Interventional Management of Acquired Lymphatic Disorders

The lymphatic system is a complex network of tissues, vessels, and channels found throughout the body that assists in fluid balance and immunologic function. When the lymphatic system is disrupted related to idiopathic, iatrogenic, or traumatic disorders, lymphatic leaks can result in substantial morbidity and/or mortality. The diagnosis and management of these leaks is challenging. Modern advances in lymphatic imaging and interventional techniques have made radiology critical in the multidisciplinary management of these disorders. The authors provide a review of conventional and clinically relevant variant lymphatic anatomy and recent advances in diagnostic techniques such as MR lymphangiography. A detailed summary of technical factors related to percutaneous lymphangiography and lymphatic intervention is presented, including transpedal and transnodal lymphangiography. Traditional transabdominal access and retrograde access to the central lymph nodes and thoracic duct embolization techniques are outlined. Newer techniques including transhepatic lymphangiography and thoracic duct stent placement are also detailed. For both diagnostic and interventional radiologists, an understanding of lymphatic anatomy and modern diagnostic and interventional techniques is vital to the appropriate treatment of patients with acquired lymphatic disorders. ^©RSNA, 2022.

Transsplenic Portal System Catheterization: Review of Current Indications and Techniques

Multiple diseases of the portal system require effective portal vein access for endovascular management. While percutaneous transhepatic and transjugular approaches remain the standard methods of portal vein access, transsplenic access (TSA) has gained recognition as an effective and safe technique to access the portal system in patients with contraindications to traditional approaches. Recently, the utility of percutaneous TSA has grown, with described treatments including recanalization of chronic portal vein occlusion, placement of stents for portal vein stenosis, portal vein embolization of the liver, embolization of gastric varices, placement of complicated transjugular intrahepatic portosystemic shunts, and interventions after liver transplant. The authors provide a review of percutaneous TSA, including indications, a summary of related portal vein diseases, and the different techniques used for access and closure. In addition, an imaging-based review of technical considerations of TSA interventions is presented, with a review of potential procedural complications. With technical success rates that mirror or rival the standard methods and reported low rates of major complications, TSA can be a safe and effective option in clinical scenarios where traditional approaches are not feasible. ^©RSNA, 2022.

Performance of an algorithm for diagnosing acute cholecystitis using clinical and sonographic parameters

PURPOSE

Identify an algorithm using clinical and ultrasound (US) parameters with high diagnostic performance for acute cholecystitis.

METHODS

Consecutive emergency department (ED) patients from 4/1/2019 to 12/31/2019 were retrospectively reviewed to record non-US parameters and make US observations. Outcomes were categorized as either: (1) acute cholecystitis; or (2) negative acute cholecystitis. Pivot tables identified parameter combinations either not found with acute cholecystitis or with predictive value for acute cholecystitis to establish the algorithm. US Division radiologists finalized an US report prior to ED disposition without use of the algorithm. Radiologist impression and algorithm prediction for acute cholecystitis were categorized as either (1) acute cholecystitis; (2) negative acute cholecystitis; or (3) inconclusive.

RESULTS

Three hundred and sixty-six studies on 357 patients (mean age, 51 yrs ± 20 yrs; 215 women) met the inclusion criteria. 10.9% (40/366) of US studies had acute cholecystitis, 12.6% (46/366) had pathologically identified chronic cholecystitis without acute cholecystitis, and 76.5% (280/366) were negative acute cholecystitis. Algorithm compared to radiologist diagnostic performance was as follows: (1) sensitivity: 90.0% vs. 55.0%, p < 0.001; (2) augmented sensitivity (defined as when inconclusive categorization is considered consistent with acute cholecystitis): 100% vs. 85.0%, p < 0.001; (3) specificity: 93.6% vs. 94.8%, p = 0.50; (4) diagnostic rate (opposite of inconclusive rate): 96.4% vs. 93.2%, p = 0.04; (5) adverse outcome rate: 0.0% vs. 1.6%, p undefined.

CONCLUSION

For acute cholecystitis, an algorithm using non-binary ultrasound and clinical assessments had higher sensitivity, higher diagnostic rate, and fewer adverse outcomes, than subspecialty radiologist impressions.

