Mym Chen

Cystic changes in hepatic and peritoneal metastases from gastrointestinal stromal tumors treated with Gleevec.

AbstractBackground: Tyrosine kinase inhibitor (Gleevec or STI-571) must be considered the treatment of choice for metastatic gastrointestinal stromal tumors (GISTs). The purpose of this article is to address and illustrate a long-term follow-up of computed tomographic (CT) radiologic findings in patients with metastases from GIST after Gleevec treatment. Methods: We performed a retrospective review of seven patients (four male, three female) with unresectable metastases from GIST who were treated with STI-571 in a 1-year period. Patients were followed every 2–4 months by contrast-enhanced CT for up to 12 months. The size and attenuation of hepatic and peritoneal metastases on CT were measured and correlated. Results: Hepatic metastases from GISTs showed significant decreased attenuation from a mean of 60 HU to a mean of 32 HU (p < 0.01) in the first 2 months and continued decreasing attenuation to 23 HU at the 12-month follow-up. These metastases superficially resembled simple cysts. Most metastases became smaller, with more defined borders, after treatment. Histologic examination in a resected specimen revealed hepatic cyst with no residual tumor cells, regression of omental lesions, and extensive necrosis. Conclusions: CT findings of unresectable hepatic and peritoneal metastases from GIST displayed decreasing, near cystic attenuation and size as an effective regression in response to STI-571 treatment.

Defecography: Results in 55 patients and impact on clinical management

We reviewed the medical records and defecograms in 55 consecutive patients to determine the impact of results of defecography on clinical management. Main indication for defecography was constipation, present in 40 (73%) of 55 patients. In the remaining 15 patients, indications included obstructed defecation (5), incontinence (5), and miscellaneous symptoms (5). Defecography evaluated pelvic floor motion by assessing changes in the anorectal angle (ARA) and anorectal junction (ARJ) during various maneuvers, extent of evacuation, and structural abnormalities. Patients were grouped based on results of defecography as being normal (26) or abnormal (29). Comparison of measurements of the ARA and ARJ with various maneuvers showed no significant differences between the two groups. Clinical impact was determined by analyzing therapy done following defecography and subsequent patient response. In the normal group, 15 patients were managed medically, seven surgically, and four lost to follow-up. Clinical improvement occurred in 13 (59%) of 22 patients, with similar results between medical (60%) and surgical (57%) therapy. In the abnormal group, 16 had medical management, seven surgical therapy, and six lost to follow-up. Clinical improvement occurred in 13 (57%) of 23 patients but surgical therapy showed more improvement. In conclusion, most standard measurements of the ARA and ARJ were of no value in determining abnormality. Results of defecography did not alter selection of medical or surgical therapy, and had little impact on patient response to therapy.

Efficacy of hysterosalpingography in evaluating endometriosis.

Endometriosis is a common disease in young women being evaluated for infertility. Although endometriosis may cause tubal abnormalities on hysterosal-pingography, efficacy of radiographic evaluation in this disease is not clear. We reviewed the radiographic and laparoscopic examinations in 50 women being studied for infertility. Laparoscopy was normal in 15 women and showed endometriosis in 35 patients. Endometriosis was staged at laparoscopy using the classification of the American Fertility Society. Radiographic examinations were reviewed blindly and tubal status noted in each patient. Criteria for tubal abnormality included incomplete or absent filling and ampullary dilatation or convolution. Radiographic efficacy was determined by correlating the tubal appearance to the severity and location of endometriosis. A total of 98 tubes were correlated but only 10 (10%) were felt to be involved by endometriosis based on laparoscopic findings. Radiologic sensitivity was 40% (4 of 10) and specificity was 83% (73 of 88). Positive predictive value was 21% (4 of 19) due to 15 false-positive diagnoses in tubes uninvolved by endometriosis. In conclusion, endometriosis, regardless of its severity, rarely causes radiographic abnormalities on hysterosalpingography because of the location of disease in the pelvis.

Therapeutic ERCP: Spectrum of procedures performed in 60 consecutive patients

Therapeutic applications of endoscopic retrograde cholangiopancreatography (ERCP) have increased dramatically, and endoscopic sphincterotomy (ES) is the cornerstone of these techniques. Indications include treatment of retained biliary duct stones, papillary stenosis, benign and malignant strictures, and acute cholangitis and pancreatitis. We reviewed our recent experience to assess the spectrum of procedures done and their results. Medical records and radiographic examinations in 60 consecutive patients undergoing therapeutic ERCP were studied. Patients were placed into one of three treatment groups; Group 1, ES alone (N=21); Group 2, ES plus stone retrieval (N=15); and Group 3, ES plus stent placement (N=24). In Group 1, all of eight patients with ductal stones had spontaneous passage. In 11 patients with papillary stenosis, nine had relief of symptoms following ES. Two patients with pancreatitis improved after ES. In Group 2, all 15 patients with ductal stones had successful retrieval. In Group 3, patients were treated for biliary stricture alone (4), retained stones (7), pancreatitis (5), neoplasms (6) and papillary stenosis (2). In these 24 patient, 21 (88%) were treated successfully or had palliation of their symptoms. In our series, a wide variety of therapeutic applications of ERCP was used to manage simple and complex biliary disease. ES alone or in combination with other techniques was done in all patients. Overall, 55 (92%) of 60 interventional procedures were successful as defined by removal of stones and relief or palliation of symptoms.

Hysterosalpingography after hysteroscopic surgery

We reviewed pre- and postoperative appearances of the uterine cavity on hysterosalpingography (HSG) in 28 patients who had hysteroscopic surgery. Twelve patients presented with primary infertility and 16 patients with secondary infertility. The uterine abormalities included synechiae (12), septa (8), submucosal fibroids (7), and polyp (1). The size and number of lesions in the uterus, the extent of improvement after surgery, and the postoperative pregnancy rate were recorded. The uterine cavity was restored to a normal appearance in 23 (82%) of 28 patients. In patients after fibroid resection, all uterine cavities reverted to normal after surgery. Two patients developed adhesions after septal resection. Three patients with lysis of synechiae remained unchanged or had worsened intrauterine scarring. The postoperative pregnancy rate was 35% (six of 17) in those patients followed for more than 6 months. One patient had a spontaneous abortion. In the six patients who became pregnant, four had secondary infertility, and all had normal or substantial improvement in the appearance of the uterine cavity after surgery. Perforation of the uterus occurred in one patient after resection of a fibroid.