Unusual Sites of High-Grade Neuroendocrine Carcinomas: A Case Series and Review of the Literature

Case series

Patient: Female, 29 • Female, 69 • Female, 52 • Female, 71 • Male, 62 • Female, 67

Final Diagnosis: Neuroendocrine carcinoma

Symptoms: Abdominal pain

Medication: —

Clinical Procedure: —

Specialty: Oncology

Repeatability of two-dimensional chemical shift imaging multivoxel proton magnetic resonance spectroscopy for measuring human cerebral choline-containing compounds

AIM

To investigate the repeatability of proton magnetic resonance spectroscopy in the in vivo measurement of human cerebral levels of choline-containing compounds (Cho).

METHODS

Two consecutive scans were carried out in six healthy resting subjects at a magnetic field strength of 1.5 T. On each occasion, neurospectroscopy data were collected from 64 voxels using the same 2D chemical shift imaging (CSI) sequence. The data were analyzed in the same way, using the same software, to obtain the values for each voxel of the ratio of Cho to creatine. The Wilcoxon related-samples signed-rank test, coefficient of variation (CV), repeatability coefficient (RC), and intraclass correlation coefficient (ICC) were used to assess the repeatability.

RESULTS

The CV ranged from 2.75% to 33.99%, while the minimum RC was 5.68%. There was excellent reproducibility, as judged by significant ICC values, in 26 voxels. Just three voxels showed significant differences according to the Wilcoxon related-samples signed-rank test.

CONCLUSION

It is therefore concluded that when CSI multivoxel proton neurospectroscopy is used to measure cerebral choline-containing compounds at 1.5 T, the reproducibility is highly acceptable.

Does size matter? The impact of calf muscle volume on venous return in patients with venous leg ulcers

Objectives: The calf muscle pump is recognized as an integral component of effective venous return from the lower limbs. The aim of this study was to determine if there is a correlation between calf muscle volume and venous blood flow among patients with venous leg ulcers.

Methods: Nine patients with venous leg ulceration were recruited for this study. These patients underwent haemodynamic testing using duplex ultrasound to measure peak venous velocities in response to voluntary maximum plantar flexion, with and without compression bandaging. Each patient then had magnetic resonance imaging (MRI) of the lower limbs. Calf muscle volume was calculated from the MRI images using a specially designed Matlab computer program to identify and count muscle pixels. Analyses applied Pearson's correlation coefficient to determine correlation between calf muscle volume and mean peak venous velocities in response to voluntary contraction.

Results: No correlation was seen between calf muscle volume and haemodynamic venous return in response to voluntary contraction, with or without compression bandaging.

Conclusion: The volume of calf muscle available for promoting venous return alone may not be an accurate indicator of muscle functioning capability.

Unilateral Warthin's tumour in a patient of Afro-Caribbean descent

Warthin's tumours are the second most common benign tumours of the parotid gland. The authors report the case of a 40-year-old man of Afro-Caribbean decent who presented with a painless mass at the angle of the right mandible. It was an incidental finding while shaving and was not associated with any symptoms. Arrangements were made for him to undergo an ear, nose and throat (ENT) evaluation. Axial contrast-enhanced CT of head and neck region revealed a well-defined cystic lesion. Fine-needle aspiration cytology was inconclusive. Right superficial partial parotidectomy was performed to remove the lesion. Histological examination confirmed a diagnosis of a Warthin's tumour.

Good clinical and radiological response to BRAF inhibitor in patient with metastatic thin melanoma

The authors herein report the case of a 32-year-old man with advancing metastatic malignant melanoma, who has progressed through all previous lines of therapy, presenting with ongoing respiratory tract symptoms of exertional shortness of breath and cough. CT restaging confirmed clinical findings of deteriorating pulmonary disease; histological review revealed V600E BRAF mutation. He was started on targeted biological therapy with BRAF inhibitor GSK2118436, and is having a good clinical and radiological response without significant lasting toxicity.

Erratum: Primary gastric Hodgkin's lymphoma: favourable outcome following multi-agent chemotherapy without surgical intervention

[This corrects the article DOI: 10.1136/bcr.11.2010.3476.].

