[Breast angiosarcoma: sonographic, mammographic and MRI features]

The purpose of this paper is to report the clinical, imaging (sonographic, mammographic and MRI) and pathological features of breast angiosarcoma, a rare but aggressive tumor, based on a review of two cases.

Pelviscanner hélicoïdal en basse dose : évaluation de la dose d’irradiation et du traitement d’images

PURPOSE

to estimate from phantom measurements the radiation dose and the accuracy of helical ct pelvimetry.

MATERIALS AND METHODS

Eight helical CT acquisitions using different tube current (100, 50, 25 or 10mAs) and pitch factor (1.125 or 1.375) settings but identical collimation (2mm) and kilovoltage (120 kVp) were evaluated using a four-channel MDCT scanner and compared with conventional CT pelvimetry including a single scout and two transverse images. A plexiglas phantom combined with an ionization chamber was used to calculate the CTDIw and DLP for each acquisition. Then, an ex vivo phantom of bony pelvis was used to evaluate the accuracy of helical acquisitions for the measurement of pelvic diameters (i.e. the antero-posterior inlet, the transverse inlet and the interspinous distance). Reconstructions of helical acquisitions were performed using 2D MPR, 3D MIP and 3D SSD algorithms.

RESULTS

CTDIw and DLP of conventional pelvimetry were 26 mGy and 42 mGy.cm respectively. The radiation dose of helical acquisitions decreased linearly with tube current (CTDIw: from 13 to 1.3 mGy, DLP: from 218.3 to 18.7 mGy.cm). Compared to conventional CT, the dose was nearly similar at 25 mAs and reduced at 10 mAs. Helical acquisitions provided accurate measurements of pelvic diameters with a pitch of 1.125 and a 2D MPR algorithm to evaluate the AP inlet and a 3D MIP algorithm to evaluate the transverse inlet and the interspinous distance. Variations of tube current did not influence the accuracy of pelvic diameter measurement.

CONCLUSION

Our results suggest that accurate low-dose helical CT pelvimetry using 10-25 mAs and a pitch factor of 1.125 combined with 2D MPR and 3D MIP reconstructions is possible.

Imagerie des complications neurologiques du carcinome bronchique

The natural history of bronchogenic carcinoma shows that 42% of patients are diagnosed with cancer-related neurological complications either at initial presentation or at follow-up that can be separated in 3 different categories: - locoregional involvement of cervicothoracic nerves (recurrent laryngeal nerves, phrenic and vagus nerves, brachial plexus and sympathetic cervical chains), - metastatic disease characterized by intracranial lesions (brain, meningeal, ependymal and pituitary metastases) and spinal (extradural, subarachnoid and medullary metastases) lesions, - paraneoplastic syndromes including limbic encephalitis, Lambert-Eaton syndrome and paraneoplastic cerebellar degeneration. These neurological disorders usually are associated with advanced cancer for which radical surgical management seldom is indicated. All imaging studies performed at the time of initial staging for bronchogenic carcinoma should therefore be carefully reviewed in order to detect signs that could suggest the presence of one or several neurological complications. The goals of this paper are to describe the clinical signs and to illustrate the imaging features of neurological complications related to bronchogenic carcinoma at conventional radiography, CT and MRI.

[Miliary pulmonary tuberculosis following intravesical BCG-therapy]

A patient given intravesical BCG immunotherapy developed miliary pulmonary tuberculosis. After resection of a superficial bladder tumor, the patient was given weekly intravesical BCG infusions. After the 4th session, the patient developed fever (40 degrees C), shivers, dry cough, profuse sweating, and weight loss. Initially, the chest x-ray was normal. The patient was given isoniazid (5 mg/kg) in a single-drug regimen. Rapid degradation of the general status led to a new chest x-ray, 10 days later, which demonstrated a reticulonodular syndrome. High-resolution thoracic CT confirmed the diagnosis of miliary pulmonary tuberculosis. A three-drug antituberculosis regimen associated with corticosteroids was followed by restoration of the general status. Antituberculosis therapy was continued for 9 months. The 9-month thoracic CT revealed a smaller number of micronodules in the pulmonary parenchyma. This case illustrates the discussion concerning the appropriate treatment for patients who develop a systemic infection after intravesical BCG-therapy.

[Adenocarcinomas of the distal esophagus and cardia. Anatomy and volume of irradiation]

The esophagus is divided into four regions: cervical esophagus, intrathoracic esophagus with upper, mid and lower thoracic portion. Cancer may occur on each of these regions. Computed tomography of the thorax and superior abdomen and endoscopic ultrasound are necessary for reliable staging. CT simulation allows accurate definition of tumor volume. GTV includes tumor volume and regional lymph nodes. CTV encompasses GTV plus safety margin and lymph nodes areas considered to harbor potential microscopic disease. The extent of prophylactic lymph node irradiation depends on the anatomic location of the primary tumor.

