CT findings in tuberculous otomastoiditis: A case report

Purpose: Otomastoiditis is a rare but important manifestation of tuberculosis and is well recognizable when information on its clinical course is considered in connection with the radiographic changes.

Material and Method: A patient with a clinical history of chronic otorrhea, resistant to conventional therapy but without dramatic symptoms, was referred for CT examination.

Results: CT revealed widespread soft tissue densities in the tympanic cavity and in the mastoid process, with bone erosions in the latter. Surgery and bacteriology confirmed the diagnosis of Mycobacterium tuberculosis infection.

Conclusion: CT evidence of widespread bone destruction without clinical signs of aggressive infection should suggest the diagnosis of a mycobacterial process. Early treatment is essential in order to avoid propagation of the disease and lasting loss of function.

Anatomic Variations of the Cochlea and Relations to other Temporal Bone Structures

A thorough knowledge of the normal range of variation of anatomy and topography of the cochlea is necessary for optimal reproduction of this structure and correct interpretation of the radiographs. Radiographic identification of incomplete cochlear coils is essential in the diagnosis of congenital malformations such as Modini's deformity. Furthermore, a diagnosis of otosclerosis/otospongiosis has to be based on recognition of changes in the otic capsule. The size and shape of the human cochlea and the normal ranges of variation of its dimensions were evaluated in 95 plastic casts, prepared from temporal bone specimens. The normal range of variation is fairly small, and is not age-dependent. Obvious digression from this range, associated with pertinent clinical symptoms, indicates an abnormality.

Caroli's Disease in Two Sisters

Caroli's disease is a rare congenital disease with multiple segmental dilatations of the bile ducts. It may present in two forms: one (the simple form) with segmental dilatations only, and the other with dilatations combined with fibroangioadenomatosis, frequently complicated by portal hypertension. The disease is thought to be recessively inherited, but few familial cases have been reported. We have observed two sisters with the disease, one with the simple form, the other with fibroangioadenomatosis. Their case histories and diagnostic findings, with special reference to ultrasonography and computed tomography, are presented, and the potential for diagnosis by different imaging modalities is discussed.

Cavitary Pulmonary Nodules in Atypical Collagen Disease and Lupoid Drug Reaction

The case histories of two patients with cavitary pulmonary nodules and the findings at chest radiography are reviewed. The first patient had a connective tissue disease with features common to systematic lupus erythematosus and Wegener's granulomatosis. In the second patient the lung changes developed as part of a drug reaction to carbamezapine and/or phenytoin. The common denominator of the cavitating nodules is probably the presence of granulomas, developing as a sequela of pulmonary vasculitis.

Osteoid Osteomas of the Hand

Osteoid osteoma is infrequently localized to the hand. Initially the lesion causes unspecific symptoms, and the radiographic changes are discrete. Three cases were seen during a period of 5 years. Bone scintigraphy was a useful diagnostic tool, and CT facilitated the identification of the nidus. One of the lesions was a double nidus osteoid osteoma of the scaphoid bone. Only 12 instances of multifocal osteoid osteomas have been reported, none of which was localized to the carpal bones.

The Cochlea and the Carotid Canal

The carotid canal conveys a large artery and lies in close topographic relationship to the basal turn of the cochlea. The bony wall between them consists in some cases only of the petrous bone of the otic capsule. It can be as thin as 0.2 mm. In other cases the distance can be more than 6 mm. A systematic assessment of the relationship between these two structures was performed on plastic casts of 173 human temporal bone specimens in order to investigate the range of normal variation. The topography in this region can be visualized by multidirectional tomography or CT.

Unilateral Hydronephrosis with Congenital Absence of Contralateral Kidney in Children

The case histories of six children with absence of functioning renal parenchyma on one side and dilatation of the contralateral pelvis are reviewed. The hydronephrosis was obstructive in two cases. In the others no cause could be found. The development of this combination of renal malformations is discussed against an embryologic background.

