Does hydration status influence kidney volume in autosomal dominant polycystic kidney disease?

Autosomal dominant polycystic kidney disease (ADPKD) is a progressive kidney disease where the size of the kidneys is correlated to the stage of kidney failure. Total kidney volume (TKV) is used as a prognostic marker to determine disease stage, progression, and possible effect of treatment. It has been shown that water restriction is associated with reduced kidney volume in healthy subjects. The aim of this study was to evaluate the relationship between TKV and hydration status in ADPKD patients. 40 ADPKD patients with chronic kidney disease stage 1 - 3 were randomized to either 3 hours of water restriction (n = 21) or 1 hour of water loading (n = 19; intake: 20 mL/kg). The patients had a mean age of 38 years (19 - 73) and mean plasma creatinine level of 91 (54 - 178) µmol/L. Magnetic resonance imaging of the kidneys was performed before and after intervention, and TKV was measured using the ellipsoid formula. Water restriction resulted in an insignificant 0.67% increase in TKV (median: 1.48, interquartile range (IQR): 6.1, range: -1. - 4.5). Water loading resulted in an insignificant 2.67% increase in TKV (median: 3.18, IQR: 11.4, range: -3.6 - 7.8). Interestingly, a 7.09% increase in right-kidney volume was found after water loading (median: 5.58, IQR: 9.4 range: 1.9 - 11.3, p < 0.05), whereas the left-kidney volume showed an insignificant decrease of 0.18% after water loading (median: -1.65, IQR: 18.0, range: -12.5 - 5.5). We found in ADPKD patients that neither short-term water restriction nor acute water loading had significant effects, suggesting that the use of TKV for disease staging is independent of hydration level in these patients.

Epidemiological Study of Malignant Paediatric Liver Tumours in Denmark 1985-2020

BACKGROUND

Malignant liver tumours in children are rare and national outcomes for this tumour entity are rarely published. This study mapped paediatric liver tumours in Denmark over 35 years and reported on the incidence, outcomes and long-term adverse events.

METHODS

We identified all liver tumours from the Danish Childhood Cancer Registry and reviewed the case records for patient and tumour characteristics, treatment and clinical outcome.

RESULTS

We included 79 patients in the analyses. Overall crude incidence was ~2.29 per 1 million children (<15 yr) per year, with 61 hepatoblastomas (HB), 9 hepatocellular carcinomas and 9 other hepatic tumours. Overall 5-year survival was 84%, 78% and 44%, respectively. Nine patients had underlying liver disease or predisposition syndrome. Seventeen children underwent liver transplantation, with two late complications, biliary stenosis and liver fibrosis. For HB, age ≥ 8 years and diagnosis prior to 2000 were significant predictors of a poorer outcome. Adverse events included reduced renal function in 10%, reduced cardiac function in 6% and impaired hearing function in 60% (19% needed hearing aids). Behavioural conditions requiring additional support in school were registered in 10 children.

CONCLUSIONS

In Denmark, incidences of malignant liver tumours during the last four decades have been increasing, as reported in the literature. HB survival has improved since the year 2000 and is comparable with international results. Reduced hearing is the major treatment-related side effect and affects approximately 60% of patients.

[Diagnosis and treatment of a multisystemic disorder in children called congenital portosystemic shunts]

Congenital portosystemic shunts (CPSS) are rare malformations, which connect the portal venous system and the systemic circulation. The disorder is discovered at prenatal screening, neonatal cholestasis as an incidental finding or by systemic complications such as pulmonary hypertension, encephalopathies or liver nodules. CPSS are associated to cardiac malformations and several syndromes. Intervention radiology plays a key role in treatment by closure of the shunt, which is indicated, if the patient has complications, the shunt is extrahepatic, or it is still persistent at two years of age, using a two-step approach, as summarised and discussed in this review.

How should liver hypertrophy be stimulated? A comparison of upfront associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) and portal vein embolization (PVE) with rescue possibility

Background

The role of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in comparison to portal vein embolization (PVE) is debated. The aim of this study was to compare successful resection rates (RR) with upfront ALPPS vs. PVE with rescue ALPPS on demand and to compare the hypertrophy of the liver between ALPPS and PVE plus subsequent rescue ALPPS.