[Gross tumor volume and clinical target volume: esophageal tumors]

The oesophagus is divided into four regions: cervical oesophagus, and intrathoracic oesophagus with an upper, mid- and lower thoracic portion. Cancer may occur on each of these regions. Computed tomography of the thorax and superior abdomen and endoscopic ultrasound are necessary for reliable staging. CT simulation allows accurate definition of tumour volume. GTV includes tumour volume and regional lymph nodes. CTV encompasses GTV plus a safety margin and lymph node areas considered to harbour potential microscopic disease. The extent of prophylactic lymph node irradiation depends on the anatomic location of the primary tumour.

[Does renal transplantation increase the risk of breast diseases?]

PURPOSE

To evaluate the risk of breast pathology occurrence in a group of kidney transplanted patients.

MATERIAL

and methods. In the last five years, 30 kidney-transplanted women underwent systematic breast evaluation in our institution and were included in this retrospective study (exposed-group). To compare with this exposed-group, 90 non transplanted women undergoing breast evaluation in the same period at our institution (non-exposed group), were retrospectively randomized. In both groups, results of breast evaluation were classified in two categories (normal and abnormal) and distribution of benign and malignant breast pathologies were evaluated. The mean exposition-time was determined in months in the exposed-group. Comparative analysis of both groups included a comparison of mean patients age and evaluation of the relative risk (RR) of breast pathology occurrence.

RESULTS

Mean exposition time was 72.7+/-66.6 months. The percentages of benign breast pathology were 93.7% in the exposed-group and 83.3% in the non-exposed group. Percentages of cancer were respectively 6.3 and 16.7%. Mean patient age was quite similar in the exposed-group (50.7+/-10 years) and in the non-exposed group (50.6+/-10.5 years). The relative risk of breast pathology occurrence was 1.70 (0.99<RR<2.91) and was not significant.

CONCLUSION

In this retrospective series, no risk of breast pathology occurrence was demonstrated in a population of kidney-transplanted patients.

[Strategy for early diagnosis of lung involvement in systemic scleroderma]

Systemic sclerosis (SSc) is an autoimmune disorder characterized by accumulation of collagen in affected organs, mainly the skin and the lungs, associated with abnormalities of the arterioles and capillaries. There are two types of pulmonary involvement, which influence long term prognosis: infiltration of the lungs and/or pulmonary artery hypertension. Full investigations into possible lung involvement must be performed systematically when SSc is diagnosed and during follow-up. The double pathophysiology sometimes makes diagnosis difficult but it must be made as early as possible in order to decide on the optimal treatment. The aim of this study was to evaluate the usual explorations and to propose biological markers to identify patients requiring more detailed lung investigations, in order to establish a diagnostic approach to treatment and follow-up patients with SSc.

[Wegener's disease mimicking acute infectious pleurisy]

A 75-year-old woman followed for Wegener's disease was hospitalized for pleural effusion. The clinical presentation and cytology of the pleural fluid suggested the diagnosis of purulent pleurisy in this immunodepressed patient. The final diagnosis was a pleural involvement of Wegener's disease, a rarely described localization, as proven by the typical pathology findings.

Relationship between abnormalities on high-resolution CT and pulmonary function in systemic sclerosis

STUDY OBJECTIVES

To determine the predictive value of abnormalities on high-resolution CT (HRCT) on pulmonary disease in systemic sclerosis.

PATIENTS

Fifty-two patients suffering from systemic sclerosis.

DESIGN

Pulmonary disease was defined by pulmonary function test abnormalities, ie, total lung capacity (TLC) <80% of predicted value and/or diffusion of carbon monoxide (DLCO) <75% of predicted value, without any pulmonary event other than systemic sclerosis in the medical history. Patients were divided in two groups, group A with pulmonary disease (29 patients) and group B without pulmonary disease (23 patients). HRCT abnormalities were scored on whole lungs. A decision matrix was constructed to determine sensitivity, specificity, positive and negative predictive values, and false-positive and false-negative rates. A receiver operating characteristic curve was constructed to determine the best compromise between sensitivity and specificity.

RESULTS

HRCT total scores were higher in group A (9.0+/-4.3) than in group B (5.0+/-2.8) (p < 0.001) and they correlated with TLC (r =-0.39, p < 0.005) and DLCO (r = -0.50, p < 0.0002). An HRCT score of 7 corresponded to the best compromise between sensitivity (0.60) and specificity (0.83), with a positive predictive value of 0.82. Taking into account a value of 10 for the HRCT score increased specificity to 1 but decreased sensitivity to 0.41.

