Spinal and meningeal metastatic disease

This contribution presents an approach to diagnosis in patients known to have malignant disease, who present with neurological symptoms and signs which may be a result of epidural spinal cord compression or intradural spinal disease.

Metastatic carcinoma of the breast: the appearances of metastatic spread to the abdomen and pelvis as demonstrated by CT

This review illustrates some CT appearances of metastatic breast cancer in the subdiaphragmatic abdomen and pelvis. Such manifestations are not uncommon in advanced disease and familiarity will enable confident diagnosis in patients at risk for metastatic disease.

The pathway study: results of a pilot feasibility study in patients suspected of having lung carcinoma investigated in a conventional chest clinic setting compared to a centralised two-stop pathway

The best chance of cure in non-small cell lung cancer (NSCLC) is surgical resection, but UK rates of 8% compare poorly to 25% in the USA and Europe. Delays in diagnosis in the current UK system may be one reason for such discrepancy. To address this problem we set up a rapid diagnostic system and compared it to the conventional method of investigations in a pilot randomised trial.

METHODS

Eighty-eight patients were prospectively enrolled from three District General Hospitals and randomised to either investigation locally or to the rapid system at The Royal Marsden Hospital. The pilot end-points were feasibility and audit of radical treatment rates to enable estimates for patient numbers for the full study.

RESULTS

Forty-five and 43 patients were in the central and conventional arms, respectively (65% male, median age 69 years). There was a 4-week improvement in time to first treatment in those in the central arm (P=0.0025) with 13/30 (43%) and 9/27 (33%) patients having radical treatment in the central and conventional arms, respectively. Patients in the conventional arm felt the diagnostic process was too slow (P=0.02) while those in the central arm seemed to have a better care experience (P=0.01). There were significantly less visits to the general practitioner (GP) in the central arm (P=0.02).

CONCLUSIONS

This pilot study demonstrates that the full study is feasible but would require the commitment and involvement of a large number of patients and physicians. The results show several advantages to investigations and diagnosis in the central arm, particularly in time to treatment initiation, patient satisfaction and rate of radical treatments. The improved rate of radical treatment could lead to an improved survival rate.

Vertebral compression fractures in acute lymphoblastic leukaemia and remodelling after treatment

Three children, aged 7-10 years, with acute lymphoblastic leukaemia presented with back pain, along with a mild kyphosis. Collapse of the vertebral bodies at multiple levels was shown on imaging. Chemotherapy resulted in pain resolution and spontaneous remodelling of the vertebrae.

Pneumomediastinum complicating bleomycin related lung damage

We describe two patients who developed spontaneous pneumomediastinum without pneumothorax against a background of bleomycin-induced pulmonary interstitial disease whilst on treatment for metastatic germ cell tumours of the testis. Pneumomediastinum is a rare but recognized complication of bleomycin-induced lung toxicity, which has previously only been described in association with pneumothorax.

Assessment of response following treatment for malignant disease

Monitoring tumour response to therapy is an increasingly important aspect of oncological radiology. Cancer is increasing in incidence in the UK and recent advances in treatment have resulted in many more patients surviving with treated disease. Concurrent advances in imaging techniques over the past two decades permit us to obtain detailed morphological and functional information from treated tumours. This article reviews clinical strategies for imaging patients following treatment for cancer with particular reference to techniques which are currently under continuing scientific evaluation.

Oral magnetic particles (ferristene) as a contrast medium in abdominal magnetic resonance imaging

RATIONALE AND OBJECTIVES

In this phase III study, we evaluated the efficacy and safety of a negative contrast medium, ferristene (oral magnetic particles), among 277 patients undergoing magnetic resonance (MR) imaging of the abdomen.

METHODS

Enhanced (800 ml ferristene) MR images were compared with unenhanced MR images in an intraindividual-patient control design. Adverse events were recorded. The examinations were performed on 1.5-T MR systems (T1- and T2-weighted sequences).

RESULTS

Ferristene increased the diagnostic information in 50.9% of the patients, particularly in those with abdominal masses, lymphoma, or pancreatic disease. Distribution of ferristene in the stomach, duodenum, jejunum, and ileum was complete or sufficient in 70.5-85% of the studies. In 64% of the patients, we were confident in the MR findings after the use of ferristene, and ferristene disclosed additional findings in 22% of the patients. The incidence of adverse events was 9.0%, but only 3.6% of all patients experienced ferristene-related adverse events (e.g., nausea, vomiting). Most events were mild or moderate in intensity.

CONCLUSION

Ferristene was well tolerated, and for 50% of the patients it added useful diagnostic information.

Radiology in the staging of bladder cancer

Careful staging of bladder cancer at presentation is necessary for a rational choice of treatment and gives a clear indication of the long-term prognosis. In the past 20 years computer-based imaging technology has improved the precision of staging.

Case report: ossifying fibromatosis of the breast

We report the first described case of ossifying fibromatosis of the breast. This condition warrants consideration as a rare differential diagnosis of carcinoma of the breast and dense calcification on mammography.