CT-Diagnosis of Deep-Seated Lipomas with Alarming Symptoms

Deep-seated lipomas can present with symptoms very different from those of the common subcutaneous variety. Rapid growth and nerve encroachment may cause suspicion of malignancy. The case histories as well as the clinical and radiographic findings of 2 patients with alarming symptoms from deep-seated lipomas of hand and forearm, respectively, are described. By means of CT an accurate preoperative diagnosis could be made, and surgery planned accordingly.

Diagnosis by Ultrasound of Dislocated Ulnar Collateral Ligament of the Thumb

The ability of ultrasound to assess a displaced ulnar collateral ligament of the 1st metacarpo-phalangeal (MCP) joint was evaluated. If the ligament is ruptured and displaced proximal to the adductor aponeurosis, a surgical repair should be undertaken to restore stability. Ultrasound accurately diagnosed these lesions in 32/39 operated patients. In 4 cases the ultrasound examination suggested a more severe lesion than was found at operation. In 3 cases a lesser injury was suspected than later proved to be present.

Diagnosis of Ganglions in the Hand and Wrist by Sonography

In the practice of hand surgery, imaging of soft tissue structures can provide useful information for diagnosis and preoperative planning. Sonography with high frequency technique giving high spatial resolution is especially rewarding. In a joint project of the Departments of Radiology and Hand Surgery we evaluated the diagnostic accuracy and clinical value of sonographic assessment of ganglions of the hand and wrist. The material comprises 68 soft tissue lesions clinically suspected to be ganglions. Sonography revealed a ganglion in 53 cases, 34 of which went to surgery. The diagnosis was confirmed in every case. One collapsed ganglion was missed. Nonpalpable ganglions causing clinical symptoms could be demonstrated, and a suspected ganglion could sometimes be ruled out in favor of other diagnoses. Sonography could delineate the entire ganglion and often its connection with the joint space.

Resiquimod as an immunologic adjuvant for NY-ESO-1 protein vaccination in patients with high-risk melanoma

The Toll-like receptor (TLR) 7/8 agonist resiquimod has been used as an immune adjuvant in cancer vaccines. We evaluated the safety and immunogenicity of the cancer testis antigen NY-ESO-1 given in combination with Montanide (Seppic) with or without resiquimod in patients with high-risk melanoma. In part I of the study, patients received 100 μg of full-length NY-ESO-1 protein emulsified in 1.25 mL of Montanide (day 1) followed by topical application of 1,000 mg of 0.2% resiquimod gel on days 1 and 3 (cohort 1) versus days 1, 3, and 5 (cohort 2) of a 21-day cycle. In part II, patients were randomized to receive 100-μg NY-ESO-1 protein plus Montanide (day 1) followed by topical application of placebo gel [(arm A; n = 8) or 1,000 mg of 0.2% resiquimod gel (arm B; n = 12)] using the dosing regimen established in part I. The vaccine regimens were generally well tolerated. NY-ESO-1-specific humoral responses were induced or boosted in all patients, many of whom had high titer antibodies. In part II, 16 of 20 patients in both arms had NY-ESO-1-specific CD4⁺ T-cell responses. CD8⁺ T-cell responses were only seen in 3 of 12 patients in arm B. Patients with TLR7 SNP rs179008 had a greater likelihood of developing NY-ESO-1-specific CD8⁺ responses. In conclusion, NY-ESO-1 protein in combination with Montanide with or without topical resiquimod is safe and induces both antibody and CD4⁺ T-cell responses in the majority of patients; the small proportion of CD8⁺ T-cell responses suggests that the addition of topical resiquimod to Montanide is not sufficient to induce consistent NY-ESO-1-specific CD8⁺ T-cell responses.