Advanced and rapidly progressing head and neck cancer: good palliation following intralesional bleomycin

The authors herein report the case of a 61-year-old man undergoing adjuvant therapy for locally advanced laryngeal cancer, who developed parastomal recurrence in his radiation field around his tracheotomy site, while he was undergoing radiation therapy, and compromised the secure placement of his tracheotomy tube and maintenance of his upper airway. MRI restaging and biopsy confirmed recurrence and progressive disease in his mediastinum. He underwent local therapy with intralesional bleomycin with good palliation, and ability to maintain the patency of his upper airway.

Wall shear stresses remain elevated in mature arteriovenous fistulas: a case study

Maintaining vascular access (VA) patency continues to be the greatest challenge for dialysis patients. VA dysfunction, primarily due to venous neointimal hyperplasia development and stenotic lesion formation, is mainly attributed to complex hemodynamics within the arteriovenous fistula (AVF). The effect of VA creation and the subsequent geometrical remodeling on the hemodynamics and shear forces within a mature patient-specific AVF is investigated. A 3D reconstructed geometry of a healthy vein and a fully mature patient-specific AVF was developed from a series of 2D magnetic resonance image scans. A previously validated thresholding technique for region segmentation and lumen cross section contour creation was conducted in MIMICS 10.01, allowing for the creation of a 3D reconstructed geometry. The healthy vein and AVF computational models were built, subdivided, and meshed in GAMBIT 2.3. The computational fluid dynamic (CFD) code FLUENT 6.3.2 (Fluent Inc., Lebanon, NH) was employed as the finite volume solver to determine the hemodynamics and shear forces within the healthy vein and patient-specific AVF. Geometrical alterations were evaluated and a CFD analysis was conducted. Substantial geometrical remodeling was observed, following VA creation with an increase in cross-sectional area, out of plane curvature (maximum angle of curvature in AVF=30 deg), and angle of blood flow entry. The mean flow velocity entering the vein of the AVF is dramatically increased. These factors result in complex three-dimensional hemodynamics within VA junction (VAJ) and efferent vein of the AVF. Complex flow patterns were observed and the maximum and mean wall shear stress (WSS) magnitudes are significantly elevated. Flow reversal was found within the VAJ and efferent vein. Extensive geometrical remodeling during AVF maturation does not restore physiological hemodynamics to the VAJ and venous conduit of the AVF, and high WSS and WSS gradients, and flow reversal persist. It is theorized that the vessel remodelling and the continued non-physiological hemodynamics within the AVF compound to result in stenotic lesion development.

Profound and persistent painful paclitaxel peripheral neuropathy in a premenopausal patient

The authors herein report the case of a 35-year-old woman undergoing adjuvant therapy for node positive breast cancer, who presented with short and rapidly progressive history of bilateral lower limb symptoms of peripheral neuropathy following therapy with paclitaxel. MRI of her neural axis revealed no leptomeningeal enhancement or focal metastatic lesions. Neurophysiological tests favoured toxic sensory axonal polyneuropathy. She remains symptomatic following discontinuation of therapy 20 months ago, and is under review with pain management.

Alopecia universalis, hypothyroidism and pituitary hyperplasia: polyglandular autoimmune syndrome III in a patient in remission from treated Hodgkin lymphoma

We herein report a case of a 33-year-old man in remission from Hodgkin lymphoma, who presented with reduced potency and hair loss. Initial endocrine tests revealed autoimmune hypothyroidism. An MRI of his pituitary gland at onset revealed hyperplasia. He tolerated replacement endocrine therapy with good response, but with no improvement in his alopecia universalis. A repeat MRI, 6 months after his initial endocrine manipulation, showed resolution of his pituitary hyperplasia.

Use of finite element analysis in presurgical planning: treatment of mandibular fractures

BACKGROUND

The current clinical procedure for mandible fracture fixation is plate application. 3D reconstructions are used to validate procedures numerically preceding experimental analysis. This study outlines the methods used to reconstruct a numerical model of the mandible.

METHODS

A CT scan from a 22-year-old male patient with a healthy unfractured mandible was obtained. A 3D reconstruction was carried out using Mimics via thresholding and segmentation techniques. Boundary conditions and muscle forces were applied, and simulations were performed using ABAQUS.

RESULTS

3D reconstruction allows for precise anatomical dimensions, which can be used for further engineering analysis. Using the surgical Champy technique as an example, results showed that the mandible model returned to normal function post-plating.