Methods

A retrospective analysis of all patients treated with PVE for colorectal liver metastasis (CRLM) or ALPPS (any diagnosis, rescue ALPPS included) at five Scandinavian university hospitals during the years 2013-2016 was conducted. A Chi-square test and a Mann-Whitney U test were used to assess the difference between the groups. A successful RR was defined as liver resection without a 90-day mortality.

Results

A total of 189 patients were included. Successful RR was in 84.5% of the patients with ALPPS upfront and in 73.3% of the patients with PVE and rescue ALPPS on demand (P=0.080). The hypertrophy of the future liver remnants (FLRs) with ALPPS upfront was 71% (48-97%) compared to 96% (82-113%) after PVE and rescue ALPPS (P=0.010).

Conclusions

Upfront ALPPS offers a somewhat higher successful RR than PVE with rescue ALPPS on demand. The sequential combination of PVE and ALPPS leads to a higher overall degree of hypertrophy than upfront ALPPS.

Effect of Dosage of 17ß-Estradiol on Uterine Growth in Turner Syndrome-A Randomized Controlled Clinical Pilot Trial

CONTEXT

Most Turner syndrome (TS) girls need exogenous estrogen treatment to induce puberty and normal uterine growth. After puberty, the optimal estrogen treatment protocol has not been determined.

OBJECTIVE

To compare 2 doses of oral 17ß-estradiol on uterine size.

DESIGN

A double-blind, 5-year randomized controlled clinical trial.

SETTING

Ambulatory care.

PARTICIPANTS

Twenty young TS women (19.2 ± 2.5 years, range 16.0-24.9) participated. Sixteen patients completed the study. No patients withdrew due to adverse effects.

INTERVENTION

The lower dose (LD) group took 2 mg 17ß-estradiol/d orally and placebo. The higher dose (HD) group took 4 mg 17ß-estradiol/d orally.

MAIN OUTCOME MEASURE(S)

Uterine volume evaluated by transabdominal ultrasound yearly.

RESULTS

Uterine size increased significantly more in the HD group compared with the LD group (P = 0.038), with a gain in uterine volume within the first 3 years of treatment of 19.6 mL (95% confidence interval [CI] = 4.0-19.0) in the HD group compared with 11.5 mL (95% CI = 11.2-27.9) in the LD group. The difference in 3-year gain was 8.1 mL (95% CI = 0.7-15.9). At the last visit, there were no significant differences in uterine volume between the groups.

CONCLUSION

HD oral 17ß-estradiol induces a steeper increase in uterine volume within the first years of treatment compared with the LD. However, the uterine growth potential seems to be the same in most young TS women making the duration of treatment equally significant as estrogen dose, although a few TS women did not experience sufficient uterine growth on 2 mg of estradiol.

CLINICALTRIALS.GOV

NCT00134745Abbreviations: BMI, body mass index; BSA, body surface area; DHEAS, dihydroepiandrosteronesulfate; HD, higher dose; HRT, hormone replacement therapy; LD, lower dose; TS, Turner syndrome; US, ultrasound.

Segment 4 occlusion in portal vein embolization increase future liver remnant hypertrophy - A Scandinavian cohort study

BACKGROUND

The additional value of including segment 4 (S4) portal branches in right portal vein embolization (rPVE) is debated. The aim of the study was to explore this in a large multicenter cohort.

MATERIAL AND METHODS

A retrospective cohort study consisting of all patients subjected to rPVE from August 2012 to May 2017 at six Scandinavian university hospitals. PVE technique was essentially the same in all centers, except for the selection of main embolizing agent (particles or glue). All centers used coils or particles to embolize S4 branches. A subgroup analysis was performed after excluding patients with parts of or whole S4 included in the future liver remnant (FLR).

RESULTS

232 patients were included in the study, of which 36 received embolization of the portal branches to S4 in addition to rPVE. The two groups (rPVE vs rPVE + S4) were similar (gender, age, co-morbidity, diagnosis, neoadjuvant chemotherapy, bilirubin levels prior to PVE and embolizing material), except for diabetes mellitus which was more frequent in the rPVE + S4 group (p = 0.02). Pre-PVE FLR was smaller in the S4 group (333 vs 380 ml, p = 0.01). rPVE + S4 resulted in a greater percentage increase of the FLR size compared to rPVE alone (47 vs 38%, p = 0.02). A subgroup analysis, excluding all patients with S4 included in the FLR, was done. There was no longer a difference in pre-PVE FLR between groups (333 vs 325 ml, p = 0.9), but still a greater percentage increase and also absolute increase of the FLR in the rPVE + S4 group (48 vs 38% and 155 vs 112 ml, p = 0.01 and 0.02).

