Harpreet K. Pannu

Clinically occult recurrent ovarian cancer: patient selection for secondary cytoreductive surgery using combined PET/CT.

OBJECTIVE The aim of this study was to evaluate the utility of combined positron emission tomography/computed tomography (PET/CT) for identifying ovarian cancer tumor masses > or =1 cm in patients with clinically occult recurrent disease by conventional CT imaging. METHODS Twenty-two patients with epithelial ovarian cancer, rising serum CA125 levels, and negative or equivocal conventional CT imaging > or =6 months after primary therapy underwent combined PET/CT imaging followed by surgical reassessment. Fishers exact test was used to measure the ability of PET/CT to predict macroscopic disease > or =1 cm. RESULTS The median patient age was 55 years, and 91% of patients had FIGO Stage IIIC/IV disease. The median increase in serum CA125 was 24 U/ml (range 10 to 330 U/ml). Conventional CT was reported as negative (n = 15) or equivocal (n = 7) in all cases. Eighteen patients were ultimately found to harbor recurrent ovarian cancer measuring > or =1 cm at the time of surgery, with a median maximal tumor diameter of 2.3 cm (range 1.5 to 3.2 cm). The overall patient-based accuracy of PET/CT in detecting recurrent disease > or =1 cm was 81.8%, with a sensitivity of 83.3% and positive predictive value of 93.8% (P = 0.046). Of patients with recurrent ovarian cancer > or =1 cm, complete cytoreduction to no gross residual tumor was accomplished in 72.2%. CONCLUSION PET/CT imaging demonstrates high sensitivity and positive predictive value in identifying potentially resectable, macroscopic recurrent ovarian cancer among patients with biochemical evidence of recurrence and negative or equivocal conventional CT findings. In appropriately selected patients, early identification of macroscopic recurrent disease may facilitate complete surgical cytoreduction.

Early Invasive Cervical Cancer: Tumor Delineation by Magnetic Resonance Imaging, Computed Tomography, and Clinical Examination, Verified by Pathologic Results, in the ACRIN 6651/GOG 183 Intergroup Study

PURPOSE To compare magnetic resonance imaging (MRI), computed tomography (CT), and clinical examination for delineating early cervical cancer and for measuring tumor size. PATIENTS AND METHODS A 25-center study enrolled 208 patients with biopsy-proven invasive cervical cancer for MRI and CT before attempted curative radical hysterectomy. Each imaging study was interpreted prospectively by one onsite radiologist and retrospectively by four independent offsite radiologists, who were all blinded to surgical, histopathologic, and other imaging findings. Likelihood of cervical stromal and uterine body involvement was rated on a 5-point scale. Tumor size measurements were attempted in three axes. Surgical pathology was the standard of reference. RESULTS Neither MRI nor CT was accurate for evaluating cervical stroma. For uterine body involvement, the area under the receiver operating characteristic curve was higher for MRI than for CT for both prospective (0.80 v 0.66, respectively; P = .01) and retrospective (0.68 v 0.57, respectively; P = .02) readings. Retrospective readers could measure diameter by CT in 35% to 73% of patients and by MRI in 79% to 94% of patients. Prospective readers had the highest Spearman correlation coefficient with pathologic measurement for MRI (r(s) = 0.54), followed by CT (r(s) = 0.45) and clinical examination (r(s) = 0.37; P < .0001 for all). Spearman correlation of multiobserver diameter measurements for MRI (r(s) = 0.58; P < .0001) was double that for CT (r(s) = 0.27; P = .03). CONCLUSION In patients with cervical cancer, MRI is superior to CT and clinical examination for evaluating uterine body involvement and measuring tumor size, but no method was accurate for evaluating cervical stroma.

Dynamic pelvic magnetic resonance imaging and cystocolpoproctography alter surgical management of pelvic floor disorders

PURPOSE: Pelvic organ prolapse results in a spectrum of progressively disabling disorders. Despite attempts to standardize the clinical examination, a variety of imaging techniques are used. The purpose of this study was to evaluate dynamic pelvic magnetic resonance imaging and dynamic cystocolpoproctography in the surgical management of females with complex pelvic floor disorders. METHODS: Twenty-two patients were identified from The Johns Hopkins Pelvic Floor Disorders Center database who had symptoms of complex pelvic organ prolapse and underwent dynamic magnetic resonance, dynamic cystocolpoproctography, and subsequent multidisciplinary review and operative repair. RESULTS: The mean age of the study group was 58 ± 13 years, and all patients were Caucasian. Constipation (95.5 percent), urinary incontinence (77.3 percent), complaints of incomplete fecal evacuation (59.1 percent), and bulging vaginal tissues (54.4 percent) were the most common complaints on presentation. All patients had multiple complaints with a median number of 4 symptoms (range, 2–8). Physical examination, dynamic magnetic resonance imaging, and dynamic cystocolpoproctography were concordant for rectocele, enterocele, cystocele, and perineal descent in only 41 percent of patients. Dynamic imaging lead to changes in the initial operative plan in 41 percent of patients. Dynamic magnetic resonance was the only modality that identified levator ani hernias. Dynamic cystocolpoproctography identified sigmoidoceles and internal rectal prolapse more often than physical examination or dynamic magnetic resonance. CONCLUSIONS: Levator ani hernias are often missed by physical examination and traditional fluoroscopic imaging. Dynamic magnetic resonance and cystocolpoproctography are complementary studies to the physical examination that may alter the surgical management of females with complex pelvic floor disorders.