CONCLUSIONS

The study shows the clinical relevance of 3D reconstructions to plan surgical procedures. Results illustrate the benefit of carrying out numerical validations as a prerequisite to experimental modelling and as a method of pre-validating surgical procedures.

Correlation of serum CA125 with stage, grade and survival of patients with epithelial ovarian cancer at a single centre

To evaluate the relationship between serum CA125 tumour marker level before and after surgery of epithelial ovarian carcinoma and assess its potential role as a prognostic factor. A retrospective review of 87 patients with epithelial ovarian carcinoma at a single centre between January 2001 and December 2005 was performed. Serum CA125 levels were assessed for their relationship to pathological stage, tumour grade, tumour volume and age as well as overall survival. A total of 75 patients, mean age 58.94 years and median follow-up of 24 months were included in the analysis. While the preoperative CA125 level did not correlate significantly with stage, tumour grade or survival, the postoperative CA125 correlated to FIGO stage (p<0.0001), tumour grade (p<0.0001) and overall survival (p=0.01). Reduced survival was noted with increasing age at the time of surgery (p=0.009) and bulk of the residual disease postoperatively (p=0.011).

A technique for the computation of lower leg muscle volume from MRI images in the context of venous return

A technique to automatically calculate the volume of a patient's calf muscle using MRI scans in the context of venous insufficiency is presented. Rather than giving a quantifiable measurement of volume, the technique provides a pixel count which can be used to compare the calf muscle volume of one leg of a patient against the other in the context of unilateral leg ulcers or to compare one patient's calf muscle volume against another patient. A custom MATLAB program reads the MRI scans (in the form of JPEG images) and determines the number of pixels (right and left limbs separately) that fall within a user defined gray-scale band, designated as being muscle. The output from the MATLAB program was compared with a manual counting method. The pixel counting algorithm was found to have an acceptable accuracy with results indicating a percentage difference from the manual method of between 2 and 9.5%.

Correlation of serum CA125 levels with stage, grade and survival of patients with epithelial ovarian cancer

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Background: Serum levels of the tumor marker CA125 and its relation to disease stage, grade, tumor volume, survival and prognosis have been studied with conflicting results. This study was conducted in a single center serving a population of 340,000. Methods: Newly diagnosed patients referred between Jan 1 2001 and Dec 31 2005 were included. Serum CA125 levels were recorded before and after optimal debulking surgery and before each cycle of chemotherapy. Patients received standard adjuvant or palliative chemotherapy. Disease was staged using the FIGO staging system. Tumors were graded by the Broders Classification. CT scan within 6 weeks of surgery was used to quantify residual disease. Disease status as of Dec 2006 was used for measurements of overall survival (OS). The relationships between preoperative CA125 and stage, grade and OS were retrospectively evaluated. Post surgical levels of CA125 were also analysed and correlated to the same parameters. The influence of age and bulk of residual disease on OS were also examined. Kaplan- Meier (univariate) analysis was applied for survival analysis and Spearman's method was used to study the correlation of CA125 and the multiple variables. Results: 91 newly diagnosed ovarian cancer referrals were received in the study period. This report is based on the 75 patients of this total group for whom full data was available. Length of follow up ranged from 2 to 71 months (median of 24, mean of 28.2 months). Preoperative CA125 level did not correlate significantly with stage, tumor grade or OS (p=0.08. p=0.113 and p=0.847 respectively). A strong correlation was seen however between postoperative CA125 level (recorded prior to commencement of chemotherapy) and stage, tumor grade and OS (p<0.0001, p<0.0001 and p<0.01respectively) OS for the total group was 37%, and OS for those with stage III and IV disease (n=43) was 17%. The mean age of the patients was 59.6 years. Older age at time of surgery (p=0.009) followed by bulk of residual disease (p=0.011) correlated strongly with shortened OS. Kaplan-Meier curves will be available for presentation. Conclusion: In our study, CA125 levels after optimal surgery correlated well with FIGO stage, tumor grade and overall survival. No correlation was seen with preoperative CA125 levels.

No significant financial relationships to disclose.

