Neil T. Wolfman

Malignant papillary cystic tumor of the pancreas

An example of the rare papillary cystic tumor of the pancreas was diagnosed cytologically by aspiration of the primary neoplasm. Subsequently, it metastasized, proving its low‐grade malignant behavior. Diagnostic cytomorphologic features included abundant straight and branched papillary tissue fragments, and uniform, pale nuclei with folds or grooves. Although the primary tumor had a typical histologic appearance, metastases demonstrated increased nuclear pleomorphism and hyperchromasia, bizarre tumor giant cells, and an increased mitotic rate. Vimentin was diffusely positive, whereas neuron‐specific enolase and somatostatin were focally and weakly reactive. Neurosecretory and zymogen granules were absent ultrastructurally. By flow cytometric study, the tumor was aneuploid (DNA Index = 1.3).

Assessment of rectal tumor infiltration utilizing endorectal MR imaging and comparison with endoscopic rectal sonography

The preoperative assessment of depth of invasion of rectal carcinoma is increasingly important as new treatment methodologies are developed. Accuracy of preoperative endorectal MR imaging was therefore compared with that of the endoscopic rectal sonography in determining depth of invasion of rectal carcinomas.

Ultrasonographic diagnosis of varicoceles

OBJECTIVE To assess the ability of color duplex scrotal ultrasonography to detect subclinical varicoceles and confirm the diagnosis of clinical varicoceles. DESIGN Physical examination, color duplex scrotal ultrasonography and internal spermatic venography was performed on 64 testicular units in 33 men. SETTING Male fertility center. PATIENTS Two hundred sixty-two consecutive men being evaluated for male factor infertility of whom 33 agreed to undergo venography. MAIN OUTCOME MEASURES Ultrasonographic measurement of scrotal vein diameter of patients in the supine and upright position, before and during valsalva maneuver, and scrotal vein blood flow reversal with valsalva maneuver was compared with the findings of varicocele by physical examination and venography. RESULTS The best predictor of a varicocele was internal spermatic vein diameter, and the best overall performance of ultrasonography was achieved with the patient at rest in the supine position. The best cutoff point for venous diameter for a clinical varicocele was 3.6 mm and 2.7 mm for a subclinical varicocele, but the overall accuracy was only 63%. CONCLUSIONS Confirmatory studies are needed to support the ultrasonographic diagnosis of varicoceles before considering surgical repair.

Interpretation of abdominal CT: Analysis of errors and their causes

PURPOSE Our goal was to analyze those factors contributing to the error rate in the interpretation of abdominal CT scans at an academic medical center. METHOD From a total of 694 consecutive patients (329 male, 365 female), we evaluated the error rates of interpreting abdominal CT studies. The average patient age was 54 years. All abdominal CT studies were reviewed by three to five CT faculty radiologists on the morning after the studies were performed. The error rate was correlated with reader variability, the number of cases read per day, the presence of a resident, inpatient versus outpatient, organ systems, etc. The chi 2-test was used for statistical analysis. RESULTS A total of 56 errors were found in the reports of 53 patients (overall error rate = 7.6%). Of these errors, 19 were judged to be clinically significant and 7 affected patient management. A statistically significant difference in error rates was noted among the five faculty radiologists (3.6-16.1%, p = 0.00062). No significant correlates between error rates and any of the other variables could be established. CONCLUSION The primary determinant of error rates in body CT is the skill of the interpreting radiologist.

MR imaging of anterior cruciate ligament repair.

Magnetic resonance (MR) imaging is an accurate means of analyzing disruptions of the native anterior cruciate ligament (ACL). Various techniques may be used to repair a disrupted ACL. A common repair is the Macintosh lateral-substitution over-the-top repair in which a strip of fascia lata from the iliotibial band is used as a “neoligament.” The results of 27 MR examinations of 17 athletes with this repair were analyzed to determine the appearance of the neoligament on MR. Thirteen of the 17 patients had returned to full athletic activity and four were capable of strenuous activity. Examinations were made at both 0.5 and 1.5 T in varied extents of external rotation from 0 to 20°, and at variable time intervals after surgery from 1 to nearly 40 months. Only two patients clinically required postrepair arthroscopy, but both had normal repairs. Neoligaments were classified as well-defined (n = 6 studies), ill-defined (n = 10), and not discernible (n = 11), based on clarity of appearance. Reasons for this variable appearance include the variable presence of fibrous and fatty tissue investing the neoligament. We conclude that the normal neoligament, unlike the normal active ACL, has a variable appearance, including nonvisualization on MR and that criteria used in evaluating the native ligament will be inadequate to assess the repair.

Occult pneumothorax in patients with abdominal trauma: CT studies.