β-Blockers for Cardiac CT: A Primer for the Radiologist

OBJECTIVE The objective of this article is to describe a protocol for the administration of beta-blockers for cardiac CT. A low and regular heart rate is necessary for optimal visualization of the coronary arteries on CT and can be achieved by the administration of medications. CONCLUSION Beta-blockers can be safely given, orally or IV, to most patients to lower the heart rate for cardiac CT. A protocol can be implemented and patients can be screened for certain contraindications to allow successful administration of these medications by radiologists.

MR imaging of mediastinal lymph nodes: Evaluation using a superparamagnetic contrast agent

The purpose of this study was to determine whether intravenous injection of a magnetic resonance (MR) contrast agent, ultrasmall superparamagnetic iron oxide (ferumoxtran‐10), can be useful in characterizing lymph nodes in patients with lung cancer. Twelve patients with known or suspected lung cancer were studied. Pre‐ and postcontrast injection of ferumoxtran‐10 MR scans of the chest were obtained. Analysis of the signal intensities and bronchoscopic fine needle aspiration of a single node were performed in each patient. Six of 12 patients had a final diagnosis of lung cancer. T1‐weighted images were best for localizing mediastinal lymph nodes. Signal intensity changes before and after contrast were best visualized on T2‐weighted and gradient‐echo images. All four patients with lung cancer who had nodes positive for malignancy at biopsy had no change in signal intensity of the nodes on T2 images. The signal intensity decreased in the remaining two patients, and the nodes were benign. Of the eight patients with benign disease, five had no change in signal intensity of the nodes. Therefore the sensitivity for tumor involvement of the nodes is 100%, but the specificity is only 37.5%. Ferumoxtran‐10 is a contrast agent that can alter the signal intensity of lymph nodes. Lack of signal change may be due to malignant or inflammatory change. Studies in a larger population of lung cancer patients may help to characterize the utility of this agent further. J. Magn. Reson. Imaging 2000;12:899–904.

PELVIC FLOOR ANATOMY IN CLASSIC BLADDER EXSTROPHY USING 3-DIMENSIONAL COMPUTERIZED TOMOGRAPHY: INITIAL INSIGHTS

PURPOSE We present the pelvic floor anatomy of the major pelvic floor musculature in classic bladder exstrophy, including the levator ani, obturator internus and obturator externus. By improving our knowledge of pelvic floor anatomy we hope to understand better the relationship of the pelvic floor to the bony anatomy as well as the role of osteotomy in changing pelvic floor anatomy to enhance urinary control after surgery. MATERIALS AND METHODS 3-Dimensional computerized tomography was done in 6 boys and 1 girl, including 5 patients 2 days to 5 months old (mean age 7 months) undergoing primary closure and 2 who were 4 and 8 years old undergoing repeat closure. The pelvic floor musculature, including the levator ani, obturator internus and obturator externus, in these cases was compared to that in 26 age and sex matched controls. RESULTS The levator ani musculature encompasses a significantly wider area of 9.5 cm.2 in patients with classic bladder exstrophy than in controls. The anterior segment of the levator ani was shorter (1.2 cm.) and the posterior segment of the levator ani was longer (2.5 cm.) than in controls. The degree of divergence of the levator ani in classic exstrophy was significantly more outwardly rotated (38.8 degrees) than controls. In addition, the transverse diameter of the levator hiatus was 2-fold that in our control group and in that of published controls, while the length of the hiatus was 1.3-fold that in normal controls. There was also significant flattening, involving a 31.7 degree decrease in steepness between the right and left halves of the levator ani, of the puborectal sling in classic bladder exstrophy versus controls. Because of these findings, there is more anterior superior rotation in the pelvic floor in exstrophy cases. The obturator internus was more outwardly rotated (15.1 degrees) in exstrophy and the obturator externus also showed more outward rotation (16.9 degrees) than in controls. CONCLUSIONS This study provides better understanding of the pelvic floor anatomy in classic bladder exstrophy. Significant differences have been documented in the pelvic floor in classic bladder exstrophy cases and controls. Hopefully these differences may have a pivotal role in providing new insight into long-term issues, such as urinary and fecal incontinence, and pelvic organ prolapse, in classic bladder exstrophy.

