John C. Scatarige

Fatty infiltration of the liver: ultrasonographic and computed tomographic correlation.

To evaluate the accuracy of ultrasonography in diagnosing fatty infiltration of the liver (FIL), the authors compared gray‐scale B‐mode ultrasonography and unenhanced computed tomographic (CT) liver images in a study of 47 patients. The CT scans, which served as the diagnostic standard, were classified as normal, Grade 1 (mild FIL), Grade 2 (moderate FIL), and Grade 3 (severe FIL). Applying predetermined sonographic textural criteria, two experienced radiologists independently graded each ultrasound study for the presence and severity of FIL. The overall accuracy of ultrasonography in detecting FIL was 85 per cent, with 100 per cent sensitivity and 56 per cent specificity. The sonographic/CT correlation in grading the severity of FIL was particularly good for Grade 2 and Grade 3 FIL. Ultrasound is a sensitive and reasonably accurate diagnostic tool in assessing fatty infiltration of the liver.

Computed tomography of endometriosis.

Six examples of pelvic masses due to endometriosis were detected by computed tomography (CT) in a group of women aged 30–43. Lower abdominal or pelvic pain was the chief complaint in four cases. The ileum and rectosigmoid were routinely opacified with contrast material prior to examination. Endometriosis exhibited a variety of findings including a constricting rectosigmoid mass, a lesion of the pelvic side wall, bowel wall implants, and posthysterectomy pelvic masses. There was no standard CT density: the lesion near the pelvic side wall appeared solid, one cul-de-sac mass appeared solid, and a second had a mixed eystic and solid appearance. Discrete adnexal endometriosis appeared as thick-walled cystic masses (two cases) or as a simple eyst (one case). Bowel wall involvement and the pelvic side wall lesion were not successfully identified by ultrasound. It is concluded that CT can play a role in the diagnosis of endometriosis.

Gastric leiomyosarcoma: CT observations.

The abdominal CT examinations of seven patients with gastric leio-myosarcoma (GLMS), proven by surgical or endoscopic biopsy or both in five patients and percutaneous aspiration biopsy in two, are reviewed. In the six patients studied prior to therapy, CT demonstrated that each of the primary gastric tumors was spherical or ellipsoidal, large (mean diameter 15 cm), and predominantly exogastric in location. Additional CT features of the primary tumor included necrosis in all six masses, a distinct gastric mural attachment in four, bubbles of gas or an air-fluid level or both in three, and mucosal ulceration in two. Direct tumor invasion of nearby organs was suggested by CT in four of the six patients, the spleen and pancreas representing the most frequent sites. Intraperitoneal spread of tumor was present in two patients: necrotic liver metastases accompanied three of the six primary tumors and were found in an additional patient examined 4 years after gastric resection. By accurately reflecting the biological behavior of GLMS, CT is an ideal imaging modality for studying this unusual neoplasm. Differential diagnosis and specificity of the CT findings are discussed.

Computed tomography of calcified liver masses

Our retrospective study of 230 computed tomographic (CT) studies of hepatic masses yielded 28 cases (12.2%) which contained calcification. Calcific deposits were noted in 9 of 59 patients (15.3%) with hepatocellular carcinoma (HCC), 15 of 82 patients (18.3%) with liver metastases from colorectal carcinoma (MCRC), 2 of 71 patients (2.8%) with noncolonic liver metastases, and 2 of 18 patients (11%) with a benign liver mass. The patterns of calcification in HCC and MCRC were highly variable and exhibited some overlap. Although the CT demonstration of calcification in HCC and MCRC is not uncommon, particularly in patients who have undergone radiotherapy or chemotherapy, we could identify no specific diagnostic pattern.