CONCLUSION

In this large multicenter cohort study, additional embolization of S4 did demonstrate superior growth of the FLR compared to standard right PVE.

Intrapancreatic accessory spleen mimicking malignant tumor: three case reports

Intrapancreatic hypervascular lesions may represent metastases, neuroendocrine tumors, or intrapancreatic accessory spleens. The benign intrapancreatic accessory spleen can be difficult to separate from a malignant neuroendocrine tumor or metastasis. We report three cases of pancreatic lesions that underwent pancreatic surgery due to suspicion of malignancy on imaging; all cases were histologically intrapancreatic accessory spleens. Our cases point to the importance of performing single-photon emission computed tomography with heat-damaged Tc-99m-pertechnetate labelled erythrocytes to identify splenic tissue, even though small lesions can show a false-negative result.

Screening for Abdominal Aortic Aneurysm in 295 Outpatients with Intermittent Claudication

In an attempt to establish the prevalence of abdominal aortic aneurysm (AAA) in outpatients with intermittent claudication (IC), 295 patients had ultrasonic screening of their abdominal aorta. There were 123 women and 172 men, median age sixty-eight years range from thirty-eight to eighty-six years. Prevalence of AAA was 5.5% (16/291 patients; examination was inconclusive in 4). All of the AAAs except 1 were found in patients older than sixty years. The prevalence in women was high and there was no significant difference between the sexes in number of AAAs: men, 12/172; women, 4/123 (p > 0.16). Of all patients, 71% were smokers and 13 AAAs were in smokers. No AAAs were found in nons mokers. 3 AAAs were found among 27 patients with unknown smoking status. The percentage of smokers was about equal in the two sexes. Because only one third of the AAAs were identified by abdominal palpation, it was insufficient as a screening procedure. The authors conclude that patients of both sexes and more than sixty years old with IC should be offered ultrasonic screening for AAA.

Interobserver and Intraobserver Reproducibility with Volume Dynamic Contrast Enhanced Computed Tomography (DCE-CT) in Gastroesophageal Junction Cancer

The purpose of this study was to assess inter- and intra-observer reproducibility of three different analytic methods to evaluate quantitative dynamic contrast-enhanced computed tomography (DCE-CT) measures from gastroesophageal junctional cancer. Twenty-five DCE-CT studies with gastroesophageal junction cancer were selected from a previous longitudinal study. Three radiologists independently reviewed all scans, and one repeated the analysis eight months later for intraobserver analysis. Review of the scans consisted of three analysis methods: (I) Four, fixed small sized regions of interest (2-dimensional (2D) fixed ROIs) placed in the tumor periphery, (II) 2-dimensional regions of interest (2D-ROI) along the tumor border in the tumor center, and (III) 3-dimensional volumes of interest (3D-VOI) containing the entire tumor volume. Arterial flow, blood volume and permeability (k^trans) were recorded for each observation. Inter- and intra-observer variability were assessed by Intraclass Correlation Coefficient (ICC) and Bland-Altman statistics. Interobserver ICC was excellent for arterial flow (0.88), for blood volume (0.89) and for permeability (0.91) with 3D-VOI analysis. The 95% limits of agreement were narrower for 3D analysis compared to 2D analysis. Three-dimensional volume DCE-CT analysis of gastroesophageal junction cancer provides higher inter- and intra-observer reproducibility with narrower limits of agreement between readers compared to 2D analysis.

The Multidisciplinary Team Conference's Decision on M-Staging in Patients with Gastric- and Gastroesophageal Cancer is not Accurate without Staging Laparoscopy

BACKGROUND

The implementation of the multidisciplinary team conference has been shown to improve treatment outcome for patients with gastric- and gastroesophageal cancer. Likewise, the staging laparoscopy has increased the detection of patients with disseminated disease, that is, patients who do not benefit from a surgical resection. The aim of this study was to compare the multidisciplinary team conference's decision in respect of M-staging with the findings of the following staging laparoscopy.