Percutaneous Image-Guided Ablation of Lung Tumors

Tumors of the lung, including primary cancer and metastases, are notoriously common and difficult to treat. Although surgical resection of lung lesions is often indicated, many conditions disqualify patients from being surgical candidates. Percutaneous image-guided lung ablation is a relatively new set of techniques that offers a promising treatment option for a variety of lung tumors. Although there have been no clinical trials to definitively compare its efficacy to those of traditional treatments, lung ablation is widely practiced and generally accepted to be safe and effective. Especially encouraging results have recently emerged for cryoablation, one of the newer ablative techniques. This article reviews the indications, techniques, contraindications, and complications of percutaneous image-guided ablation of lung tumors with special attention to cryoablation and its recent developments in protocol optimization.

Single-Center Review of Celiac Plexus/Retrocrural Splanchnic Nerve Block for Non-Cancer Related Pain

RATIONALE AND OBJECTIVES

Celiac plexus and retrocrural splanchnic nerve (CP/RSN) blocks are widely used for cancer-related abdominal pain, but there is limited literature on their efficacy for non-cancer related pain. Our aim was to determine the indications and effectiveness of CT-guided CP/RSN blocks performed on patients with abdominal pain from non-cancer related sources.

MATERIALS AND METHODS

CT-guided CP/RSN blocks for non-cancer related abdominal pain from 2011-2020 were retrospectively reviewed for patient demographics, procedure details, duration of pain relief, and complications. Effective blocks were defined as patient-reported pain relief or decrease in opioid use lasting 2 or more days for temporary blocks and 14 or more days for permanent blocks.

RESULTS

Of 72 CT-guided CP/RSN blocks for non-cancer related abdominal pain, 48 (67%) were effective for a mean of 51 days (median 14, range 2-700). Of the 18 permanent blocks, 9 (50%) were effective for a mean of 111 days (median 90, range 14-390). Of the 54 temporary blocks, 39 (72%) were effective for a mean of 37 days (median 9, range 2-700). Indications included postural orthostatic tachycardia syndrome/dysautonomia (77% effective, 20/26), pancreatitis (86% effective, 12/14), postsurgical pain (62% effective, 8/13), median arcuate ligament syndrome (70% effective, 7/10), chronic pain syndrome (20% effective, 1/5), gastroparesis (80% effective, 4/5), and renal cystic disease (33% effective, 1/3). For postural orthostatic tachycardia syndrome /dysautonomia, pancreatitis, post-surgical pain, and MALS, there were no statistically significant differences in effectiveness between celiac vs. splanchnic blocks in groups matched by indication and intended duration (temporary/permanent).

CONCLUSIONS

CT-guided CP/RSN blocks can effectively manage non-cancer related abdominal pain, though there is discrepancy in efficacy between temporary and permanent blocks.

Added Benefit and Risk of an Additional Biopsy or Targeting With Contrast-Enhanced Ultrasound for Patients With Renal Transplants

OBJECTIVES

To determine whether renal transplant diagnoses substantially change when 2 biopsy sites are chosen and whether contrast-enhanced ultrasound (CEUS) has value for targeting the second site.

METHODS

We prospectively enrolled 40 patients undergoing ultrasound-guided renal transplant biopsy within 2 years of transplant: 20, surveillance; and 20, for cause. A CEUS examination was performed to identify cortical regions with subjectively altered flow. One biopsy was performed at the operator-preferred (primary) site regardless of CEUS findings. Another biopsy was done at a second location, either targeted to an area in which CEUS perfusion findings differed from the primary site (targeted) or at a random location (secondary) if no other area differed. Specimens were randomly labeled A or B; pathologists were blinded to the CEUS result and biopsy location. Location-specific CEUS assessments were recorded. Pathologic results were compared, including acute and chronic Banff scores and any new findings from the targeted or secondary biopsy.

RESULTS

Forty patients were enrolled between January 2016 and December 2018. No location-specific pathologic differences correlated with differences in CEUS assessments. The second biopsy provided additional information that changed management in 4 of 40 patients (10.0% [95% confidence interval, 2.8%-23.7%]). Major bleeding complications occurred in 3 of 40 (7.5%) patients.

CONCLUSIONS

Contrast-enhanced ultrasound targeting was not useful. Major bleeding complications were higher than expected, possibly due to the additional biopsy away from the operator-preferred location. Obtaining a second renal transplant biopsy from a substantially different area than the initial operator-preferred location provided additional clinically useful information in 10% of patients.