Do high-resolution CT findings of usual interstitial pneumonitis obviate lung biopsy? : Views of pulmonologists

Background: High-resolution CT (HRCT) of the lungs has become an essential component to evaluate patients with diffuse lung disease. Little is known, however, about the current practices of pulmonologists caring for patients with these complex conditions, and, in particular, whether HRCT can obviate the need for surgical lung biopsy. Objectives: To investigate the practices of pulmonologists concerning the acceptability of a HRCT diagnosis in lieu of lung biopsy in diffuse lung disease. Methods: We asked practicing pulmonologists among membership of the American College of Chest Physicians whether HRCT results could replace lung biopsy in 16 diffuse lung diseases. Responses were examined in light of published evidence, practice guidelines, and certain practice parameters. Results: Two hundred and thirty (52.6%) of 437 eligible physicians responded. Sixty-seven percent (67%) of respondents accepted HRCT diagnosis for idiopathic pulmonary fibrosis/usual interstitial pneumonia (IPF/UIP) despite their awareness of guidelines recommending histological diagnosis. Most would not accept a radiologic diagnosis for lymphangioleiomyomatosis (LAM; 37%) or eosinophilic granuloma (Langerhans’ cell histiocytosis, LCH; 19%), even though CT findings are frequently characteristic. Responses were similar by type of clinical practice and recency of fellowship training. Chest physicians who referred patients for HRCT more frequently were more likely to accept HRCT diagnosis (p = 0.008) and those who had higher self-ratings of proficiency in reading HRCT (p = 0.004) were more likely to believe HRCT often suggests specific diagnosis. Conclusions: Most US pulmonologists will accept an HRCT diagnosis of IPF/UIP without lung biopsy, but are reluctant to do so for most other diffuse lung conditions including LAM and LCH.

Low attenuation nodal metastases in testicular carcinoma

Abdominal and thoracic computed tomography examinations were abnormal in 23 of 57 patients (40.5%) with seminomatous and nonseminomatous testicular tumors. Lymph node metastases measuring less than 30 Hounsfield units (HU) occurred in 10 of these 23 patients (43.5%), five with seminoma, four with mixed germ cell tumors, and one patient with embryonal cell carcinoma. Biopsy material was obtained from low attenuation metastases in four patients. Three patients who had completed chemotherapy had evidence of extensive necrosis, but two of three had persistent tumor. In the fourth patient, a case of untreated mixed germ cell tumor, there were numerous small epithelial-lined cystic spaces. Biopsies from five patients with nodal masses measuring greater than 30 HU showed no necrosis or cystic change. There was no significant correlation between the attenuation characteristics of the metastases and clinical activity of the tumor.

Distribution of metastases in breast carcinoma: CT evaluation of the abdomen

To determine the frequency and distribution of extrahepatic and extraskeletal metastases in patients with breast carcinoma, the abdominal CT scans of 260 consecutive patients were systematically evaluated. Extrahepatic and extraskeletal metastases were demonstrated in 26 patients (10%). Confirmation of findings was made by biopsy, autopsy, or by demonstration of progression or regression of disease. Twelve patients (4.6%) demonstrated metastases to the stomach, eleven of whom presented with a linitis plastica pattern. Retroperitoneal and/or mesenteric adenopathy was noted in 10 patients (3.8%), of whom three demonstrated associated hydronephrosis and one demonstrated associated biliary obstruction. Ascites was seen in 14 (5.4%) and peritoneal carcinomatosis in 7 (2.6%). Genitourinary involvement included metastases to the kidney (one case), ureter (one), and uterus (one). Direct invasion of the diaphragm by adjacent pleural metastases (two cases) as well as a soft tissue metastasis (one case) was also demonstrated. Metastases to the ovaries, adrenals, or pancreas could not be identified. Although lesions to the liver and skeleton account for the largest group of metastases from breast carcinoma seen in the abdomen, one should be aware of the potential for other locations of metastatic disease.