Phase I/II study of resiquimod as an immunologic adjuvant for NY-ESO-1 protein vaccination in patients with melanoma

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Background: The TLR 7/8 agonist, Resiquimod has been shown to induce local activation of immune cells, production of cytokines, and antigen-presentation by dendritic cells, features desirable for cancer vaccine adjuvants. In this study, we evaluated the safety and immunogenicity of vaccination with NY-ESO-1 protein emulsified in Montanide ISA-51 VG when given with or without Resiquimod in patients with surgically resected stage IIB-IV melanoma patients. Methods: This is a two-part study design. Part I represents an open-label dose-escalation with Resiquimod using 2 cohorts treated with 100ug NY-ESO-1 protein emulsified in 1.25mL Montanide (day1) followed by topical application of 1000mg of the 0.2% Resiquimod gel on days 1 and 3 for cohort-1 (N=3) or days 1, 3, and 5 for cohort-2 (N=3). The cycles were repeated every 3 weeks, total of 4 cycles. Part II of the study is blinded. Patients were randomized to receive 100ug NY-ESO-1 protein emulsified in 1.25mL Montanide (day1) followed by topical application of placebo gel (Arm-A; N=8) or 1000mg of 0.2% Resiquimod gel (Arm-B; N=12) using the dosing regimen established in Part I. Blood samples were collected at baseline, one week after each cycle of vaccination, and at follow-up visit for the assessment of NY-ESO-1-specific humoral and cellular immune responses. Results: Enrollment has been completed. 25/26 patients received all 4 vaccinations. The treatment was generally well-tolerated, with no grade 4 adverse events or study-related deaths. The most common toxicities were mild to moderate and included local injection site reactions (granuloma, pruritus, induration) and systemic flu-like symptoms. One patient experienced a grade 3 syncopal episode that was deemed unrelated to the drug. Another patient experienced a grade 3 injection site necrosis that was possibly related to the study drug and was removed from the study prior to receiving the 4th vaccine. Conclusions: This study demonstrates the safety of Resiquimod as an adjuvant for NY-ESO-1 protein vaccination. The study will remain blinded until all immune monitoring assays have been completed. An updated abstract will be submitted once the study is unblinded.

Early loosening of the stemmed McMinn cup

The stemmed McMinn cup was used in 26 acetabular reconstructions (median age, 59 [range, 33-85 years]; 21 women) at 5 orthopaedic centers in Sweden between 1995 and 1998. Of the patients, 24 (92%) had severe bone defects (Gustilo-Pasternak grade 3 and 4). At a clinical and radiographic follow-up of median 3 years (range, 1-5 years), 4 (17%) cups were rerevised at 1 (2 cups), 2, and 3 years owing to symptomatic aseptic loosening. Another 8 cups (40%) were radiographically definitely loose and 1 (5%) was probably so. With an overall mechanical failure rate (rerevised plus definitely loose devices) of 43.8% at a minimum 3-year follow-up, the stemmed McMinn cup does not seem to be a reliable solution in acetabular reconstruction.

Computed assisted detection of interval breast cancers

OBJECTIVES

To examine interval cancer detection rate for a system of computer assisted detection (CAD) and its influence on radiologists' sensitivity/specificity in a screen-like retrospective review situation.

MATERIALS AND METHODS

Three screening radiologists reviewed previous screen images of 59 interval cancers mixed with other screening mammograms (ratio 1:5) and non-mixed. Mixed interval cases were interpreted both without and with aid of CAD.

RESULTS

CAD detected a number of 14 interval cancers while the three radiologists detected 17, 12 and 11 without and 16, 10 and 13 with CAD. Although CAD specificity was low (38%) no reduction in radiologists' specificity occurred using CAD (73%, 82% and 89% without and 78%, 90% and 92% with CAD). Non-mixed reading increased radiologists' detection rate to 21, 17 and 19 interval cancers respectively.

CONCLUSION

Despite sufficiently high sensitivity for CAD alone no increase in radiologist sensitivity (or decrease in specificity) occurred with CAD. Improving CAD specificity, with unaffectedly high sensitivity, should make radiologists more inclined to revise interpretations according to CAD. The potential sensitivity increase, noted when using CAD as a double reader, could be realised in this way.

Radiological review of incidence breast cancers

OBJECTIVES

To examine the rate of incidence cancers detectable on review of previous screening mammograms using two reviewing methods. To compare the results with a previous study of interval cancers using the same reviewing methods.