Correction to: Ultrasound-guided renal transplant biopsy: practical and pragmatic considerations

The original version of this article unfortunately contained an error. Though one of the coauthor names correctly appeared in the published version, it is incorrectly displayed in indexing sites due to a tagging error in metadata.

Use of a steerable needle for CT-guided nerve plexus blockade

PURPOSE

Demonstrate the use of a new steerable needle for CT-guided neural plexus blockade to avoid traversing the kidneys.

MATERIALS AND METHODS

Retrospective evaluation of 23 consecutive CT-guided neural plexus blockade procedures in which a new steerable needle was used in the last 13 and compared with the prior 10 procedures in which a standard needle was used.

RESULTS

Use of the steerable needle was beneficial to reach the target area without traversing a kidney or other organs in 6/13 (46%) procedures; in the other 7 procedures there was no benefit. A kidney was traversed in 0/13 procedures performed with the steerable needle. In contrast, a kidney was traversed in 4/10 (40%) procedures using a standard needle (P = 0.02). There was no significant difference in clinical benefit (P = 1.00) or complications (P = 0.56) between procedures using the steerable needle versus a standard needle. Three complications were observed (1 major and 2 minor) felt to be related to the injection and not the needle type.

CONCLUSIONS

The utility of a steerable 21-gauge needle during neural plexus blockades was found to allow for avoidance of the kidneys when compared to a standard (non-steerable) needle. Interventional radiologists may find this needle and its future iterations useful for neural blockades, as well as other procedures, when intervening structures need to be avoided.

LEVEL OF EVIDENCE

Level 3, Non-randomized controlled cohort.

Ultrasound-guided renal transplant biopsy: practical and pragmatic considerations

Sonographically guided percutaneous core biopsy of renal allografts has been performed for decades, providing valuable information in monitoring the status of normally functioning renal transplants as well as investigating the cause of renal transplant dysfunction. This article reviews practical aspects of biopsy technique using the cortical tangential approach, with consideration of factors that may influence biopsy success, including selection of biopsy device. Clinically important complications from renal transplant biopsy are uncommon; the most recent experience for one institution is analyzed in the context of existing evidence regarding the frequency and timing of these major complications, to understand pragmatic implications for peri-procedural care.

Colorectal-Vaginal Fistulas: Imaging and Novel Interventional Treatment Modalities

Colovaginal and/or rectovaginal fistulas cause significant and distressing symptoms, including vaginitis, passage of flatus/feces through the vagina, and painful skin excoriation. These fistulas can be a challenging condition to treat. Although most fistulas can be treated with surgical repair, for those patients who are not operative candidates, limited options remain. As minimally-invasive interventional techniques have evolved, the possibility of fistula occlusion has enriched the therapeutic armamentarium for the treatment of these complex patients. In order to offer optimal treatment options to these patients, it is important to understand the imaging and anatomical features which may appropriately guide the surgeon and/or interventional radiologist during pre-procedural planning.

Developing Interventional Radiology Anticoagulation Guidelines: Process and Benefits †

We created, posted, and updated radiology department anticoagulation guidelines and identified various steps in the process, including triggering events, consensus building, legal analysis, education, and distribution of the guidelines to nurses and clinicians. Supporting data collected retrospectively, before and after implementation, included nursing satisfaction survey results and the number of procedure cancellations. After the guidelines were developed and posted, significantly fewer procedures were cancelled, nursing satisfaction was higher, and radiologists performed procedures with less variability. Anecdotally, radiologists had fewer queries about anticoagulation. The development and dissemination of radiologic procedure anticoagulation guidelines should be considered as a departmental quality improvement project.

Rationale for catheter directed therapy in pulmonary embolism

Pulmonary embolism (PE) is a widespread health concern associated with major morbidity and mortality. Catheter directed therapy (CDT) has emerged as a treatment option for acute PE adding to the current potential options of systemic thrombolysis or anticoagulation. The purpose of this review is to understand the rationale and indications for CDT in patients with PE. While numerous studies have shown the benefits of systemic thrombolysis compared to standard anticoagulation, these are balanced by the increased risk of major bleeding. With this in mind, CDT has the potential to offer the benefits of systemic thrombolysis and in theory, a reduced risk of bleeding. This article will review current treatment guidelines in both massive and submassive PE evaluating both short and long term benefits. The role of CDT will be highlighted, with an emphasis on efficacy and safety.