METHODS

Patients considered operable and resectable within the multidisciplinary team conference in the period 2010-2012 were retrospectively reviewed. Patient data were retrieved by searching for specific diagnosis and operation codes in the in-house system. The inclusion criteria were as follows: biopsy-verified cancer of the esophagus, gastroesophageal junction or stomach, and no suspicion of peritoneal carcinomatosis or liver metastases on multidisciplinary team conference before staging laparoscopy. Furthermore, an evaluation with staging laparoscopy was required.

RESULTS

In total, 222 patients met the inclusion criteria. Most cancers were located in the gastroesophageal junction, n = 171 (77.0%), and most common with adenocarcinoma histology, n = 196 (88.3%). The staging laparoscopy was M1-positive for peritoneal carcinomatosis in eight patients (16.7%) with gastric cancer versus nine patients (5.3%) with gastroesophageal junction cancer. Furthermore, liver metastases were evident in zero patients (0.0%) and four patients (2.3%) with gastric- and gastroesophageal junction cancer, respectively. The staging laparoscopy findings regarding peritoneal carcinomatosis were significantly different between gastric- and gastroesophageal junction cancers, p = 0.01. No significant differences were found regarding T-/N-stage or histological tumor characteristics between the positive- and negative-staging laparoscopy group.

CONCLUSION

The M-staging of the multidisciplinary team conference without staging laparoscopy lacks accuracy concerning peritoneal carcinomatosis. Staging laparoscopy remains an essential part of the preoperative detection of disseminated disease in patients with gastric- and gastroesophageal cancer.

[Hepatocellular adenoma - new classification and recommendations]

Hepatocellular adenoma (HCA) is a rare benign hepatocellular tumour developed in an otherwise healthy liver. The two main complications are bleeding from the HCA or malignant transformation to hepatocellular carcinoma (HCC). Risk factors for HCC include gender (men), size (> 8 cm) and subtype. Based on new molecular genetic analyses this review describes a new classification of adenomas using both genotype and phenotype. We want to provide an update on adenomas and give updated recommendations for diagnosis and treatment.

Circulating AMH reflects ovarian morphology by magnetic resonance imaging and 3D ultrasound in 121 healthy girls

CONTEXT

In adult women, Anti-Müllerian hormone (AMH) is produced by small growing follicles, and circulating levels of AMH reflect the number of antral follicles as well as primordial follicles. Whether AMH reflects follicle numbers in healthy girls remains to be elucidated.

OBJECTIVE

This study aimed to evaluate whether serum levels of AMH reflects ovarian morphology in healthy girls.

DESIGN AND SETTING

This was a population-based cohort study involving the general community.

PARTICIPANTS

Included in the study were 121 healthy girls 9.8-14.7 years of age.

MAIN OUTCOME MEASURES

Clinical examination, including pubertal breast stage (Tanner's classification B1-5), ovarian volume, as well as the number and size of antral follicles were assessed by two independent modalities: magnetic resonance imaging (MRI), Ellipsoid volume, follicles ≥2 mm; and Transabdominal ultrasound, Ellipsoid and 3D volume, follicles ≥1 mm. Circulating levels of AMH, inhibin B, estradiol, FSH, and LH were assessed by immunoassays; T and androstenedione were assessed by liquid chromatography-tandem mass spectrometry.

RESULTS

AMH reflected the number of small (MRI 2-3 mm) and medium (4-6 mm) follicles (Pearson's Rho [r] = 0.531 and r = 0.512, P < .001) but not large follicles (≥7 mm) (r = 0.109, P = .323). In multiple regression analysis, small and medium follicles (MRI ≤ 6 mm) remained the main contributors to circulating AMH (β, 0.501; P < .001) whereas the correlation between AMH and estradiol was negative (β, -0.318; P = .005). In early puberty (B1-B3), the number of AMH-producing follicles (2-6 mm) correlated positively with pubertal stages (r = 0.453, P = .001), whereas AMH levels were unaffected (-0.183, P = .118).

CONCLUSIONS

Similarly to adult women, small and medium antral follicles (≤6 mm) were the main contributors to circulating levels of AMH in girls.