SETTING

Almost 50000 women are regularly invited for service screening at Stockholm Söder Hospital. From 1989 to 1993, 119 women were identified with breast cancer detected at screening and the previous round attendance (incidence cancer).

METHODS

Screening mammograms, obtained before detection of the incidence cancers, were reviewed first mixed with other screening images (ratio 1:8) and then non-mixed. Reviewers from the screening unit responsible for the mammograms as well as reviewers from other units interpreted all images by both single and double reading.

RESULTS

The proportion detected on retrospective review varied between 5% and 50% depending on the review method used and the number of reviewers included to classify a case as truly identified. Generally more cancers were detected when non-mixed samples of mammograms were reviewed than when mixed samples were reviewed (mean increase 23%) and when interpreted by double reading compared with single reading (mean increase 14%).

CONCLUSIONS

In an experimental retrospective set up, fewer incidence cancers were identified in mixed than in non-mixed review. Generally more incidence cancers were identified on review (22%) than previously reported for interval cancers (14%), probably reflecting differences in tumour biology and growth. How many women with potentially visible incidence cancers would have benefited from earlier tumour detection still needs to be evaluated.

CT findings in tuberculous otomastoiditis. A case report

PURPOSE

Otomastoiditis is a rare but important manifestation of tuberculosis and is well recognizable when information on its clinical course is considered in connection with the radiographic changes.

MATERIAL AND METHOD

A patient with a clinical history of chronic otorrhea, resistant to conventional therapy but without dramatic symptoms, was referred for CT examination.

RESULTS

CT revealed widespread soft tissue densities in the tympanic cavity and in the mastoid process, with bone erosions in the latter. Surgery and bacteriology confirmed the diagnosis of Mycobacterium tuberculosis infection.

CONCLUSION

CT evidence of widespread bone destruction without clinical signs of aggressive infection should suggest the diagnosis of a mycobacterial process. Early treatment is essential in order to avoid propagation of the disease and lasting loss of function.

Two models for radiological reviewing of interval cancers

OBJECTIVES

To compare two different review methods of examining how many of our interval cancers could be regarded as missed cases (overlooked and misinterpreted owing to observer's error).

SETTING

A mass screening programme in Stockholm 1989-91, performed at five independent screening units. 107,846 women attended for screening (70.6% of those invited), and 207 women with interval breast cancers were identified. Interval cancers from two of the units, 104 cases, are reviewed in this study.

METHODS

Screening examinations preceding the interval cancer diagnoses were reviewed both mixed with other screening images in a ratio 1:8 and non-mixed. Both internal reviewers (from the two units responsible for the screening mammograms) and external reviewers (from the other units) took part in the study.

RESULTS

The proportion regarded as missed cases varied between 7% and 34%, depending on what review method was used, and on the number of reviewers included to identify a case as missed. Mixed reviewing reduced the number identified as missed cases by 50% compared with non-mixed reviewing. Whether the reviewer was internal or external made no difference to the results.

CONCLUSIONS

Comparing the rate of missed cases from different studies may be misleading unless the same review method is used. No difference in detection rate could be shown whether the radiologist reviewed images from his/her own screening unit or not. Most of our interval cancers were not regarded as missed cases by either of the two methods.

A statistical model for ultrasound diagnosis of soft-tissue tumours in the hand and forearm

PURPOSE

The ultrasound characteristics of 5 common tumours of the hand and forearm were used to build a statistical model that could assess the weight of each trait or combination of traits in the correct diagnosing of the tumours. The model was used for calculating the first and second diagnostic alternatives.

MATERIAL AND METHODS

The basic data of the model were the ultrasound findings in previously presented material on the 5 common benign soft-tissue tumours. The material consisted of 96 tumours: 18 villonodular synovites, 26 haemangiomas, 14 lipomas, 27 nerve tumours, and 11 glomus tumours. To build the statistical model, the ultrasound characteristics that were significant at 5% level were calculated. With stepwise logistic regression, 3 of these were selected as explaining variables. The degree of influence of the explaining variable on the response variable was calculated by way of odds quotients. The material was then analysed by means of the statistical model. The correct diagnosis was calculated as first and second alternatives for each tumour and for the whole material.