Abdominal CT, which routinely includes the lower thorax, is an important adjunct to supine chest radiography in detecting chest injury in patients with blunt abdominal trauma. In 1,086 consecutive patients with blunt abdominal trauma, 223 of whom had both supine chest radiography and abdominal CT, 49 patients examined with both techniques had pneumothoraces, 28 of them occult (seen only on CT). To help guide management, we established three categories of occult pneumothorax, based on size and location: (a) minuscule (<1 cm in greatest thickness, seen on four or fewer images); (b) anterior (>1 cm in greatest thickness, but not extending beyond the midcoronal line); (c) anterolateral (extending beyond the midcoronal line). In our study four of six patients with minuscule pneumothorax, including one who required mechanical ventilation, were observed without complications; two of six patients had chest tube placement. Seven of 14 cases with anterior pneumothorax were observed and resolved without complication; seven had chest tube placement. All eight patients with anterolateral pneumothoraces underwent percutaneous tube thoracostomy, regardless of proposed management. Index Terms: Pneumothorax—Trauma—Abdomen, wounds and injuries—Thorax—Computed tomography.

Computed tomography evaluation of colorectal carcinoma.

Knowledge of the extent of primary colorectal carcinoma at initial diagnosis is critical for proper management of disease. Currently, CT does not have a role in screening for colorectal carcinoma, though promising work on virtual colonoscopy is on the horizon. In patients with proven colorectal carcinoma, accurate prospective noninvasive assessment can identify those who may benefit from preoperative local radiotherapy, hepatic resection or cryoablation, or intra-arterial chemotherapy. CT should be considered complementary to the clinical assessment of colorectal carcinoma and to other modalities, such as barium enema, endorectal ultrasonography, MRI, and immunoscintigraphy. Although limited in evaluation of the primary tumor and local spread, CT has proven useful in assessing patients thought to harbor extensive local or metastatic disease. CT is generally the modality of choice for imaging the postoperative patient. The cross-sectional display of CT clearly depicts the operative bed, particularly after abdominoperineal resection. Baseline examinations should be obtained 2 to 4 months after surgery, with follow-up examinations every 6 to 9 months for 2 years, and yearly studies thereafter. CT-guided biopsies should be performed when findings suggest recurrent carcinoma.

Evaluation of aortocoronary bypass graft status by computed tomography.

Abstract The efficacy of contrast-enhanced computed tomography to define graft patency status was studied in 42 patients with 100 aortocoronary vein grafts. The status of each graft had been determined earlier by anglography. A rotary fan beam whole body scanner with a 2 second scan duration was used. Initial scans determined the optimal level for study of the graft; patency was assessed by computed tomographic enhancement of the graft after intravenous bolus injection of 30 ml meglumine and sodium diatriazoate. The computed tomographic studies were evaluated without knowledge of the anglographic findings; graft status by computed tomography was interpreted as patent, occluded or equivocal. Overall, computed tomography correctly defined graft patency status in 79 of the 100 grafts and incorrectly identified it in 9; in 12 grafts, the computed tomographic diagnosis was equivocal. Computed tomography correctly identified 61 of 74 patent grafts and 18 of 26 occluded grafts. Patency status was correctly defined by computed tomography in 35 of 37 grafts to the left anterior descending artery, 23 of 30 grafts to circumflex branches and 19 of 31 grafts to the right coronary artery. These data indicate that computed tomography is a promising noninvasive method of determining patency of aortocoronary bypass grafts, especially of grafts to the left anterior descending artery.

Magnetic Resonance Imaging of the Renal Mass

To compare the effectiveness of magnetic resonance imaging with that of excretory urography, retrograde pyelography, ultrasound, computerized tomography, angiography and venography 34 patients with renal masses, including 25 renal cell carcinomas, were examined on a 0.15 Tesla Picker 1100 magnetic resonance imager with multiple pulse sequences. Pathological proof was available for all cases except renal cysts, for which ultrasound or computerized tomographic findings were accepted. Differentiation of solid from cystic lesions was seen with magnetic resonance imaging, ultrasound and computerized tomography but not excretory urography. Tumor invasion of the renal vein and inferior vena cava was visualized in 7 patients by magnetic resonance imaging, ultrasound, computerized tomography and venography but not by excretory urography. Magnetic resonance T1 contrast scans best characterized renal masses, with good resolution of metastatic lymphadenopathy and renal cysts. Scans showing T2 contrast were best for identification of pseudocapsules in renal carcinoma, venous invasion by tumors and papillary adenocarcinoma. Advantages of magnetic resonance imaging include differentiation of solid masses from benign cystic lesions, and identification of major blood vessels and vascular invasion without administration of contrast medium. Disadvantages of magnetic resonance imaging are long imaging times and motion artifacts. Advances by the manufacturer in solving these problems will strengthen the role of magnetic resonance imaging in renal evaluation.

Ultrasonic characteristics of pancreatic tumors

The ultrasonic features of 40 pancreatic tumors were analyzed. The tumors were categorized by texture, attenuation, shape, size, and location. Secondary effects of pancreatic duct visualization, biliary stasis, splenic vein involvement, metastases, and ascites were reviewed. Thirty of thirty-one adenocarcinomas had a similar ultrasonic texture consisting of a background of faint, low-level echoes with varying amounts of superimposed coarse echoes. Tumors are detectable prior to enlargement or distortion of the pancreas. Secondary features were present in 94% of the adenocarcinomas. Significant information regarding the possibility and complexity of resection can be provided.