Determination of adrenal volume by MRI in healthy children: associations with age, body size, pubertal stage and serum levels of adrenal androgens

BACKGROUND

Adrenal disorders such as congenital adrenal hyperplasia result in abnormal adrenal size and morphology, but little is known about the clinical value of magnetic resonance imaging (MRI) in determining adrenal volume.

OBJECTIVE

To evaluate the potential usefulness of MR methodology, to estimate adrenal size in healthy children and to evaluate determinants of adrenal volume such as age, gender, body size, pubic hair stage and serum levels of adrenal androgens.

DESIGN

Two hundred and thirty-five healthy children (116 girls and 119 boys) (age range 10.0-14.8 years) were examined by MRI. Clinical examinations (anthropometry and pubertal staging) were performed, and five androgen metabolites were measured in blood samples by liquid chromatography-tandem mass spectrometry (LC-MS/MS).

RESULTS

It was possible to determine adrenal volume in 115/235 children using MRI. The adrenals were not measurable in 51% of children due to breathing and moving artefacts. The median volume of the right adrenal gland was 0.46 ml in girls and 0.46 ml in boys. The median volume of the left adrenal gland was 0.34 ml in girls and 0.40 ml in boys. Adrenal size was positively associated with body surface area (estimate B = 0.34 ml/year, P = 0.03), age (estimate B = 0.05 ml/year, P = 0.021) and pubic hair stage (estimate B = 0.05 ml/stage, P = 0.075). No associations between adrenal size and serum levels of adrenal androgens were observed.

CONCLUSION

It was possible to determine adrenal volume by MRI in only 50% of healthy children aged 10-15 years. Adrenal volume increased with age and Tanner stage of pubic hair. Future studies will unravel whether adrenal MRI is useful when evaluating children with adrenal diseases.

Differential nongenetic impact of birth weight versus third-trimester growth velocity on glucose metabolism and magnetic resonance imaging abdominal obesity in young healthy twins

CONTEXT

Low birth weight is associated with type 2 diabetes, which to some extent may be mediated via abdominal adiposity and insulin resistance. Fetal growth velocity is high during the third trimester, constituting a potential critical window for organ programming. Intra-pair differences among monozygotic twins are instrumental in determining nongenetic associations between early environment and adult metabolic phenotype.

OBJECTIVE

Our objective was to investigate the relationship between size at birth and third-trimester growth velocity on adult body composition and glucose metabolism using intra-pair differences in young healthy twins.

METHODS

Fifty-eight healthy twins (42 monozygotic/16 dizygotic) aged 18-24 yr participated. Insulin sensitivity was assessed using hyperinsulinemic-euglycemic clamps. Whole-body fat was assessed by dual-energy x-ray absorptiometry scan, whereas abdominal visceral and sc fat (L1-L4) were assessed by magnetic resonance imaging. Third-trimester growth velocity was determined by repeated ultrasound examinations.

RESULTS

Size at birth was nongenetically inversely associated with adult visceral and sc fat accumulation but unrelated to adult insulin action. In contrast, fetal growth velocity during third trimester was not associated with adult visceral or sc fat accumulation. Interestingly, third-trimester growth was associated with insulin action in a paradoxical inverse manner.

CONCLUSIONS

Abdominal adiposity including accumulation of both sc and visceral fat may constitute primary nongenetic factors associated with low birth weight and reduced fetal growth before the third trimester. Reduced fetal growth during vs. before the third trimester may define distinct adult trajectories of metabolic and anthropometric characteristics influencing risk of developing type 2 diabetes.

Uterus and ovaries in girls and young women with Turner syndrome evaluated by ultrasound and magnetic resonance imaging

OBJECTIVE

To determine uterine and ovarian size in Turner syndrome (TS) and to compare uterine and ovarian size evaluated by transabdominal ultrasound (US) and magnetic resonance imaging (MRI) in girls with TS and two groups of controls.

DESIGN

A cross-sectional study.

PATIENTS

Forty-one girls with TS (17·0 ± 3·3 years, range 11·2-24·9 years), 50 healthy age-matched controls (16·9 ± 3·2 years, range 12·5-25·0 years) and 107 Tanner-stage-matched controls (15·0 ± 3·2 years, range 10·1-24·2).

MEASUREMENTS

Uterine and ovarian volume by US and MRI.

