Wolf B. Schwerk

Ultrasonography in the diagnosis of acute appendicitis: A prospective study

The diagnostic accuracy and practical impact of high-resolution sonography were prospectively studied in 523 consecutive patients admitted to the hospital with suspected appendicitis. The criteria for ultrasound diagnosis of acute appendicitis included visualization of a noncompressible aperistaltic appendix, with a targetlike appearance in transverse view and a diameter greater than or equal to 7 mm. In 115 of 130 patients with proven appendicitis the inflamed appendix or appendiceal abscess could be visualized, giving a sensitivity of 88.5%. The mean diameter of ultrasonically visible appendices was 11.4 +/- 3.2 mm. The overall accuracy and specificity of sonography in the diagnosis of acute appendicitis were 95.7% and 98%, respectively. The predictive value of a positive test was 94.5% and that of a negative result 96.3%. In a separate analysis of the results in 121 women of childbearing age, who have a high risk of preoperative misdiagnosis, the overall accuracy was found to be 96.7%, with 82.6% sensitivity and 100% specificity. Twenty-four (89%) of the 27 patients with appendiceal rupture (incidence 20.8%) were correctly diagnosed with ultrasound. The other 3 cases (11%) were missed. Routine use of ultrasonography has significantly improved the diagnostic accuracy in patients with suspected appendicitis and has reduced the negative laparotomy rate from 22.9% to 13.2%.

Sonography in acute colonic diverticulitis

The clinical value of high-resolution real-time sonography for the diagnosis of acute and complicated colonic diverticulitis was prospectively studied in 130 consecutive patients with abdominal complaints, because of which the disease entered into differential consideration. The results of ultrasound investigation were compared with those of clinical examination on admission. Regarding history and initial clinical evaluation, diverticulitis was graded as “highly suspected” in 19 (36.5 percent) out of a total of 52 patients with later proven colonic diverticulitis (prevalence 40 percent), as “possible but equivocal” in 24 (46.2 percent), and as “very unlikely” in the remaining nine (17.3 percent) patients. Ultrasonography enabled the diagnosis of diverticulitis with an overall accuracy of 97.7 percent, a sensitivity of 98.1 percent, and a specificity of 97.5 percent. The predictive values of positive and negative ultrasound examinations were 96.2 percent and 98.5 percent, respectively. The echomorphologic features of acute diverticulitis include visualization of a colon segment presenting with local tenderness on gradual compression, which showed hypoechogenic thickening of the wall and a targetlike appearance in transverse view due to inflammatory changes and muscular thickening. Sonographic signs of peridiverticulitis (hyperechoic halo) were found in 96 percent of patients, echogenic diverticula in 86 percent. Twelve (92 percent) of 13 abdominal abscesses were detected on initial ultrasound examination and could be treated by percutaneous drainage in seven cases, while six required surgical intervention. These results indicate that high-resolution sonography with graded compression is highly sensitive and specific for the imaging diagnoses of acute colonic diverticulitis and complicating abscess.

Ultrasound diagnosis of C‐cell carcinoma of the thyroid

Ultrasound screening in 9 and 21 members, respectively, of two families affected by familial C‐cell carcinoma, as well as sonographic findings in 6 patients with sporadic medullary carcinoma of the thyroid (MCT), are reported. Unilateral and bilateral tumor nodules were identified by sonography in 12 of fl total of 13 patients with MCT (n = 9) or local tumor recurrence following thyroidectomy (n = 4); one carcinoma, 3 × 6 mm in diameter, was missed. Nine of the 12 (75%) were clinically occult, nonpalpable C‐cell carcinomas. The smallest occult MCT correctly diagnosed by ultrasound had a diameter of 4 mm. A positive correlation was found between the sonographically determined tumor mass (number/size of nodules/metastases) and the plasma calcitonin level. Pheochromocytomas were diagnosed by ultrasound as part of a multiple endocrine neoplasia (MEN IIa) in two patients with MCT. The echomorphologic findings of the intrathyroid C‐cell carcinomas and their metastases display characteristic but nonspecific features. Sonographic findings on these tumors should therefore not be interpreted without consideration of plasma calcitonin assays.

Adrenal masses in lung cancer: Sonographic diagnosis and follow-up

Ultrasound has become an important diagnostic modality in the staging of patients with lung cancer. Between 1980 and 1990, 410 patients with histologically proved lung cancer were evaluated. In 44 patients (11%) an adrenal mass was discovered on ultrasound; in 13 patients it was isolated, and in 31 further evidence of abdominal disease was shown. Sonographic follow-up examinations of adrenal masses showed changes of size in all but 2 patients, and were therefore found to be adrenal metastases. In the 2 patients with isolated and stable adrenal disease, fine-needle biopsy revealed adenomas. Adrenal masses in patients with lung cancer are more likely to be metastatic than benign. The existence of neoplastic adrenal disease can be retrospectively confirmed by changes of size during sonographic follow-up examinations in almost all patients. Histologically verification would only appear necessary in stable adrenal disease and in cases with isolated adrenal disease in which prompt diagnosis affects treatment decision.

Concomitant Primary Low Grade Non-Hodgkin's Lymphoma of the Spleen and Breast Carcinoma

A case is described of a 71 year old woman with scirrhous breast cancer and multiple hypoechogenic lesions in the spleen. The patient was treated successfully by mastectomy and splenectomy. Morphologic examination of the spleen showed a primary, centroblastic-centrocytic, low grade non-Hodgkins lymphoma. Eight months after splenectomy the patient still remains in complete remission.

196. Das C-Zell-Carcinom der Schilddrüse (medulläres Carcinom)

SummaryA review of the case histories of 44 patients showed an increasing incidence of C-cell carcinoma with an increasing amount of “occult” familiary tumors diagnosed at young age. Early diagnosis is important: lymph node metastases, which occur frequently and early, are decisive with regard to prognosis. The important diagnostic methods for family screening, sporadic (palpable) tumors and follow-up are stimulation of s-calcitonin (Pentagastrin), ultrasonography, CMT and selective venous catheterization. The presence of an MEN II syndrome should be known preoperatively. Surgical strategy has to take into account the differences between sporadic and familiary tumors and early stages in the familiary form. In occult tumors total thyroidectomy should also be performed together with an appropriate lymph node dissection.ZusammenfassungAm Krankengut von 44 Patienten wird die Zunahme der Incidenz und der Anteil familiärer, vor allem „occulter” Carcinome, die schon in jugendlichem Alter diagnostiziert werden können, beschrieben. Die frühe Diagnose ist entscheidend, da LK-Metastasierung häufig und früh erfolgt und einen entscheidenden prognostischen Faktor darstellt. Wichtige diagnostische Hilfsmittel bei Screening und Follow-up sind neben dem Calcitonin-Stimulationstest die Sonographie, das CT und die selektive Venenkatheterisierung. Ein MEN II-Syndrom sollte präoperativ bekannt sein. Das chirurgische Therapiekonzept orientiert sich am sporadischen bzw. familiären TU und bei letzterem am unterschiedlich frühen Tumorstadium. Es schließt auch bei occultem TU stets eine angemessene Lymphknotendissektion ein.