Isolated hypoglossal nerve palsy: a harbinger of malignancy

The hypoglossal nerve is an underrated nerve usually consigned to a few words in anatomical text books, under the last four cranial nerves. However, paralysis of this nerve may be the first indication of a serious underlying disorder. Excluding previous surgery, radiotherapy and trauma, 50 per cent of cases of isolated hypoglossal nerve palsy are idiopathic. A further 20 per cent are malignant, 20 per cent are vascular and 10 per cent are due to miscellaneous causes. Presentation of an isolated hypoglossal nerve palsy is therefore an ominous sign. There is confusion over both cause and investigation, and management protocols for isolated hypoglossal nerve palsy are ill-defined. We present a case of isolated hypoglossal palsy which was due to a metastatic skull base deposit. This case illustrates the fact that magnetic resonance imaging is the investigation of choice in assessing the entire course of the hypoglossal nerve.

3-D numerical simulation of blood flow through models of the human aorta

A Spiral Computerized Tomography (CT) scan of the aorta were obtained from a single subject and three model variations were examined. Computational fluid dynamics modeling of all three models showed variations in the velocity contours along the aortic arch with differences in the boundary layer growth and recirculation regions. Further down-stream, all three models showed very similar velocity profiles during maximum velocity with differences occurring in the decelerating part of the pulse. Flow patterns obtained from transient 3-D computational fluid dynamics are influenced by different reconstruction methods and the pulsatility of the flow. Caution is required when analyzing models based on CT scans.

A magnetic resonance imaging-based study of retropubic haematoma after sling procedures: preliminary findings

OBJECTIVE

To determine, using magnetic resonance imaging (MRI), the incidence of retropubic haematoma and any associated clinically significant effects after a xenograft (porcine dermis) sling (XS) or the tension-free vaginal tape (TVT) procedure.

PATIENTS AND METHODS

Between October 2003 and March 2004, 24 consecutive patients presenting with stress urinary incontinence (SUI) were enrolled in this prospective study; 12 each underwent an XS or TVT procedure. A vaginal balloon pack was used for only 3 h after XS and not after TVT. All patients had pelvic MRI 6-8 h after surgery. The primary outcome measure was the incidence and distribution of retropubic haematoma after each sling technique. Secondary outcome measures included the interval to the first three spontaneous voids, the bladder emptying efficiency of the first three voids, a visual analogue scale pain score at 24 h after surgery, and the short-term (6-month) cure rate for SUI.

RESULTS

Overall, six (25%) patients (four XS and two TVT) developed a retropubic haematoma. Most commonly, they spread along the right paravesico-urethral space between the right half of the levator ani and the bladder neck. Patients with large haematomas took significantly longer to void (median 14.5 vs 6.0 h, P = 0.048). There was no difference in pain score in patients with or with no haematoma. None of the patients had clinically detectable haematomas in the suprapubic wound. All six patients with haematomas were cured or improved at the 6-month follow-up.

CONCLUSIONS

MRI is a useful noninvasive method for detecting retropubic haematomas soon after surgery. There was a surprisingly high incidence of retropubic haematomas, especially after the XS procedure. Retropubic haematomas may influence postoperative voiding efficiency.

Metastatic pulmonary ameloblastoma. An unusual case

We present a patient who had a large metastatic pulmonary ameloblastoma resected 25 years after removal of an apparently benign primary ameloblastoma of the jaw. It highlights three areas: problems with the histopathological diagnosis of pulmonary metastases using fine needle aspiration; a noted radiological improvement after a 5-year course of oral cyclophosphamide, in keeping with occasional patients who have responded to chemotherapy; and the technical difficulties of resection of a large pulmonary metastasis, particularly when it is adherent to the mediastinum.

Endovascular exclusion of iliac artery to iliac vein fistula after lumbar disk surgery

Iliac arteriovenous (AV) fistula is rare after lumbar disk surgery. Traditionally, open repair through the arterial lumen was performed. We report endovascular exclusion of an iliac AV fistula in a 41-year-old woman 8 years after lumbar diskectomy. An angiogram showed an AV fistula connecting the right common iliac artery and vein. This was repaired with placement of two covered wall stents in the right common artery and external iliac artery, and embolization of the right internal iliac artery. Contrast medium-enhanced computed tomography scan at 5 months confirmed elimination of the AV fistula and right iliac artery patency. This technique should be considered in management of iliac AV fistulas.

Magnetic resonance imaging appearances of the uterus following microwave endometrial ablation

AIM

Microwave endometrial ablation (MEA) is a treatment for dysfunctional uterine bleeding. It is a second generation ablative technique which is as effective as hysteroscopic methods but quicker and easier to perform. Our aim is to describe the Magnetic Resonance Imaging (MRI) appearances of the uterus following this procedure.