RESULTS

Ovaries were detected in 37% in TS by US and in 55% in TS by MRI (P = 0·1). Total ovarian volume was lower in TS compared to both groups of controls (TS vs C-US: median 1·1 ml (range 0·1-29·3) vs 11·52 ml (1·9-77·9), P = 0·001, TS vs C-MRI: 1·0 ml (0·1-34·2) vs 13·2 ml (2·4-30·1), P < 0·0005). Mean difference in total ovarian volume measured by MRI and US in patients with TS was 2·3 ± 3·8 ml (P = 0·01). Mean uterine volume by MRI was lower in TS compared to controls (29·5 ± 25·1 vs 54·3 ± 23·3 ml, P < 0·0005). Uterine volume by US was lower in TS at Tanner stage B5 compared to controls (TS vs C: 33·6 ± 18·2 vs 50·2 ± 18·0 ml, P = 0·007).

CONCLUSIONS

A larger ovarian volume was detected by MRI in TS compared to US. This finding is important with the advancements of performing ovarian biopsies for cryopreservation and later reimplantation. Mean uterine volumes by MRI and US in fully matured TS were lower compared to controls despite appropriate hormonal replacement therapy in TS.

[Mesenteric panniculitis is a rare inflammation of the mesenteric adipose tissue]

Mesenteric panniculitis (MP) is a rare condition affecting the mesentery of the small bowel and/or colon. Obtaining a diagnosis is dependent on radiological and histological findings. With the increasing use of abdominal CT, more cases of MP will be discovered. We report a case of MP accidentally found at CT in a 64 year-old woman who was evaluated for upper abdominal discomfort. Percutaneous ultrasonography guided biopsy secured the diagnosis. There is no consensus on the treatment and management of MP. An approach guided by the patient's symptoms seems suitable.

[Localization diagnostics of neuroendocrine gastrointestinal tumours]

Localization diagnostics of neuroendocrine tumours is relevant in relation to staging and planning of therapy, including surgery. Imaging modalities are also relevant in relation to biopsy guidance. Currently, the most frequently used methods are somatostatin receptor scintigraphy, computed tomography with contrast and endoscopic ultrasound. The strengths of the different modalities are discussed and it is concluded that frequently a combination of imaging modalities is necessary in the work-up of patients with neuroendocrine tumours.

Treatment of knee osteoarthritis with pulsed electromagnetic fields: a randomized, double-blind, placebo-controlled study

OBJECTIVE

The investigation aimed at determining the effectiveness of pulsed electromagnetic fields (PEMF) in the treatment of osteoarthritis (OA) of the knee by conducting a randomized, double-blind, placebo-controlled clinical trial.

DESIGN

The trial consisted of 2h daily treatment 5 days per week for 6 weeks in 83 patients with knee OA. Patient evaluations were done at baseline and after 2 and 6 weeks of treatment. A follow-up evaluation was done 6 weeks after treatment. Activities of daily living (ADL), pain and stiffness were evaluated using the Western Ontario and McMaster Universities (WOMAC) questionnaire.

RESULTS

Within group analysis revealed a significant improvement in ADL, stiffness and pain in the PEMF-treated group at all evaluations. In the control group there was no effect on ADL after 2 weeks and a weak significance was seen after 6 and 12 weeks. Significant effects were seen on pain at all evaluations and on stiffness after 6 and 12 weeks. Between group analysis did not reveal significant improvements over time. Analysis of ADL score for the PEMF-treated group revealed a significant correlation between less improvement and increasing age. Analysis of patients <65 years using between group analysis revealed a significant improvement for stiffness on treated knee after 2 weeks, but this effect was not observed for ADL and pain.

CONCLUSIONS

Applying between group analysis we were unable to demonstrate a beneficial symptomatic effect of PEMF in the treatment of knee OA in all patients. However, in patients <65 years of age there is significant and beneficial effect of treatment related to stiffness.