Peri-procedural use of anticoagulants in radiology: an evidence-based review

Peri-procedural anticoagulant management hinges on the balance of hemorrhagic and thrombotic complications. The radiologist is tasked with accurately assessing the hemorrhagic risk for patients undergoing procedures, taking into account procedural bleeding rates, underlying coagulopathy based on lab tests, and use of anticoagulants. The purpose of this article is to provide a contemporary review of commonly used anticoagulants and, incorporating published evidence, review their management related to image-guided procedures.

Detection of transplant renal artery stenosis: determining normal velocities at the renal artery anastomosis

PURPOSE

Renal artery anastomosis peak systolic velocity (RAA PSV) exceeding 250 cm/s and a ratio of the renal artery to the adjacent external iliac artery (RAA:EIA) exceeding 1.8 historically suggest significant transplant renal artery stenosis (TRAS). However, the range of RAA PSV in transplants without TRAS has not been established.

METHODS

A retrospective review of renal transplants at a single institution over 5 years was performed identifying patients without graft dysfunction, failure, or refractory hypertension. RAA PSV obtained during interval postoperative sonograms was recorded.

RESULTS

Of 1141 patients, 844 met the inclusion criteria. Mean RAA PSV for 377 patients evaluated within 2 days of transplant measured 195 cm/s; RAA PSV exceeded 250 cm/s in 97 patients (26%). Mean RAA PSV for 820 patients evaluated 1-month post-transplant measured 206 cm/s; RAA PSV exceeded 250 cm/s in 224 patients (27%). Mean RAA PSV for 785 patients evaluated 4-month post-transplant measured 203 cm/s; RAA PSV exceeded 250 cm/s in 201 patients (26%). Mean RAA PSV for 766 patients evaluated 1-year post-transplant measured 189 cm/s; RAA PSV exceeded 250 cm/s in 141 patients (18%). At each of the given time points, 24%-34% of normal patients had RAA-to-EIA ratios greater than 1.8.

CONCLUSION

Approximately, 26% of patients without TRAS have RAA PSV > 250 cm/s in the first 9 months, and 18% do at 1 year. Similar findings also occurred with regards to the RAA-to-EIA ratio threshold of 1.8. In isolation, a PSV over 250 cm/s or 1.8 ratio threshold for suspicion of TRAS will lead to a large number of false-positive assessments.

Ex Vivo Renal Stone Characterization with Single-Source Dual-Energy Computed Tomography: A Multiparametric Approach

RATIONALE AND OBJECTIVES

We aimed to investigate a multiparametric approach using single-source dual-energy computed tomography (ssDECT) for the characterization of renal stones.

MATERIALS AND METHODS

ssDECT scans were performed at 80 and 140 kVp on 32 ex vivo kidney stones of 3-10 mm in a phantom. True composition was determined by infrared spectroscopy to be uric acid (UA; n = 14), struvite (n = 7), cystine (n = 7), or calcium oxalate monohydrate (n = 4). Measurements were obtained for up to 52 variables, including mean density at 11 monochromatic keV levels, effective Z, and multiple material basis pairs. The data were analyzed with five multiparametric algorithms. After omitting 8 stones smaller than 5 mm, the remaining 24-stone dataset was similarly analyzed. Both stone datasets were also analyzed with a subset of 14 commonly used variables in the same fashion.

RESULTS

For the 32-stone dataset, the best method for distinguishing UA from non-UA stones was 97% accurate, and for distinguishing the non-UA subtypes was 72% accurate. For the 24-stone dataset, the best method for distinguishing UA from non-UA stones was 100% accurate, and for distinguishing the non-UA subtypes was 75% accurate.

CONCLUSION

Multiparametric ssDECT methods can distinguish UA from non-UA stones of 5 mm or larger with 100% accuracy. The best model to distinguish the non-UA renal stone subtypes was 75% accurate. Further refinement of this multiparametric approach may increase the diagnostic accuracy of separating non-UA subtypes and assist in the development of a clinical paradigm for in vivo use.

Factors Contributing to the Success of Ultrasound-Guided Native Renal Biopsy

OBJECTIVES

The purpose of this study was to evaluate factors contributing to the success of ultrasound-guided native renal biopsy.

