Ernest J. Ferris

Magnetic Resonance Imaging in Multiple Myeloma: Diagnostic and Clinical Implications

PURPOSE Magnetic resonance imaging (MRI) permits the detection of diffuse and focal bone marrow infiltration in the absence of osteopenia or focal osteolysis on standard metastatic bone surveys (MBSs). PATIENTS AND METHODS Both baseline MBS and MRI were available in 611 of 668 myeloma patients who were treated uniformly with a tandem autologous transplantation-based protocol and were evaluated to determine their respective merits for disease staging, response assessment, and outcome prediction. RESULTS MRI detected focal lesions (FLs) in 74% and MBS in 56% of imaged anatomic sites; 52% of 267 patients with normal MBS results and 20% of 160 with normal MRI results had FL on MRI and MBS, respectively. MRI- but not MBS-defined FL independently affected survival. Cytogenetic abnormalities (CAs) and more than seven FLs on MRI (MRI-FLs) distinguished three risk groups: 5-year survival was 76% in the absence of both more than seven MRI-FLs and CA (n = 276), 61% in the presence of one MRI-FL (n = 262), and 37% in the presence of both unfavorable parameters (n = 67). MRI-FL correlated with low albumin and elevated levels of C-reactive protein, lactate dehydrogenase, and creatinine, but did not correlate with age, beta-2-microglobulin, and CA. Resolution of MRI-FL, occurring in 60% of cases and not seen with MBS-defined FL, conferred superior survival. CONCLUSION MRI is a more powerful tool for detection of FLs than is MBS. MRI-FL number had independent prognostic implications; additionally, MRI-FL resolution identified a subgroup with superior survival. We therefore recommend that, in addition to MBS, MRI be used routinely for staging, prognosis, and response assessment in myeloma.

Results of a multicenter study of the modified hook-titanium Greenfield filter

Initial efforts to modify the stainless steel Greenfield filter for percutaneous insertion led to development of a titanium Greenfield filter, which could be inserted by use of a 12F carrier. This device functioned well as a filter but had an unacceptable 30% rate of migration, tilting, and penetration. Therefore a titanium Greenfield filter with modified hooks was developed and has been tested in 186 patients at 10 institutions. Successful placement occurred in 181 (97%); placement of the remainder was precluded by unfavorable anatomy. A contraindication to anticoagulation was the most frequent indication for insertion (75%). All but two were inserted percutaneously, predominantly via the right femoral vein (70%). Initial incomplete opening was seen in four patients (2%), which was corrected by guide wire manipulation and asymmetry of the legs in 10 (5.4%). Insertion site hematoma occurred in one patient, and apical penetration of the cava during insertion occurred in a second patient. Both events were without sequelae. Follow-up examinations were performed at 30 days at which time 35 deaths had occurred. Recurrent embolism was suspected in six patients (3%) and two of three deaths were confirmed by autopsy. Filter movement greater than 9 mm was seen in 13 patients, (11%) and increase in base diameter greater than or equal to 5 mm was seen in 17 patients (14%). CT scanning showed evidence of caval penetration in only one patient (0.8%). Insertion site venous thrombosis was seen in 4/46 (8.7%) patients screened. The modified hook titanium Greenfield filter is inserted percutaneously or operatively through a sheath, eliminating concern for misplacement from premature discharge.(ABSTRACT TRUNCATED AT 250 WORDS)

Perioperative asymptomatic venous thrombosis: Role of duplex scanning versus venography * **

We compared combined B-mode/Doppler (duplex ultrasonic scanning and venography in routine preoperative and postoperative screening for major proximal deep vein thrombosis in 78 patients undergoing total hip or knee arthroplasty. Of 309 extremity examinations, duplex scanning had an overall sensitivity of 85.7% (12/14) and a specificity of 97.3% (287/295). The preoperative prevalence and postoperative incidence of major deep vein thrombosis were 2.5% and 14.1% of patients, respectively, despite intensive mechanical and pharmacologic prophylaxis. In addition, venography documented a preoperative prevalence and postoperative incidence of isolated calf deep vein thrombosis in 2.5% and 16.7% of patients, respectively. Whereas such disease extended proximally even in the absence of anticoagulation in only 18% of patients studied by serial duplex scans, calf deep vein thrombosis accounted for the only two instances of pulmonary embolism in this study. There were no deaths related to pulmonary embolism. This study suggests that duplex scanning is useful in screening for perioperative deep vein thrombosis in patients undergoing total hip or knee arthroplasty, which carries a significant risk of venous thromboembolism despite routine prophylaxis.