Computed tomography scanning and recurrence after laparoscopic ventral hernia repair

Laparoscopic ventral hernia repair is an advancing surgical method. It seems to have fewer recurrences than open surgery. However, with patients suspected of recurrence after laparoscopic hernia repair, it can be very difficult to determine whether or not there is recurrence by clinical examination alone. The purpose of this article is to show that computed tomography is a valuable diagnostic tool in excluding recurrence after laparoscopic ventral hernia repair. A total of 35 patients were included in a prospective study. They underwent laparoscopic ventral hernia repair, and all patients suspected of recurrence were computed tomography scanned. Four patients were suspected of recurrence. They all presented symptoms of swelling or pain or both. The computed tomography scanning did not show the presence of recurrence in any of the 4 cases. Computed tomography scanning can provide exact information about the content of swelling and whether there is recurrence or not. We conclude that computed tomography scanning is suitable as a valid imaging method in doubtful cases considering ventral hernia recurrence after laparoscopic ventral hernia repair.

[Staging of rectal cancer by means of MRI. Experiences with the first twenty-five patients]

INTRODUCTION

The Danish Surgical Society recommends preoperative radiation for patients with T4 tumours of the rectum. However, the clinical examination with regard to fixation, especially for tumours in the upper part of the rectum, is encumbered by much uncertainty. MR imaging is a new modality in the staging procedure of the patient with rectal cancer. Our experience with the first 25 patients is presented.

METHODS

After clinical examination, an MRI of the rectum was done and in the case of a T4 tumour preoperative radiotherapy was established. Preoperative MRI staging was correlated with the histopathology of the resection specimen.

RESULTS

In cases of tumours in the lower third of the rectum, we found total agreement between the clinical examination and the MRI findings. In the middle third it was impossible to assess clinical fixation in two out of seven patients and in the upper third it was impossible in eight out of ten. With respect to possible involvement of lymph nodes, the MRI revealed a true positive diagnostic frequency of 0.78, a true negative diagnostic frequency of 0.92, a true positive nosographic frequency of 0.88 and a true negative nosographic frequency of 0.85. The corresponding values for tumour invasion were 0.94, 0.75, 0.94 and 0.75.

DISCUSSION

Our results seem to indicate that preoperative MRI--especially in patients with tumours in the upper two-thirds of the rectum--is suitable for predicting fixation. MRI also seems to be suitable in the complete staging of the patient with a tumour of the rectum.

MRI of autosomal dominant pure spastic paraplegia

We examined 16 patients with autosomal dominant pure spastic paraplegia (HSP) and 15 normal controls matched for age and sex using MRI of the brain and spinal cord. Images were assessed qualitatively by two independent radiologists, blinded to the clinical diagnosis. Areas of the brain and corpus callosum on one midsagittal slice and the area of the brain on one axial slice were measured and a "corpus-callosum index" expressing the size of the corpus callosum relative to that of the brain was calculated. Cross-sectional areas and anteroposterior and transverse diameters of the spinal cord at the levels of C 2, C 5, T 3, T 6, T 9 and T 11 were measured. No significant differences between patients and controls were found on qualitative evaluation of the images. The patients had a significantly smaller corpus callosum and "corpus-callosum index" than controls. This finding, not reported previously, might indicate that the disease process in pure HSP is not confined to the spinal cord. The anteroposterior diameters of the spinal cord at T 3 and T 9 were significantly smaller in patients than in controls. This might correspond to the degeneration of the pyramidal tracts and the dorsal columns described at neuropathological examination.

Gliomatosis cerebri--an appropriate diagnosis? Case reports

PURPOSE

To evaluate the premises for the diagnosis gliomatosis cerebri in relation to diffuse astrocytomas.

MATERIAL AND METHODS

CT, MR images and pathological analyses were used to assess the cases of 4 patients with diffusely infiltrating astrocytic tumours that radiologically, clinically and pathologically resembled gliomatosis cerebri.

RESULTS AND CONCLUSION

Some astrocytomas have an immense potential for diffuse infiltration and they would seem to be more frequent than recognized hitherto. The definition of gliomatosis cerebri as a separate entity is questionable, and a diagnosis of diffusely infiltrating astrocytoma is recommended in such cases.

Modified midfacial degloving. A practical approach to extensive bilateral benign tumours of the nasal cavity and paranasal sinuses

Midfacial degloving is a well-known technique for entering the nasal and paranasal cavities, the rhinopharynx and the base of the skull. We report our experience with a modification of midfacial degloving, applied to two patients with extensive bilateral benign tumours in the nasal cavities and the paranasal sinuses. No rhinoplastic procedure is necessary in this modification, and the access to the upper part of the nasal cavity is improved.