METHODS

We retrospectively identified patients who had ultrasound-guided native renal biopsy at our institution over a 10-year period. We reviewed the imaging and electronic medical records to collect demographic information and clinical data, including pathologic results. Biopsy samples were categorized and compared on the basis of the number of glomeruli (optimal [≥20] versus suboptimal [<20]) and the pathologist's reported diagnostic confidence (high confidence versus limited confidence). Procedure details, including the operator and the use of the cortical tangential approach, were also obtained.

RESULTS

For 282 patients with biopsies using 18-gauge needles, the number of passes made was significantly higher for optimal (P < .001) and high-confidence (P < .001) specimens than for suboptimal and limited-confidence specimens. The cortical tangential approach was used more frequently for optimal (P< .001) and high-confidence (P = .01) specimens than for suboptimal and limited-confidence specimens. Radiologists routinely doing ultrasound-guided procedures of all types had significantly more optimal (P= .01) and high-confidence (P= .001) specimens than radiologists with limited ultrasound experience. The distance to the kidney, cortical thickness, glomerular filtration rate, and body mass index were not significant factors.

CONCLUSIONS

The ultrasound-guided procedural experience of the operator, taking more than 1 specimen, and the use of the cortical tangential approach significantly improved the pathologic material obtained during native renal biopsies.

The accordion sign in the transplant ureter: ramifications during balloon dilation of strictures

PURPOSE

This study was designed to demonstrate the accordion sign within the transplant ureter and evaluate its ramifications during balloon dilation of strictures.

METHODS

A retrospective electronic chart and imaging review included demographic characteristics, procedure reports, and complications of 28 renal transplant patients having ureteral strictures treated with percutaneous balloon dilation reported in our transplant nephrology database during an 8-year period. The accordion sign was deemed present or absent on the basis of an imaging review and was defined as present when a tortuous ureter became kinked and irregular when foreshortened after placement of a wire or a catheter. Procedure-related urine leaks were categorized as occurring at the stricture if within 2 cm; otherwise, they were considered away from the stricture.

RESULTS

The accordion sign was associated with a significantly greater occurrence of leaks away from the stricture (P = 0.001) but not at the stricture (P = 0.34).

CONCLUSIONS

The accordion sign is an important consideration when performing balloon dilation procedures on transplant ureteral strictures, given the increased risk of leak away from the stricture. Its presence should prompt additional care during wire and catheter manipulations.

Partial preparation computed tomographic colonography: a feasibility study

We retrospectively evaluated computed tomographic colonography examinations of patients who have had a partial bowel preparation and compared the quality of their preparation with patients who have had a full bowel preparation. In total, 27 patients undergoing computed tomographic colonography examination (10 patients with partial bowel preparation and 17 with full bowel preparation) had their examinations retrospectively reviewed by three independent radiologists in a blinded manner, with evaluation of residual stool, distention, residual fluid, and overall bowel preparation quality. Six colon segments were evaluated individually and independently for these four variables (a total of 161 segments tested). Comparisons were made with the Mann-Whitney test between the partial preparation group and the full preparation group. Partial preparation included stool and fluid tagging plus 20 mg of bisacodyl orally; full preparation included stool and fluid tagging plus 2 L of polyethylene glycol solution. No significant clinical difference was found in colon preparation between the partial and full bowel preparation groups--when evaluated with individual colon segments or by independent readers. Interreader correlation was high. This pilot study indicates that full bowel preparation is not required for diagnostic-quality computed tomographic colonography examination. Further evaluation of this partial bowel preparation regimen is warranted.

Direct percutaneous embolization of bleeding stomal varices

Stomal variceal bleeding can develop in patients with underlying cirrhosis and portal hypertension. Most patients are best treated with transjugular intrahepatic portosystemic shunt (TIPS) creation because this addresses the underlying problem of portal hypertension. However, some patients are not good candidates for TIPS creation because they have end-stage liver disease or encephalopathy. We describe such a patient who presented with recurrent bleeding stomal varices, which was successfully treated with percutaneous coil embolization. The patient had bleeding-free survival for 1 month before death from unrelated causes.

Carotid pseudostring sign from vasa vasorum collaterals

OBJECTIVE

To describe the spectral and color Doppler imaging findings in 2 cases of internal carotid artery occlusion with vasa vasorum collateral flow, which we term the "pseudostring sign."

METHODS

Spectral and color Doppler imaging findings in both cases were reviewed. Magnetic resonance angiography in 2 cases and conventional angiography in 1 case were also reviewed.