RESULTS

The diagnostic accuracy for the whole material was 51% in the first choice and 77% in first plus second choices.

CONCLUSION

Ultrasound should be the first imaging modality for soft-tissue tumours of the hand. However, MR should also be performed when diagnosis continues to be obscure and when malignancy is suspected.

Ultrasound characteristics of five common soft-tissue tumours in the hand and forearm

PURPOSE

This retrospective investigation reviewed the ultrasound images of 96 benign soft-tissue tumours of the hand and forearm. The aim of the investigation was to determine whether there was any correlation between the ultrasound picture and the histopathological diagnosis.

MATERIAL AND METHODS

Five common types of benign tumour in the hand and forearm were studied: localized villonodular synovites, haemangiomas, lipomas, nerve tumours, and glomus tumours. Only tumours that had been operated on and sent for histopathological examination were investigated.

RESULTS AND CONCLUSION

The study found 5 key ultrasound characteristics that were important for differentiating the tumours: existence or not of vessels, existence or not of a capsule, echogenicity, echo structure, and pattern of growth. Taking these traits into consideration should make it easier for the examiner to make the right diagnosis with a reasonable degree of accuracy.

Postmeningitic labyrinthine ossification primarily affecting the semicircular canals

In a series of six cochlear-implant candidates, including three small children, labyrinthine ossification in various stages of development was observed at CT. In four of the candidates the ossifying process was more advanced in the semicircular canals than in the cochleae, and in two equally distributed. The ossifying process developed during a period of 4-5 months in two of the children. Asymmetry of its extension was found in four patients. The causative organisms were Hemophilus influenzae and Streptococcus pneumoniae. The radiologic assessment of cochlear-implant candidates should include the semicircular canals where the ossification may start, and herald the development of cochlear ossification.

Diagnosis by ultrasound of dislocated ulnar collateral ligament of the thumb

The ability of ultrasound to assess a displaced ulnar collateral ligament of the 1st metacarpo-phalangeal (MCP) joint was evaluated. If the ligament is ruptured and displaced proximal to the adductor aponeurosis, a surgical repair should be undertaken to restore stability. Ultrasound accurately diagnosed these lesions in 32/39 operated patients. In 4 cases the ultrasound examination suggested a more severe lesion than was found at operation. In 3 cases a lesser injury was suspected than later proved to be present.

CT-diagnosis of deep-seated lipomas with alarming symptoms

Deep-seated lipomas can present with symptoms very different from those of the common subcutaneous variety. Rapid growth and nerve encroachment may cause suspicion of malignancy. The case histories as well as the clinical and radiographic findings of 2 patients with alarming symptoms from deep-seated lipomas of hand and forearm, respectively, are described. By means of CT an accurate preoperative diagnosis could be made, and surgery planned accordingly.

Diagnosis of ganglions in the hand and wrist by sonography

In the practice of hand surgery, imaging of soft tissue structures can provide useful information for diagnosis and preoperative planning. Sonography with high frequency technique giving high spatial resolution is especially rewarding. In a joint project of the Departments of Radiology and Hand Surgery we evaluated the diagnostic accuracy and clinical value of sonographic assessment of ganglions of the hand and wrist. The material comprises 68 soft tissue lesions clinically suspected to be ganglions. Sonography revealed a ganglion in 53 cases, 34 of which went to surgery. The diagnosis was confirmed in every case. One collapsed ganglion was missed. Nonpalpable ganglions causing clinical symptoms could be demonstrated, and a suspected ganglion could sometimes be ruled out in favor of other diagnoses. Sonography could delineate the entire ganglion and often its connection with the joint space.

