been made in mammographic surveillance. A retrospective, comparative analysis of two separate breast cancer populations at risk for bilateral breast cancer was done on patients who entered into the system before effective mammographic monitoring (BEM) and after effective mammographic monitoring (AEM). The first group of patients consisted of 500 consecutive patients with primary breast cancer diagnosed during the years 1969 through 1975, of whom 37 (7.4%) had bilateral breast cancer. The second group consisted of 557 consecutive patients diagnosed during the years 1977 through 1984, of whom 36 (6.5%) had bilateral breast cancer. The staging percentages of the second breast cancer in the BEM group were Stage 0, 5.4%; Stage I, 48.6%; Stage II, 10.8%; Stage III, 21.6%; and Stage IV, 13.5%. The second group had an improvement in stage, with 33.3% being Stage 0, 22.2% Stage I, 29.6% Stage II, 3.7% Stage III, and 3.7% Stage IV (P less than 0.05). The median interval between primary lesions was 39 months in the first group and 19 months in the second group (in part, this difference may represent increased identification of synchronous cancers). The second breast cancer was undetected by mammography in 9 of 34 (26%) patients. Six were detected by contralateral biopsy (all were lobular carcinomas in situ), and three were found by clinical examination (all were invasive cancers). It was concluded that more aggressive monitoring of the second breast by frequent clinical examination, mammography, and selected contralateral biopsy appears to have increased the early detection rate of second breast cancers in patients under observation.

Computed tomography of mediastinal cystic hygroma in an adult: case report and review of the literature

Conventional and computed tomography findings in a cystic hygroma (lymphangioma) of the middle mediastinum in an adult are reported and compared with previously reported cases. The pertinent literature is reviewed.

Silicone granuloma following closed capsulotomy of mammary prosthesis

Rupture of the silicone prosthesis can occur following external closed compression capsulotomy for fibrous capsules that develop after augmentation mammaplasty. The forces needed to rupture the fibrous capsule can cause silicone gel from the prosthesis to be pressure injected into the breast tissue and surrounding musculature. Film-screen mammography can be utilized to diagnose prosthetic rupture.

Computed tomography in the management of orbital cellulitis from an imbedded eye prosthesis

Computed tomography (CT) is far superior to plain radiography or xeroradiography in the detection of orbital foreign bodies and in defining altered anatomic relationships in this region. We present a case in which CT was instrumental in the management of orbital cellulitis in a patient who had forgotten that an eye prosthesis had been inserted in the past. We stress the importance of CT in our case and discuss its usefulness in other reported clinical situations involving the orbit.

Breast skin thickness: normal range and causes of thickening shown on film-screen mammography

We measured breast skin thickness on the film-screen mammograms of 250 asymptomatic women and found a normal range of 0.7-2.3 mm in the superior quadrant and 0.7-2.7 mm in the inferior quadrant as measured on the mediolateral view and 0.6-2.4 mm in the medial quadrant and 0.5-2.1 mm in the lateral quadrant as measured on the craniocaudad view. In our experience a skin thickness of greater than 2.5 mm suggests the presence of disease. Causes of skin thickening in our series of 44 patients included carcinoma, metastases, post radiation therapy, post surgery, infection, and anasarca. Other reported causes are trauma, fat necrosis, dermatologic conditions, and lymphoma.

The "mucous plug syndrome". A pulmonary embolism mimic

Reported are ten instances of major bronchial obstruction by mucous plugs in eight patients during which the clinical features resembled pulmonary embolism. Perfusion lung studies showed significantly diminished perfusion of the involved portions of the lungs. The chest radiographs generally did not, however, reflect the severity of the airway obstruction and in some instances were completely normal. The ventilation studies indicated the extent and severity of the obstruction and matched with the perfusion scans. Pulmonary arteriograms were performed in three patients and gave direct evidence of focally diminished lung perfusion without embolism. The physiologic mechanisms underlying the condition are discussed.

Extraordinary growth of giant cell reparative granuloma during pregnancy

A 25-year-old woman had a giant cell reparative granuloma (GCRG) in the nasal fossa during the fifth month of pregnancy. This was treated with a partial excision, but the lesion recurred three months later. By this time, there was extension into the anterior fossa. Because of rapidly decreasing visual acuity, headache, and facial pain, a combined craniofacial approach was undertaken. The lesion encroached on the optic chiasm and a piecemeal, but incomplete, removal of the lesion was performed. The patient spontaneously gave birth to a normal child while in the recovery room. She received no additional therapy and her symptoms disappeared. She remains well 11 years later. The course of disease in this patient is compared with eight other patients from the literature who had GCRG during pregnancy.