RESULTS

Both patients had color Doppler images showing that the internal carotid artery was a narrow, stringlike vessel with arterial flow that had normal spectral Doppler features (velocity < 125 cm/s with a normal waveform). Magnetic resonance angiography in 1 patient showed total occlusion of the proximal internal carotid artery with patent vasa vasorum collaterals reconstituting the lumen distally. In the second patient, magnetic resonance angiography showed total occlusion of the proximal internal carotid artery, and conventional angiography showed proximal occlusion with collateral flow through the vasa vasorum.

CONCLUSION

Proximal internal carotid artery occlusion with vasa vasorum collateral flow should be considered when color Doppler imaging shows a seemingly narrow internal carotid artery with tortuosity and normal spectral Doppler features. Patients with these features should not undergo carotid endarterectomy directly on the basis of only the Doppler findings.

Three-dimensional reconstruction of magnetic resonance images of the anal sphincter and correlation between sphincter volume and pressure

OBJECTIVE

The purpose of this study was to assess the correlation between internal and external anal sphincter volumes and manometric anal pressures.

STUDY DESIGN

Ten healthy nulliparous women underwent anal sphincter magnetic resonance imaging and anal manometry measurement. A 3-dimensional reconstruction of magnetic resonance images was accomplished with the use of 3-dimensional slicer. Sphincter volumes were measured 3 times by the same observer for each of 10 patients. The intrarater reliability was measured with the use of the intraclass correlation coefficient (ICC = sigma (2)(patients)/(sigma (2)(patients) + sigma (2)(error))) from a 2-way analysis of variance model with terms for patient and measurement trial. Measurements that were recorded on anal manometry included squeeze length, length of the high-pressure zone, and maximal resting and squeeze pressures.

RESULTS

The mean volumes (+/- SD) were 18.77 +/- 4.64 cm(3), 13.82 +/- 3.8 cm(3), and 32.36 +/- 8.37 cm(3) for internal, external, and combined sphincters, respectively. Intrarater reliability was 98% for external sphincter volume (95% CI, 94%-99%), 98% for internal sphincter volume (95% CI, 94%-99%), and 99% for total volume (95% CI, 97%-100%). On the 3-dimensional images, the internal sphincter was found to be cylindric in shape, with an ellipse as a base. It is elongated in the anterior and posterior direction and flattened on the sides. The external sphincter was found to be funnel-shaped, being narrower caudad and widening in the cephalad direction. Similar to the internal sphincter, the external sphincter is elongated in the anteroposterior diameter. Volumes of the internal, external, and combined sphincters did not correlate with the maximum pressures at rest and squeeze. Correlations higher than r = 0.5 were observed for all 3 sphincter volume measurements versus high pressure zone at squeeze. The highest correlation, r = 0.66, was for internal sphincter volume versus high pressure zone at squeeze

CONCLUSION

Three-dimensional reconstruction of the rectal sphincter musculature can be performed easily with 3-dimensional software. Measurements of the sphincter volumes have excellent intrarater reliability. Sphincter volumes do not correlate with pressures at rest or squeeze, but the internal sphincter volume correlates with the length of the high pressure zone at squeeze. Contrary to current generalized concepts, it is possible that the internal sphincter may play some role in generating the squeeze pressure. More research is necessary in applying 3-dimensional magnetic resonance image reconstruction in patients with different parity and continence status. Reconstruction of magnetic resonance images of the rectal sphincter musculature may prove to be beneficial in planning the treatment of patients with fecal incontinence.

Salvage brachytherapy for localized prostate cancer after radiotherapy failure

OBJECTIVES

To evaluate the effectiveness and morbidity of salvage brachytherapy for locally recurrent or persistent prostate cancer after radiotherapy failure.

METHODS

In this retrospective study, 49 patients of median age 73.3 years (range 52.9 to 86.9) with biopsy-proven localized prostate cancer underwent interactive transperineal fluoroscopic-guided and biplane ultrasound-guided brachytherapy with either iodine 125 or palladium 103 after prior radiotherapy failure. Post-treatment follow-up was conducted for a median of 64.1 months (range 26.6 to 96.8) and included clinical assessment of disease status, assays of serum prostate-specific antigen (PSA) levels, and documentation of treatment-related symptoms and complications. Determination of biochemical treatment failure was based on two successive rising PSA values above the post-treatment PSA nadir value.