Comparison of Supine Magnetic Resonance Imaging With and Without Rectal Contrast to Fluoroscopic Cystocolpoproctography for the Diagnosis of Pelvic Organ Prolapse

Purpose: To compare supine magnetic resonance imaging (MRI), with and without rectal contrast, with fluoroscopic cystocolpoproctography (CCP) for the diagnosis of pelvic organ prolapse. Materials and Methods: Supine MRI and CCP studies were reviewed in 82 patients. All patients were women with an average age of 58.8 years, and the studies were done a mean of 25 days apart. Magnetic resonance imaging was performed with rectal contrast (n = 35) and without rectal contrast (n = 47). Fluoroscopic cystocolpoproctography was performed with rectal (n = 82), vaginal (n = 82), small bowel (n = 81), and bladder (n = 78) contrast, and images were corrected for magnification. Each study was independently reviewed by 2 readers, and outcome variables were presence/absence of cystocele, vaginal prolapse, enterocele, sigmoidocele, and anterior rectocele. Sigmoidoceles were included with enteroceles for data analysis. Results: For the entire patient group, the prevalence of cystoceles was 89% on CCP and 80% on MRI; vaginal prolapse was 81% on CCP and 56% on MRI; enteroceles, 38% on CCP and 24% on MRI; and anterior rectoceles, 45% on CCP and 37% on MRI. There were significantly more cystoceles (odds ratio [OR] 4.7, P = 0.003), vaginal prolapses (OR 5.2, P < 0.0005), and enteroceles (OR 3.8, P< 0.0005) on CCP than on MRI. For MRI with rectal contrast versus CCP, the prevalence of cystoceles was 94% on CCP and 91% on MRI; vaginal prolapse, 74% on CCP and 70% on MRI; enteroceles, 36% on CCP and 19% on MRI; and anterior rectoceles, 51% on CCP and 59% on MRI. There was statistical significance only for enteroceles, more of which were found on CCP (OR 7.4, P = 0.003). For MRI without rectal contrast versus CCP, the prevalence of cystoceles was 85% on CCP and 72% on MRI; vaginal prolapse, 86% on CCP and 46% on MRI; enteroceles, 40% on CCP and 28% on MRI; and anterior rectoceles, 39% on CCP and 21% on MRI. There were significantly more cystoceles (OR 6.6, P = 0.003), vaginal prolapses (OR 20.8, P < 0.0005), enteroceles (OR 2.9, P = 0.015), and rectoceles (OR 4.9, P = 0.001) on CCP than on noncontrast MRI. Conclusions: Magnetic resonance imaging without rectal contrast showed statistically fewer pelvic floor abnormalities than CCP. Except for enteroceles, MRI with rectal contrast showed statistically similar frequency of pelvic organ prolapse as CCP.

CT demonstration of high attenuation pleural-parenchymal lesions due to amiodarone therapy

We report a case in which CT demonstrated high attenuation pleural-parenchymal lesions (142-175 HU) and increased liver density (96.7 HU) in a patient on long-term amiodarone therapy.

Utility of high-resolution CT for management of diffuse lung disease: results of a survey of U.S. pulmonary physicians.

RATIONALE AND OBJECTIVES This study was performed to determine how U.S. pulmonologists rate the clinical contributions of high-resolution computed tomography (CT) in patients with diffuse lung disease, to ascertain how the technique affects management decisions, and to determine the effect of three physician characteristics on these attitudes. MATERIALS AND METHODS The authors surveyed 450 practicing pulmonologists. The questionnaire explored perceptions of the efficacy of high-resolution CT for achieving five clinical objectives, the importance of high-resolution CT in 17 diseases, and the effects of the CT results on management decisions. Responses were examined by type of clinical practice, monthly referral volume, and year of completion of pulmonary fellowship. RESULTS The response rate was 52.6%. High-resolution CT was rated most helpful for determining the extent of diffuse lung disease and least helpful for assessing disease activity and prognosis. Pulmonologists believed that high-resolution CT was most important in the idiopathic interstitial pneumonias and least important in Pneumocystis carinii pneumonia and emphysema. High-resolution CT results frequently increased the physicians confidence in a presumptive diagnosis. Recently trained pulmonologists were more likely to report that high-resolution CT results altered their management plan. There were no significant differences related to type of practice. CONCLUSION U.S. pulmonologists in a variety of practice settings value the contributions of high-resolution CT in patients with diffuse lung disease and find it particularly important in the chronic interstitial pneumonias. High-resolution CT results have their greatest effect in confirming a presumptive clinical diagnosis and less frequently alter the management plan.