METHODS

15 women underwent MRI immediately before MEA, and again at one day and 4 months after treatment. T1 and T2 sequences were performed at 1.0T using a body coil. Images were assessed by 2 independent observers for quantitative and qualitative changes. Clinical questionnaires were completed before treatment and at 4 months.

RESULTS

On images obtained one day post-ablation, 14 patients had a low signal intensity band subjacent to the treated area of the endometrial cavity on T2 images. Imaging at 4 months showed significant amounts of endometrial tissue in 11 patients, including 3 of the 6 patients who were amenorrhoeic. There were no changes in the appearances of myometrium or uterine dimensions and there were no haematometra.

CONCLUSIONS

The detection of residual endometrium by MRI means that unopposed oestrogen hormone replacement therapy should be avoided after MEA, even in women who have amenorrhoea. Thepost-operative sub-endometrial low signal intensity zone corresponds to the region of tissue necrosis detected on vital staining of the treated uterus in in vivotesting. Depth of tissue destruction is a surrogate marker for clinical effectiveness. MRI may have a role in early assessment of patients participating in clinical research who are undergoing a modified MEA technique while retaining their uterus.

Axillary lymph node metastases: a statistical analysis of various parameters in MRI with USPIO

PURPOSE

To assess the value of plain vs. iron oxide-enhanced MRI vs. the combined study (plain + postcontrast) based on qualitative and quantitative parameters of three pulse sequences.

MATERIALS AND METHODS

Data from two sites were acquired using the same technique; therefore, this data could be pooled. T1W-SE, T2W-FSE, and 3D-PSIF were used before and 24-36 hours after MRI with ultra small particles of iron oxide (USPIO) was performed. A total of 52 lymph nodes (LNs) in nine patients (25 benign, 27 malignant) were evaluated by two readers who were visually and quantitatively blinded to the histology. Combinations of the following diagnostic parameters were compared using logistic regression analysis: the short-axis diameter of the LN, the signal distribution of the LN on postcontrast agent MRI (homogeneous or heterogeneous), and qualitatively and quantitatively determined signal changes of the LN following administration of contrast agent in the three evaluated sequences.

RESULTS

Using pre- and postcontrast data, the optimized accuracy based on the statistically most significant parameters (LN diameter > 6 mm, visual assessment of signal change on T2W-SE) was 87% (81% sensitivity, 92% specificity). Precontrast data alone yielded 75% accuracy (63% sensitivity, 86% specificity). Postcontrast data alone yielded 75% accuracy (56% sensitivity, 96% specificity).

CONCLUSION

Based on our results, USPIO-MRI improved the diagnosis of metastatic axillary LNs compared with precontrast MRI alone. Both pre- and postcontrast studies are needed. T1W-SE and T2W-PSIF did not yield significant additional information. This study may help to further improve the technique of USPIO imaging.

The measurement of fetal liver T(*)(2) in utero before and after maternal oxygen breathing: progress towards a non-invasive measurement of fetal oxygenation and placental function

Utero-placental insufficiency is thought to be a major cause of growth retardation in utero and an important risk factor in the perinatal period. The purpose of this study was to investigate whether MRI could detect changes of fetal oxygenation, based on the blood oxygenation level dependence (BOLD) of the MRI tissue signal. Nine third trimester women (34-38 weeks) with normal pregnancies underwent abdominal MRI examinations. Following localization of the fetal liver using T(2)-weighted single-shot HASTE scans, up to 7 breath-held transaxial single-slice gradient-echo image sets were obtained through the fetal liver. The mother then commenced oxygen breathing with the imaging procedure repeated after 20 minutes of O(2) breathing. For each image set, T(*)(2) values are calculated using linear regression of log (signal) versus TE for a region of interest within the fetal liver selected by the attending radiologist. Fetal liver T(*)(2) values were calculated before and after O(2) breathing for each multi-echo image acquisition set. A signed rank test was used to test for a significant change in fetal liver T(*)(2) between the pre-O(2) and post-O(2) image sets. A significant increase in T*(2) (alpha < 0.05) was seen in 5 of the 9 fetal livers, a smaller increase (of borderline statistical significance, alpha = 0.057) in 2 livers, and no significant change (alpha > 0.05) in 2 livers. Our study indicates that T(*)(2) measurement of the fetal liver may detect alteration in fetal oxygen level following maternal oxygenation using the BOLD effect. This technique may potentially be applied to the identification and understanding of placental dysfunction in intra-uterine growth retardation.