RESULTS

The actuarial rate of local prostate cancer control was 98% (95% confidence interval [CI] 94% to 99%). Actuarial disease-specific survival at 3 and 5 years was 89% (95% CI 73% to 96%) and 79% (95% CI 58% to 91%), respectively. At 3 and 5 years, actuarial biochemical disease-free survival was 48% (95% CI 32% to 63%) and 34% (95% CI 17% to 51%), respectively. Post-treatment PSA nadir was found to be a significant predictor of biochemical disease-free survival. Actuarial biochemical disease-free survival of patients who achieved a PSA nadir less than 0.5 ng/mL was 77% (95% CI 53% to 90%) and 56% (95% CI 25% to 78%) at 3 and 5 years, respectively. Of 49 patients, 23 (47%) achieved a post-treatment PSA nadir less than 0.5 ng/mL. The incidence of serious complications after salvage brachytherapy, such as incontinence and rectal complications, was lower than that reported after other types of salvage procedures.

CONCLUSIONS

Interactive transperineal fluoroscopic-guided and biplane ultrasound-guided brachytherapy is a novel, potentially curative salvage modality for patients in whom prior radiotherapy failed. In a population of patients with poor prognosis, this modality was associated with a high rate of local prostate cancer control and a 34% actuarial rate of biochemical disease-free survival at 5 years. The incidence of major complications after salvage brachytherapy appears to be lower than that after other potentially curative salvage procedures, such as radical prostatectomy and cryoablation. Salvage brachytherapy warrants further investigation.

Actuarial disease-free survival after prostate cancer brachytherapy using interactive techniques with biplane ultrasound and fluoroscopic guidance

PURPOSE

To evaluate the effectiveness and safety of interactive transperineal brachytherapy under biplane ultrasound and fluoroscopic guidance in patients with localized prostate cancer.

METHODS AND MATERIALS

Brachytherapy using 125I or 103Pd radioactive seeds either alone or in combination with adjunctive external beam radiotherapy (XRT) was administered to 490 patients at a single institution. Post-treatment follow-up included clinical assessment of disease status, assays of serum prostate-specific antigen (PSA) levels and documentation of treatment-related symptoms and complications.

RESULTS

Actuarial disease-free survival at 5 yr was 79% (95% CI, 71-85%), and the 5-yr actuarial rate of local control was 98% (95% CI, 94-99%). Post-treatment PSA nadir and pretreatment PSA level were found to be significant predictors of disease-free survival. In patients with a PSA nadir < 0.5 ng/ml, 5-yr disease-free survival was 93% (95% CI, 84-97%), compared with 25% (95% CI, 5-53%) in patients whose PSA nadir was 0.5-1.0 ng/ml and 15% (95% CI, 3-38) in patients with a PSA nadir > 1.0 ng/ml. Brachytherapy was well tolerated with few post-treatment complications.

CONCLUSION

A broad range of patients with localized prostate cancer can benefit from transperineal brachytherapy with minimal morbidity. A post-treatment PSA nadir below 0.5 ng/ml provides a useful prognostic indicator of favorable long-term outcome.

Anatomic and physiologic measurements of the internal and external anal sphincters in normal females

OBJECTIVE

To assess the correlation between anal sphincter magnetic resonance imaging (MRI) measurements and manometric anorectal vectography pressures.

METHODS

Ten healthy, nulliparous women underwent anal sphincter MRI with examination of sagittal, axial oblique, and coronal planes. Anal manometry was performed with a radial eight-channel catheter. Customary functional measurements were recorded, including anterior and posterior sphincter length, squeeze length, length of the high-pressure zone, and maximal resting and squeeze pressures. The Spearman rank correlation coefficient was used to assess correlation.

RESULTS

The manometric squeeze length and the manometric length to maximum squeeze pressure were correlated negatively with the posterior sphincter length by MRI (P = .049 and .044, respectively). The manometric high-pressure zone squeeze length was correlated positively with the posterior sphincter length by MRI (P = .042). The mean +/- standard deviation (SD) posterior sphincter length was 27.3 +/- 6.0 mm. Anatomically, the cylindric shape of the anal sphincter is characterized by a gradual increase in muscle thickness cephalad. The external striated sphincter was much thicker posteriorly (24.7 +/- 4.6 mm) than anteriorly (6.6 +/- 1.7 mm) in the proximal or caudal third. The proximal internal smooth muscle sphincter was nearly equal in thickness anteriorly and posteriorly (9.0 +/- 1.4 mm and 9.6 +/- 1.7 mm, respectively). Although variation in the thickness of both the smooth and striated muscle was found, manometric pressures did not correlate with the muscle thickness along the sphincter.