Thromboembolism in patients undergoing thoracotomy

To determine the incidence of thromboembolism in relation to thoracotomy, 77 patients undergoing pulmonary resection were prospectively studied up to 30 days postoperatively for deep venous thrombosis and pulmonary embolism. Overall, 20 of 77 patients (26%) had thromboembolic events during their hospitalization. Four deep venous thromboses and 1 pulmonary embolism were detected in 5 of 77 patients preoperatively for an incidence of 6%. Postoperative thromboembolism was detected in 15 of 77 (19%): deep venous thrombosis in 11 (14%) and pulmonary embolism in 4 (5%). No postoperative thromboembolisms occurred in the 17 patients receiving preoperative aspirin or ibuprofen, whereas they did occur in 25% of the remainder (15/60). Thromboembolism after pulmonary resection was more frequent with bronchogenic carcinoma than with metastatic cancer or benign disease (15/59 [25%] versus 0/18 [0%]; p < 0.01), adenocarcinoma compared with other types of carcinoma (11/25 [44%] versus 4/34 [12%]; p < 0.0004), large primary lung cancer (> 3 cm in diameter) compared with smaller lesions (9/19 [47%] versus 6/40 [15%]; p < 0.0001), stage II compared with stage I (7/14 [50%] versus 7/34 [21%]; p < 0.04), and pneumonectomy or lobectomy compared with segmentectomy and wedge resection (14/49 [29%] versus 1/28 [4%]; p < 0.005). Three of 4 patients with thromboembolism detected preoperatively had operation within the previous year. Postoperative pulmonary embolism was fatal in 1 of 4 (25%) and accounted for the one death. These results suggest patients undergoing thoracotomy for lung cancer, especially adenocarcinoma, should be considered for thromboembolic prophylaxis.

Is anticoagulation indicated for asymptomatic postoperative calf vein thrombosis

The purpose of this study was to determine the effect of anticoagulation on the incidence of thrombotic propagation and pulmonary embolism in patients with calf vein thrombosis after total hip or total knee arthroplasty. Patients undergoing arthroplasties had prospective surveillance for postoperative deep vein thrombosis by both bilateral contrast venography and venous duplex scanning. Calf vein thrombosis was documented by venography in 42 patients (50 limbs), including 29 of 253 patients undergoing total hip arthroplasty (11.4%) and 13 of 99 patients undergoing total knee arthroplasty (13%). Of patients on whom follow-up duplex scans were performed, heparin followed by warfarin anticoagulation was used in 11 (13 limbs) and withheld in 21 (25 limbs). Propagation of thrombosis to the popliteal or superficial femoral vein or both was detected by serial duplex scanning in 3 of 13 treated limbs (23%) and 2 of 25 untreated limbs (8%), (p = 0.43). All thrombus propagations were detected within 2 weeks of the operative procedure. There were no pulmonary emboli or deaths. Propagation of asymptomatic calf vein thrombosis after arthroplasty was not influenced by anticoagulation, suggesting that postoperative calf vein thrombosis need not be routinely treated. Serial venous duplex scanning is useful to identify the occasional patient in whom thrombotic propagation requiring anticoagulation develops.

Extended evaluation of the titanium Greenfield vena caval filter

PURPOSE The purpose of this study was to evaluate the long-term safety and efficacy of the titanium Greenfield filter-modified hook for prevention of pulmonary embolism. METHODS We conducted a prospective study in 173 patients from four institutions who underwent clinical examination, abdominal radiography, and duplex ultrasound examinations of the vena cava and lower extremities. If indicated by protocol or clinical presentation, computed tomography scans, pulmonary angiograms, or venacavograms were obtained. RESULTS The most common procedural event was filter limb asymmetry (10%), which had no clinical significance. A variety of other minor procedural events occurred in another 10% of cases. Early follow-up (< 6 months) was completed in 149 patients, and long-term evaluation was completed in 113 (> 12 months). Deaths in 24 patients were from nonembolic causes in all but one. There were four suspected or confirmed recurrent pulmonary emboli, for an incidence of 3.5% (four of 113), with one death (0.9%). Four patients had inferior vena cava occlusion at early follow-up and at long-term evaluation, only one remained occluded (1%). Insertion site venous thrombosis was seen in only two patients (2%). CONCLUSION The titanium Greenfield filter provides protection comparable to the standard stainless steel Greenfield filter after 1 year with a low incidence of recurrent pulmonary embolism (3.5%) and a high caval patency rate (99%).