CONCLUSION

A minimum score of 7 would be required to consider HRCT abnormalities in systemic sclerosis as predictive of pulmonary disease. An HRCT score of 10 makes it possible to establish the diagnosis of lung involvement severe enough to impair pulmonary function.

[Similarities between pleuropulmonary blastoma and Askin tumor]

Adult pleuropulmonary blastoma is an uncommon mesenchymal tumor of the peripheral lung parenchyma composed of undifferentiated cells. The differential diagnosis with Askin-Rosaï's tumor, an extrapulmonary pleuroparietal neuroectodermal tumor, may be a difficult task. We propose a similar therapeutic approach for these two malignant conditions: surgical excision associated with chemotherapy and autologous bone marrow transplant with adjuvant radiotherapy in case of recurrence. These two entities have many epidemiological, clinical, histological and immunohistochemical similarities.

[Bronchial casts associated with pulmonary lymphatic anomalies]

We report a case of a patient who presented with bronchial moulds. The classic causes, particularly bronchopulmonary aspergillosis could not be found. The pulmonary radiology and CT of thorax revealed an alveolar syndrome. Lymphography and lymphoscintigraphy showed evidence of lymphatic anomalies including the non-visualisation of the thoracic canal. In the absence of evidence for other diseases, we would suggest that these anomalies were responsible for the symptomatology.

Imaging of pulmonary disease in rheumatoid arthritis using J001X scintigraphy: preliminary results

The purpose of this study was to determine the ability of technetium-99m J001X scintigraphy to image active pulmonary involvement in patients suffering from rheumatoid arthritis (RA). J001X is a fully characterized acylated poly(1,3)galactoside, isolated from Klebsiella membranes, which is able to bind recruited macrophages after aerosol administration. J001X scintigraphy was compared with high-resolution computed tomography (HRCT), pulmonary function tests (PFTs) and bronchoalveolar lavage (BAL) in 15 patients suffering from RA. Patients were considered to have pulmonary involvement when they had an interstitial syndrome on HRCT and a decrease of 20% in TCO/VE (transfer coefficient) on PFTs and/or an abnormal BAL (lymphocytosis higher than 20% and/or percentage of neutrophils higher than 10%). Pulmonary involvement was present in eight patients, and absent in seven. Of the eight patients with pulmonary involvement, all had abnormal BAL, two had an interstitial syndrome on HRCT, two had decreased TCO/VE and three had positive J001X scintigraphy. Of the seven patients without pulmonary involvement, six had normal BAL (not available in one), two had an interstitial syndrome on HRCT, one had decreased TCO/VE and two had positive J001X scintigraphy. According to our gold standard of pulmonary involvement, the sensitivity of J001X scintigraphy for the detection of pulmonary involvement in RA was 37.5%, the specificity was 71.4% and the positive predictive value was 60%. The ability of J001X scintigraphy to detect active pulmonary involvement during RA appears unclear in this study but it may detect processes unnoticed by the other modalities. These patients will be followed 12 and 24 months later and the changes in J001X scintigraphy, HRCT and PFTs will be compared to demonstrate whether J001X scintigraphy is able to assess an active process in the pulmonary involvement during RA and to specify its predictive value.

Predictive value of serum III procollagen for diagnosis of pulmonary involvement in patients with scleroderma

High resolution computed tomography (HRCT) was recently demonstrated to be as good as open lung biopsy for the diagnosis of pulmonary involvement in patients with scleroderma. Nevertheless, in view of its price and related irradiation, HRCT cannot be recommended as a screening test. Serum III procollagen (sPIIINP) is an aminopropeptide of type III collagen, which is released during conversion into collagen by specific proteases. Increased levels of sPIIINP have been observed in patients with scleroderma. The aim of the present study was to assess the relationship between sPIIINP measurement and pulmonary involvement defined according to HRCT and pulmonary function tests (PFT) with single-breath carbon monoxide transfer capacity (TL,CO) in 28 patients suffering from scleroderma. Patients were divided into two groups for analysis, Group A comprising 16 patients without pulmonary scleroderma and Group B comprising 12 patients with pulmonary scleroderma. All patients had stable cutaneous disease and normal renal and hepatic function. The level of sPIIINP was determined by radioimmunoassay (RIA-gnost P-III-P, Prod. Nr. ODMT; Behring, Marburg, Germany). Mean +/- SD sPIIINP level in Group A was 0.85 +/- 0.21 U.mL-1. Individual values ranged 0.6-1.3 U.mL-1. Mean +/- SD sPIIINP value was 1.30 +/- 0.40 U.mL-1 in Group B and individual values ranged 0.7-1.9 U.mL-1. The difference in mean sPIIINP level between Group A and Group B was significant. Using a cut-off at 1.1 U.mL-1, sensitivity of sPIIINP was 0.66, specificity 0.94, positive predictive value 0.89, negative predictive value 0.79, false positive rate 0.06, and false negative rate 0.33. The value of sPIIINP correlated with HRCT score but not with PFT. This study confirms the relationship between sPIIINP and scleroderma with interstitial lung disease. We suggest that sPIIINP could be measured in patients with scleroderma to screen those patients requiring HRCT. Further studies are necessary to determine the value of sPIIINP in terms of prognosis and follow-up of patients under treatment.