Upper reproductive tract radiographic findings in DES-exposed female offspring

Earlier reports implicated the association of adenosis and adenocarcinoma of the vagina in offspring exposed in utero to diethylstilbestrol (DES). Subsequently attention was directed to the structural abnormalities of the müllerian system in the same females. In this report, the hysterosalpingographic findings in 11 DES-exposed women are presented. The external cervical os was stenotic in two patients. Multiple uterine cavity aberrations were noted: T-shaped configuration, hypoplasia, constriction deformities, and nodular or other filling defects. Tubal patency was demonstrated consistently. If structural abnormalities of the vagina and/or cervix are present, then upper reproductive tract alterations should be considered.

Pittsburgh Pneumonia Agent in a cadaveric renal transplant recipient

Pittsburgh Pneumonia Agent, Legionella micdadei, is a recently recognized source of pulmonary infection in immunocompromised hosts. A literature review suggests a typical pattern of clinical and radiologic presentation, of which the following case is representative. Eighteen of twenty-one infections have occurred in recipients of cadaveric renal transplants, defining a population at risk. The onset often occurred within days to weeks of bolus doses of corticosteroids. Fever, often accompanied by mild pulmonary symptoms usually developed, coupled with nodular or segmental chest infiltrates which were often well defined or rapidly expansile. Recognition of this pattern followed by prompt open lung biopsy may lead to increased survival.

Current perspectives on indications and limitations of mammography

Women have a 7 percent natural lifetime risk of developing breast cancer, which is the leading cause of death in women aged 40 to 50 years. Most data suggest that the earlier the disease is diagnosed, the better the chance for cure. Women with "minimal breast cancer" have an actuarial 20-year survival rate of 93.2 percent. The majority of these breast cancers are diagnosed by mammography. The radiation doses from this technique have been dramatically decreased over the last ten years to about 0.1 to 0.6 rads per study. The two largest breast cancer screening studies, the Health Insurance Plan of Greater New York and the Breast Cancer Detection Demonstration Project, have shown conclusively that women over 50 years old can benefit from annual mammography and that certain groups can benefit from mammography at close intervals before the age of 50 years. This article describes the development of mammography and outlines current perspectives on its indications and limitations.

Pittsburgh pneumonia agent: chest film manifestations

Pittsburgh pneumonia agent, Legionella micdadei, is a Gram-negative, weakly acid-fast bacillus, recently recognized as a cause of pulmonary infection in the immunocompromised host. The chest radiographic findings in seven patients with this disease are reported. These consist of single or multiple nodules and segmental infiltrates involving part of all of one or more lobes. A striking feature in this series was the rapid growth of the pulmonary densities.

Bladder base impressions in women: "female prostate"

Bladder base impressions due to prostate hypertrophy are a common urographic finding in older males. A similar appearance may be occasionally seen in females and presents a more difficult diagnostic problem. Sixteen such cases of bladder base defects in females at two institutions were identified. The impressions were caused by symphysis pubis asymmetry, postoperative change, urethral diverticulum, levator ani impression, or "urethral syndrome." Vaginal fibromyoma, ectopic ureterocele, and intramural bladder neoplasm can also cause this defect, although no such cases were found in this series.

Maxillary sinusitis after nasotracheal intubation

Maxillary sinusitis resulting from nasotracheal intubation is rare, occurring in approximately 2% of patients receiving ventilatory assistance. We have described two examples of this situation. In one case, the sinusitis caused bacteremia. The diagnosis can be made easily by a portable Water's view of the paranasal sinuses. Clinicians should be aware of this potentially serious complication in intubated patients.

Nuclear scintigraphy and ultrasound in the diagnosis of congenital ureteropelvic junction obstruction

Congenital ureteropelvic junction obstruction is well known. The traditional mainstay of diagnosis has been excretory urography. However, in the neonatal period ultrasound and renal scintigraphy should be the initial diagnostic procedures for this disease. Excretory urography may be tailored or eliminated using these 2 tests as guides. We report a case of bilateral ureteropelvic junction obstruction diagnosed in utero and suggest a diagnostic study, stressing the liabilities of excretory urography in the neonate or young child.