Signs and senses: diagnosis and prognosis in early medieval pulse and urine texts

The character of early medieval medical manuscripts makes it difficult to generalize about the nature of medical knowledge in this period. In order to reconstitute one field of medical science, namely diagnosis and prognosis, while avoiding the pitfalls of unjustified generalization, this essay limits itself to reconstructing the understanding of pulse and urine inspection available in a particular place and time: the Italian monastery of Monte Cassino at the end of the first millennium. The available texts reveal little about the rationale behind these bedside techniques; indeed, pulse and urine seem to be signs without any semiotics, any underlying theory. The clue to this paradox is the fact that these texts see pulse and urine as primarily prognostic rather than diagnostic. Prognosis was understood to be analogous to forms of intuition, judgement, revelation, and prophecy that operated outside the logic of causality. Hence a fully rationalized semiotics was not regarded as necessary for effective medical practice.

Inflammatory abdominal aortic aneurysms: diagnosis with gadolinium enhanced T1-weighted imaging

AIM

Inflammatory abdominal aortic aneurysms (IAAA) are a variant of abdominal aortic aneurysms, which are associated with an increased morbidity. The diagnosis of IAAA has traditionally been established with a combination of clinical and laboratory findings together with contrast enhanced CT. There is a high incidence of renal impairment in this group, and therefore contrast enhanced CT may be harmful.

PATIENTS AND METHODS

Five patients with IAAA underwent T1-weighted spin echo and gradient echo gadolinium enhanced abdominal MRI. A total of eight examinations were performed, including three patients who underwent repeat MRI following steroid therapy.

RESULTS

The inflammatory cuff was clearly identified following gadolinium administration in all eight examinations. The cuff enhanced homogeneously in all patients with no alteration in appearance following steroid therapy. The intravenous administration of gadolinium DTPA enabled clearer definition of locally involved structures.

CONCLUSION

Gadolinium enhanced MRI readily demonstrates features of IAAA. In view of potential renal impairment in this patient group, we recommend this technique in preference to contrast enhanced CT in the initial investigation of inflammatory abdominal aortic aneurysms.

Inventing diagnosis: Theophilus' De urinis in the classroom

This paper shows how the two earliest Latin expositions of Theophilus' De urinis understood diagnosis in different ways. The "Chartres" commentator sees urine as a sign of physiological process and something which is derived from a disease state. By contrast, the Digby commentator is more concerned with how uroscopy functions at the bedside as a tool that enables us to infer disease states from urine. Though they understand the role of diagnosis differently, both commentaries reflect the new intellectual context of twelfth century medicine, where physical signs cease to be mere prognostic omens, and become tools for attaining knowledge of processes otherwise inaccessible to the senses.

Evaluation of 18F-FDG positron emission tomography in gastric and oesophageal carcinoma

The aim of this study was to evaluate 18F-fluoro-deoxyglucose (FDG) positron emission tomography (PET) in gastric and oesophageal carcinoma. 16 patients with biopsy proven oesophageal or gastric carcinoma had PET scans. Four patients had advanced disease and received palliative treatment. The remaining 12 patients were randomized to immediate surgery or neoadjuvant chemotherapy. Three patients had repeat PET scans following chemotherapy. PET detected the primary tumour in all cases including stage T1 lesions. Involved locoregional nodes (N1, N2) were not identified separately from the primary tumour. Semiquantitative analysis was performed in the form of tumour to liver activity ratios (TLR). In general, the TLR values were higher in the higher T stages, although there was only one case each of T1 and T2 lesions. PET scanning using 18F-FDG is a sensitive method for detecting primary oesophageal and gastric cancers but is limited in locoregional staging.