PET-CT detection of abdominal recurrence of ovarian cancer:radiologic–surgical correlation

Abstract The diagnosis of recurrent ovarian cancer can be difficult on cross-sectional imaging, and variable sensitivities and specificities have been reported for positron emission tomography (PET). Combined functional and anatomic imaging with PET plus computed tomography (CT) potentially allows for improved detection of tumor masses. We investigated the sensitivity, specificity, and accuracy of PET-CT for the diagnosis of recurrent ovarian cancer. Sixteen women with previously treated ovarian cancer underwent imaging on a combined PET-CT scanner followed by surgery to assess for possible recurrent disease. The fused PET-CT images were retrospectively reviewed for recurrent disease, and the results of PET-CT were compared with the operative notes. Eleven of the 16 patients had recurrent disease at surgery. The sensitivity, specificity, and accuracy of PET-CT for disease detection on a per-patient basis were 72.7%, 40%, and 62.5%, respectively. For cases of malignant adenopathy (n = 7), 100% were detected on PET-CT. For peritoneal lesions no larger than 1 cm (n = 23), 13% were detected on PET-CT. For peritoneal lesions larger than 1 cm (n = 8), 50% were detected on PET-CT. The sensitivity of PET-CT for recurrent ovarian cancer is moderate in patients with low volume disease. A trial involving a larger number of patients with a spectrum of disease volumes is necessary to determine the impact of PET-CT in clinical practice.

Evaluation of the bony pelvis in classic bladder exstrophy by using 3D-CT: further insights☆

OBJECTIVES To provide a complete look at the bony pelvis in children with classic bladder exstrophy: dimensions, orientation, and relationships. METHODS Three-dimensional computed tomography was used in 6 boys and 1 girl, 5 of whom underwent primary closure and 2 who underwent reclosure at 4 and 8 months. These exstrophy pelves (intrapelvic angles and osseous dimensions) were compared with 26 age and sex-matched controls. RESULTS The iliac wing angle was 11.4 degrees larger in the classic bladder exstrophy cases. The sacroiliac joint angle was 9.9 degrees more externally rotated in the exstrophy cases. The pelvis was rotated 14.7 degrees in the superoinferior plane in the exstrophy cases. The mean pubic diastasis was 4.2 cm (0.6 cm in controls). The inter-triradiate distance in the patients with classic bladder exstrophy averaged 6.0 cm (4.2 cm in controls). CONCLUSIONS These new findings provide a better understanding of the bony pelvis, especially its posterior portion, in patients with classic bladder exstrophy. The results of this study revealed the orientation of the sacroiliac joints to be more externally oriented than previously thought and the pelvis to be rotated inferiorly, a previously unknown observation. Both of these factors will be important in the planning of newer osteotomies and pelvic reconstruction.

Three-dimensional computed tomographic imaging of complex congenital cardiovascular abnormalities.

Primary evaluation of congenital cardiac abnormalities traditionally relies upon echocardiography and conventional angiography, both of which have potential limitations. Echocardiography is an operator dependant study, limited by a small window and patient movement. Conventional angiography is an invasive procedure with an inherent risk of catheter complication such as vessel damage, bleeding, stroke and infection. During angiography, overlapping of the pulmonary and systemic circulation often provides a confusing picture given complex anatomy. Another limiting factor of particular significance in young children is radiation dose and contrast administration during catherization procedures. Three-dimensional MDCT provides an alternative to alleviate these pitfalls of traditional cardiac diagnostic studies. Development of multi-detector computed tomography (MDCT) and 3D software provides new methods for non-invasive visualization and evaluation of congenital cardiac abnormalities. The multiplanar, volumetric functions allow faster and more complete computed tomography diagnosis and better understanding of clinical relevance of complex cardiac anatomy. In addition, 3D imaging is particularly useful for preoperative planning and postoperative outcomes. This essay provides case studies to illustrate the usefulness of MDCT/3D CT for evaluation of complex congenital heart disease.

Coronary CT angiography with 64-MDCT: assessment of vessel visibility.

OBJECTIVE The objective of our study was to evaluate the image quality of 64-MDCT for coronary angiography. SUBJECTS AND METHODS Fifty consecutive CT coronary angiograms obtained on a 64-MDCT scanner were independently reviewed by two reviewers. Segments were scored as showing no motion (score of 1), minimal motion (2), moderate motion (3), respiratory motion (4), or vessel blurring (5). Opacification was graded as good (score of 1) or limited (2). Segments < 2 mm were graded as well seen; or as poorly seen or not seen. The scores for motion artifact, opacification, and visibility were combined for overall vessel assessment. Segments with a motion score of 1 or 2 that had good opacification and were well seen were judged to be assessable. RESULTS A total of 714 segments were analyzed in 50 patients. Seven hundred segments were assessed in all patients (segments 1-3, 11-20, 4, or 27), and a ramus intermedius segment was evaluated in 14 patients. Combining the scores for both reviewers, the average motion score was 1 for 619 segments (86.7%), the average motion score for all segments in an individual patient was 1.14 (range, 1-3.35), and the average opacification score for all segments in a patient was 1.02 (range, 1-1.38). A total of 374 segments were less than 2 mm in diameter. Combining the scores for both reviewers, an average of 36 segments (5.0% of 714) could not be identified by the reviewers, 319.5 segments (85.4%) were well seen, and 18.5 segments (4.9%) were poorly seen. Overall, an average of 637 segments (89.2%) were judged assessable by the reviewers. On a per-patient basis, 10 or more vessel segments were judged assessable in 47 patients (94%). CONCLUSION On 64-MDCT, 89% of coronary artery segments are assessable. Ten or more vessel segments are assessable in 94% of patients.