Imaging after titanium cranioplasty

Titanium cranioplasty has been used in our unit for reconstruction of cranial defects following trauma, tumour resection and bone loss due to postcraniotomy infection. It has previously been assumed that imaging to assess recurrence of disease progression after cranioplasty would be severely compromised in the presence of metallic material. Titanium is a non-ferrous metal of low atomic number, which is relatively radiolucent and allows exceptionally clear images to be obtained without significant degradation of image quality, on CT and magnetic resonance (MR) imaging. Cases are presented that demonstrate the use of CT contrast cisternography and MR imaging after titanium cranioplasty. On the basis of its strength, biocompatibility and excellent handling characteristics, allied to its suitability for all post-operative imaging techniques, we conclude that titanium plate is the material of choice for cranioplasty.

Role of magnetic resonance imaging in predicting relapse in residual masses after treatment of lymphoma

PURPOSE

This prospective study of patients treated at the Royal Marsden Hospital Lymphoma Unit was designed to evaluate the role of magnetic resonance imaging (MRI) in the assessment of residual masses evident on computed tomographic (CT) scanning following treatment of lymphoma.

PATIENTS AND METHODS

All patients had MRI, gallium-67 single-photon emission CT (67Ga SPECT), and erythrocyte sedimentation rate (ESR) performed within 3 months of completing therapy. Patients were monitored for 1 year posttreatment and observed for signs of relapse. Investigation results were correlated with disease status, and the sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) calculated. Time-to-relapse curves were derived and the log-rank test used to determine whether patients with a positive result were more likely to have a relapse within the mass than those with a negative result.

RESULTS

Thirty-four patients were studied, 14 of whom relapsed, 11 within the area of residual mass. Overall, MRI had a high specificity (90%), PPV (71%), and NPV (75%), but poor sensitivity (45%). The results for 67Ga SPECT were similar, apart from lower sensitivity (33%). ESR had inferior performance in predicting relapse compared with the other tests. MRI was the only investigation to show statistical significance (P = .14) in predicting relapse, and this was particularly evident in Hodgkin's lymphoma (P = .003). Combining results of 67Ga SPECT and MRI did not improve predictive power.

CONCLUSION

These data demonstrate that MRI is a valuable tool in the setting of a residual mass after treatment, giving clinically useful prognostic information. 67Ga SPECT also has a role, but is less effective in predicting relapse than MRI.

Phase III trial of oral magnetic particles in MRI of abdomen and pelvis

A prospective Phase III trial was performed to evaluate the efficacy in clinical practice of a new gastro-intestinal contrast agent, Oral Magnetic Particles (OMP), for use in abdominal and pelvic magnetic resonance imaging (MRI). This was an open study comprising 35 patients each given 800 ml of OMP at a concentration of 0.5 g/l. Distribution of the agent was most reliable in the small bowel. General contrast effect was satisfactory, and image quality and diagnostic confidence were enhanced. Administration of OMP increased diagnostic information in the magnetic resonance (MR) image in 50% of patients. No clinically significant adverse effects were observed. The results confirm in a clinical setting a potential role for this new contrast agent.

Sites of relapse in seminoma treated with single agent carboplatin chemotherapy: implications for further management

Between 1983 and 1990, 66 patients were treated with single agent carboplatin for advanced seminoma, and sites of relapse have been analysed with respect to sites involved before chemotherapy. Fourteen relapses were evaluable, and relapse was confined to node groups affected before chemotherapy, or those immediately adjacent, in seven patients. At present it is unclear whether single agent carboplatin should be the initial chemotherapy for seminoma, but if it is employed there may be a role for local adjuvant radiotherapy after carboplatin chemotherapy.

Intra-abdominal panniculitis can mimic recurrent stomach carcinoma

Carcinoma of the stomach is increasingly treated with chemotherapy. We describe two cases of intra-abdominal panniculitis in patients after laparotomy and chemotherapy for stomach carcinoma. Intra-abdominal panniculitis can result in mass lesions in the mesentery and omentum. The diagnosis should be considered in patients who have undergone chemotherapy for stomach carcinoma and who develop abdominal masses.

CT scanning in epidural lymphoma

This study describes the clinical features and CT findings in 18 patients with epidural lymphoma seen in a large oncology hospital over a four-year period. The variety of CT appearances seen in epidural lymphoma are illustrated. The importance of recognition of small volume epidural disease on body CT is stressed. Patients with apparently minor CT abnormalities may have significant epidural disease. The prognosis for these patients with minimal symptoms and small volume disease is much better than for those with classical signs of cord compression and more obvious abnormalities on imaging.

Digital subtraction cisternography: a new approach to fistula localisation in cerebrospinal fluid rhinorrhoea

Positive contrast cisternography with digital subtraction of fluoroscopy images before computed tomography (CT) was employed in the investigation of eight patients with cerebrospinal fluid (CSF) rhinorrhoea. Fistulae were visualised by preliminary digital subtraction cisternography (DSC) in six patients and in five patients the sites of leakage were confirmed at surgery. Fluoroscopy facilitated interpretation of CT in all the positive studies and in two patients provided information which could not be deduced from CT cisternography (CTC) alone. The combined technique is recommended for the investigation of patients with recurrent and post operative CSF rhinorrhoea and when CTC alone fails to identify the site of leakage.