Magnetic resonance imaging in oncology: an overview

This review discusses a growing area of imaging in oncology. Traditionally, the primary role of magnetic resonance imaging (MRI) has been in the investigation of neurological diseases and in the diagnosis of musculoskeletal abnormalities. With the increasing availability of MRI systems and with the advances in technology, the role of this modality out with these areas is rapidly expanding. This review outlines the areas where MRI has a specific role in the imaging of patients with cancer. In particular, emphasis is placed on areas outside of the central nervous and musculoskeletal systems. This review describes the areas where MRI may be advantageous over other imaging modalities such as computerised tomography (CT). Specific emphasis is placed on the staging of abdominal and pelvic malignancies, the detection of recurrence and the impact of MRI in hepatic imaging. In addition this article reviews the value of dynamic contrast enhanced MRI sequences, as well as the importance of newer organ specific MR contrast agents in hepatic and lymph node imaging.

Hickmans in unusual places

Radiologists now commonly insert long-term indwelling right atrial catheters. The insertion of these catheters in patients with limited venous access is a challenging clinical problem. Our experience in dealing with patients with limited venous access from a series of 500 Hickman catheter insertions is presented, as are the problems encountered during the insertion of catheters in patients with anomalies of the venous system.

CT and MRI appearances of a thoracic chordoma

A case of a chordoma in the thoracic spine is presented. This is a very rare tumour in this location and should be considered in the differential diagnosis of any posterior mediastinal mass. The appearances on CT and MRI were similar to chordomas described in other locations. On T2-weighted images septae of low signal intensity radiated throughout the large high-signal mass. This feature may be of use in differentiating chordomas from other posterior mediastinal masses.

Detection of response to chemotherapy using positron emission tomography in patients with oesophageal and gastric cancer

BACKGROUND

The aim of the study was to determine whether 2-[18F]-fluoro-2-deoxy-D-glucose (FDG)-positron emission tomography (PET) could detect response to chemotherapy in patients with oesophageal and gastric cancer.

METHODS

Fourteen patients underwent imaging before and after chemotherapy using FDG-PET. Computed tomography (CT), dysphagia scores and weight changes were used for comparison of evidence of response. Tumour to liver ratios (TLRs) and influx constants for FDG (K) were used for quantification purposes.

RESULTS

Thirteen of 14 lesions were successfully imaged before therapy. Changes were seen in all follow-up scans, ranging from a complete response to a 15 per cent increase in tumour FDG uptake. Response was demonstrated by CT in four patients; all four had large reductions in FDG uptake after chemotherapy. Two patients with an increase in FDG uptake reported no improvement in dysphagia and continued to lose weight during therapy.

CONCLUSION

Changes in tumour FDG uptake were seen in all tumours after chemotherapy. FDG-PET may have a role to play in the assessment of patients with upper gastrointestinal malignancy receiving chemotherapy.

Self-expanding metal stents in the management of colorectal carcinoma--a preliminary report

AIMS

The role of diagnostic imaging in colorectal carcinoma is in the initial diagnosis, staging and detection of complications of the disease. Seven cases of colorectal carcinoma are presented where expandable metallic stents were placed for the management of stenosing lesions in patients with advanced metastatic disease or with serious medical complications which prevented immediate surgery.

RESULTS

Seven patients (five male, two female) with an age range of 51-76 years had expandable metallic stents placed over a 9-month period. All stents were placed successfully with no immediate complications. The stents remained in situ for a range of 7-210 days.

CONCLUSION

Expandable metallic stents can be successfully and safely placed in the colon. These stents may be useful in the management of patients with advanced metastatic disease or in those presenting with large bowel obstruction in which decompression by a stent allows treatment of coexisting medical complications to enable surgery to be carried out at a later date.

Specification and initial evaluation of a multiple application teleradiology system

The digitization and transmission of medical images is becoming increasingly more important and available. The selection of appropriate clinical applications for teleradiology systems is an important factor in determining the success of such ventures. In this paper, the selection of such applications and the evaluation of the teleradiology system is described. The system (LIAISON, CAPTEC Ltd, Malahide, Ireland) is PC based and is capable of digitization and transmission of three categories of medical images: (1) plain film radiographs; (2) CT film data and (3) video sequences such as ultrasound scans. A comprehensive technical evaluation was carried out on the acquisition and display station in which various parameters such as spatial resolution, signal-to-noise ratio (SNR), and distortion were investigated. Results showed that the system performed well within specifications. An exploratory clinical evaluation was performed using a case mix of subtle fractures, chests and dislocations, and CT scans. Here the system performed well with a diagnostic accuracy of 95% for the digital image compared with the analogue image.