CONCLUSION

The length of the anal sphincter correlated positively with the functional information, as determined by manometry. An anal sphincter length of 3 cm is consistent, from an anatomic and functional view, in these ten normal women.

Renal artery stenosis: analysis of Doppler waveform parameters and tardus-parvus pattern

PURPOSE

The utility of Doppler parameters and waveform contour analysis for diagnosis of renal artery stenosis was studied in a hypertensive population screened for renovascular hypertension.

MATERIALS AND METHODS

The Doppler results were compared with those obtained with angiography in a prospective double-blind study involving 118 kidneys in 46 patients with hypertension and 11 potential renal donors with normal blood pressure. Doppler parameters measured in the distal renal artery included systolic acceleration, acceleration time, peak systolic velocity, deceleration in late systole, pulsatility and resistivity indexes, and waveform features in early systole.

RESULTS

Angiograms demonstrated 28 stenotic renal arteries. There was no significant difference between stenotic (> 50% diameter narrowing) and nonstenotic renal arteries for any parameters studied. When stenosis was further categorized as moderate (50%-79%) or severe (80%-95%), significant (P < .05) differences for acceleration time and systolic acceleration were found between nonstenotic and severely stenotic arteries.

CONCLUSION

Doppler characterization of the tardus-parvus phenomenon in the distal renal artery is not an adequate screening method for detection of renal artery stenosis.

MR imaging of fat in and around the heart

MR imaging is useful for characterizing collections of fat in and around the heart. This article illustrates the MR appearance of pericardial fat, epicardial and periaortic fat, intramural fatty involvement and intracavitary fat, with emphasis on the distinctions between fatty and nonfatty tumors.

Erosive spondyloarthropathy in long-term dialysis patients: relationship to severe hyperparathyroidism

We describe the development of a destructive, erosive spondyloarthropathy in three long-term dialysis patients (mean duration of dialysis, 96 months). In all three patients, the lesions caused symptomatic vertebral pain and developed during a period of only a few months. All patients had extremely elevated levels of immunoreactive parathyroid hormone, and two patients had evidence of severe hyperparathyroidism on bone biopsy specimens. Two patients who underwent subtotal parathyroidectomy had rapid relief of symptoms and no further radiographic evidence of progression of the spondyloarthropathy. The third patient refused subtotal parathyroidectomy and had pronounced progression of the destructive spondyloarthropathy in the cervical spine. The limited experience of others, along with our currently reported findings, strongly suggests that hyperparathyroidism plays a major role in the development of this disorder. Erosive spondyloarthropathy is increasingly recognized in long-term dialysis patients and may be a unique clinical and radiographic manifestation of severe hyperparathyroidism in this population.

Aluminum toxicity in patients undergoing dialysis: radiographic findings and prediction of bone biopsy results

Aluminum toxicity in patients undergoing dialysis currently requires bone biopsy for definitive diagnosis. The authors retrospectively reviewed clinical, histologic, and radiographic findings in 63 patients undergoing dialysis. In 30 patients, biopsy specimens were negative for aluminum toxicity, and in 33 patients, specimens were positive. In 21 of the 30 patients who had a negative biopsy specimen, absence of aluminum toxicity could be predicted by a high immunoreactive parathyroid hormone level (greater than 2,000 microliter Eq/ml [2,210 pM]) and fewer than three fractures, by the presence of osteosclerosis on radiographs, or if serum aluminum levels were less than 30 ng/ml. None of the patients who had a positive biopsy specimen met these criteria. In 18 of 33 patients who had a positive biopsy specimen, aluminum toxicity could be predicted by a low immunoreactive parathyroid hormone level (less than 500 microliter Eq/ml [553 pM]) and more than three fractures, or if serum aluminum levels were greater than 300 ng/ml. None of the patients who had a negative biopsy specimen met these criteria. Thus, based on the criteria identified, the aluminum status of 62% of these patients would have been correctly diagnosed.