Osteoid osteomas of the hand. Report of three cases and review of the literature

Osteoid osteoma is infrequently localized to the hand. Initially the lesion causes unspecific symptoms, and the radiographic changes are discrete. Three cases were seen during a period of 5 years. Bone scintigraphy was a useful diagnostic tool, and CT facilitated the identification of the nidus. One of the lesions was a double nidus osteoid osteoma of the scaphoid bone. Only 12 instances of multifocal osteoid osteomas have been reported, none of which was localized to the carpal bones.

Anatomic variations of the chorda tympani canal

The anatomic variations of the facial recess are of interest in certain otosurgical procedures. The medial border of the recess is the mastoid portion of the facial nerve canal, and the lateral border is the bony canal of the chorda tympani. These two structures were investigated in 64 polyester casts of temporal bone specimens. The point of exit of the chorda tympani canal from the facial canal was assessed together with the angle, formed between these two nerve channels. As a further way of describing the spaciousness at the facial recess, the distance between the sulcus of the stapedius muscle and the chorda tympani canal was evaluated.

Anatomic variations of the cochlea and relations to other temporal bone structures

A thorough knowledge of the normal range of variation of anatomy and topography of the cochlea is necessary for optimal reproduction of this structure and correct interpretation of the radiographs. Radiographic identification of incomplete cochlear coils is essential in the diagnosis of congenital malformations such as Modini's deformity. Furthermore, a diagnosis of otosclerosis/otospongiosis has to be based on recognition of changes in the otic capsule. The size and shape of the human cochlea and the normal ranges of variation of its dimensions were evaluated in 95 plastic casts, prepared from temporal bone specimens. The normal range of variation is fairly small, and is not age-dependent. Obvious digression from this range, associated with pertinent clinical symptoms, indicates an abnormality.

Computed tomography with intravenous cholangiography contrast: a method for visualizing choledochal cysts

Our patient presented with a typical case history and typical symptoms. She also belongs to a group with a high incidence of the disorder. The diagnosis was suspected at ultrasonography, which accurately detected the presence and location of a cyst, but could not establish its origin. Computed tomography is a better diagnostic tool, as it will detect small differences in attenuation and thus identify contrast accumulation in the bile ducts, even when the function of the lever parenchyma is decreased. As scanning is performed in the transverse plane with the patient supine, the layering of contrast medium in the dilated duct is also displayed. In the analysis of our case, the accumulation of biliary contrast medium in the lesion at CT established its origin. The fusiform nature of the dilatation (the type I form of the disorder), was demonstrated at ERCP, after which the operation was performed.

The cochlea and the carotid canal

The carotid canal conveys a large artery and lies in close topographic relationship to the basal turn of the cochlea. The bony wall between them consists in some cases only of the petrous bone of the otic capsule. It can be as thin as 0.2 mm. In other cases the distance can be more than 6 mm. A systematic assessment of the relationship between these two structures was performed on plastic casts of 173 human temporal bone specimens in order to investigate the range of normal variation. The topography in this region can be visualized by multidirectional tomography or CT.

Caroli's disease in two sisters. Diagnosis by ultrasonography and computed tomography

Caroli's disease is a rare congenital disease with multiple segmental dilatations of the bile ducts. It may present in two forms: one (the simple form) with segmental dilatations only, and the other with dilatations combined with fibroangioadenomatosis, frequently complicated by portal hypertension. The disease is thought to be recessively inherited, but few familial cases have been reported. We have observed two sisters with the disease, one with the simple form, the other with fibroangioadenomatosis. Their case histories and diagnostic findings, with special reference to ultrasonography and computed tomography, are presented, and the potential for diagnosis by different imaging modalities is discussed.

Cavitary pulmonary nodules in atypical collagen disease and lupoid drug reaction. Report of two cases

The case histories of two patients with cavitary pulmonary nodules and the findings at chest radiography are reviewed. The first patient had a connective tissue disease with features common to systematic lupus erythematosus and Wegener's granulomatosis. In the second patient the lung changes developed as part of a drug reaction to carbamezapine and/or phenytoin. The common denominator of the cavitating nodules is probably the presence of granulomas, developing as a sequela of pulmonary vasculitis.