Complications of the Nitinol Vena Caval Filter

Simon nitinol vena caval filters were placed percutaneously in 20 patients. Follow-up (average, 14 months) data were available for 16 patients, and four patients were lost to follow-up. There were no proved or suspected cases of pulmonary embolism after filter insertion. Complications encountered included caval penetration (n = 5, one acute and four at follow-up), caval thrombus (n = 4, two determined radiologically and two clinically), postplacement deep venous thrombosis (n = 2, one radiologic and one clinical), filter migration (n = 1), and delayed fracture of a filter leg (n = 2). Although no deaths or significant morbidity resulted from any complication, the relatively high complication rate, especially of significant caval penetration (documented in 25% of filter insertions), merits continued short- and long-term assessment of patient status after filter placement.

LGM Vena Cava Filter: Objective Evaluation of Early Results

One hundred one LG-Medical (LGM) vena cava filters were placed in 97 patients at four institutions. Placement was a complete technical success in 90% (91 of 101). In 6% of attempts, LGM filter insertion was complicated by incomplete opening of the filter. Pulmonary embolism after filter placement was not definitely demonstrated in any patient. The probability of inferior vena cava patency was 92% at 6 months after filter insertion. Thrombosis at the insertion site was seen in eight of 35 patients (23%) evaluated with duplex ultrasound or venography. Thrombus was observed in 37% of filters at follow-up examination, with cephalic extension of thrombus above the filter in 20% of all patients examined. Filter migration (greater than 1 cm) was seen in 12%; significant angulation was observed in only one patient (2%). In vitro experimentation demonstrated that incomplete opening of the LGM filter during placement can be avoided, in part, by brisk retraction of the insertion cannula. The low-profile introducer system of the LGM filter allows increased alternatives in selecting the site for filter insertion. The low-profile system also makes outpatient filter placement a possibility. No significant difference in the prevalence of thrombosis at the insertion site following LGM filter insertion was noted compared with previous results reported for percutaneous transfemoral placement of the Greenfield filter. The nonopaque sheath does not permit careful localization prior to filter deposition. Modification of the LGM filter to include a radiopaque sheath is suggested.

Mesoaortic compression of the left renal vein (the so-called nutcracker syndrome): Repair by a new stenting procedure

Compression of the left renal vein (LRV) between the superior mesenteric artery and the aorta has been termed the nutcracker syndrome. Although often asymptomatic, this syndrome may result in varicocele, ovarian vein syndrome, and rarely LRV hypertension, pelviureteral varices, hematuria, and flank pain. Previous surgical approaches have included nephrectomy, variceal ligation, nephropexy, or renocaval reimplantation. We report a new LRV stenting procedure that provided relief for a young woman incapacitated by daily left flank pain and microscopic hematuria. Phlebography of the LRV revealed mesoaortic compression associated with a pressure gradient of 12 mm Hg and preferential outflow down large pelviureteral varices. At operation compression of the LRV was corrected with an external stent of reinforced polytetrafluoroethylene. The patient was asymptomatic and free of hematuria for 9 months after operation and follow-up phlebography documented normal renocaval flow, elimination of the pressure gradient, and reduction of the pelviureteral varices. This represents the first description in the vascular surgical literature of this venous compression syndrome, which has been recognized in previous urologic and radiologic reports reviewed herein. Vascular surgeons should be cognizant of the nutcracker syndrome, and we recommend this new stenting procedure as a more simple and physiologic therapy than previous approaches to this problem.

Sonographic physical diagnosis 101: teaching senior medical students basic ultrasound scanning skills using a compact ultrasound system.

Abstract: This project was designed to test the feasibility of introducing ultrasound to senior medical students as a primary diagnostic tool in the evaluation of patients. Specifically, its aim was to determine if it is possible for medical students untrained in sonography to gain basic competence in performing abdominal ultrasound with limited didactic and hands-on instructions. Registered sonographers provided the students with hands-on instructions on the use of a compact ultrasound system. They were likewise shown how to evaluate specific organs and perform measurements. The results of the student measurements and those obtained by the sonographers were compared. There was close correlation between the results obtained by sonographers and students on both normal and abnormal findings. This supports the concept that medical students can be taught basic ultrasound skills with limited didactic and hands-on instructions with the potential of using these skills in the patient clinics as an adjunct to routine physical diagnosis.