Predictive value of serum III procollagen for diagnosis of pulmonary involvement in patients with scleroderma

High resolution computed tomography (HRCT) was recently demonstrated to be as good as open lung biopsy for the diagnosis of pulmonary involvement in patients with scleroderma. Nevertheless, in view of its price and related irradiation, HRCT cannot be recommended as a screening test. Serum III procollagen (sPIIINP) is an aminopropeptide of type III collagen, which is released during conversion into collagen by specific proteases. Increased levels of sPIIINP have been observed in patients with scleroderma. The aim of the present study was to assess the relationship between sPIIINP measurement and pulmonary involvement defined according to HRCT and pulmonary function tests (PFT) with single-breath carbon monoxide transfer capacity (TL,CO) in 28 patients suffering from scleroderma. Patients were divided into two groups for analysis, Group A comprising 16 patients without pulmonary scleroderma and Group B comprising 12 patients with pulmonary scleroderma. All patients had stable cutaneous disease and normal renal and hepatic function. The level of sPIIINP was determined by radioimmunoassay (RIA-gnost P-III-P, Prod. Nr. ODMT; Behring, Marburg, Germany). Mean +/- SD sPIIINP level in Group A was 0.85 +/- 0.21 U.mL-1. Individual values ranged 0.6-1.3 U.mL-1. Mean +/- SD sPIIINP value was 1.30 +/- 0.40 U.mL-1 in Group B and individual values ranged 0.7-1.9 U.mL-1. The difference in mean sPIIINP level between Group A and Group B was significant. Using a cut-off at 1.1 U.mL-1, sensitivity of sPIIINP was 0.66, specificity 0.94, positive predictive value 0.89, negative predictive value 0.79, false positive rate 0.06, and false negative rate 0.33. The value of sPIIINP correlated with HRCT score but not with PFT. This study confirms the relationship between sPIIINP and scleroderma with interstitial lung disease. We suggest that sPIIINP could be measured in patients with scleroderma to screen those patients requiring HRCT. Further studies are necessary to determine the value of sPIIINP in terms of prognosis and follow-up of patients under treatment.

[Disappearance of emphysematous bullae after infectious episodes]

The authors report 3 cases of peri-emphysematous lung infection associated with the development of air-fluid level in pre-existing emphysematous bullae. Prolonged observation revealed that both bullae and fluid disappeared completely or partially after short antibiotic treatment. The review of literature show that this favourable evolution has not often been described and that these pictures must be to differentiate from lung abscess.

Imaging of pulmonary disease in scleroderma with J001X scintigraphy

BACKGROUND

J001X is an acylated poly-galactoside isolated from the membrane of Klebsiella and able to interact with macrophages, mainly in their activated state. The aim of the present study was to determine the ability of 99m-labelled technetium (99mTc)-J001X scintigraphy to image pulmonary disease, defined by high resolution computed tomographic scanning and pulmonary function tests, in patients suffering from scleroderma.

METHODS

Patients were considered to have pulmonary disease when they had at least two positive signs on high resolution computed tomography, or a decrease in lung volume and single breath carbon monoxide transfer, or both, with no disease process other than scleroderma in their medical history. Positive J001X scintigraphic imaging was defined by symmetrical bilateral pulmonary fixation three and five hours after inhalation of 99mTc-J001X. J001X scintigraphic results were compared with disease activity as indicated by bronchoalveolar lavage (BAL) fluid lymphocytosis.

RESULTS

Seventeen patients were studied, in 12 of whom J001X scintigraphy was positive. There was no correlation between BAL lymphocytosis and J001X scintigraphic findings, nor between BAL and pulmonary scleroderma. This was not surprising because of the high specificity of macrophage targeting by J001X.

CONCLUSIONS

Follow up of a larger population over a longer period is needed to establish whether there is a prognostic value for positive J001X scintigraphic findings in scleroderma.

Embryonal rhabdomyosarcoma of the biliary tree in children: a case report

Embryonal rhabdomyosarcoma (ERS) in children is a very rare tumor. Jaundice is the capital symptom. Diagnosis can be made by echography, which shows echogenic formations without posterior conic shadows in a dilated biliary duct. The prognosis is bleak in spite of the combination of surgery, radiotherapy and chemotherapy.