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i 32i

Letters

1 Breast

Traction

Breast often

lesions

difficult

Mammography

seen adjacent

to visualize

to the chest

on craniocaudal

medially and laterally rotated views have techniques

to solve

views,

parallax

this

problem

techniques,

have

breast

wall on lateral

views,

even

been

obtained.

emerged,

are

additional

‘.

A number

such

sonography,

views

after

of

as tangential

and

breast

CT

[1].

The advantages and disadvantages of these have been described in the literature [2]. Unfortunately, some of these require three-dimensional

geometric

calculations

and apply clinically. that

does

graphic

not

in the

tissue

near

the

transparent

applying in order

chest

wall

(Fig.

beyond

the

is applied

maximally.

The to

additional to

compression

have

used

is placed

ends

(3M,

on

until

the the

of the sheets

0.0-2.3

cm) more

pared with the standard

thus

diminishing

In addition

found

breast

tissue

craniocaudal

radiation

to the

film

cassette, is

useful

in small-breasted

women.

benefit,

routinely

improve

traction.

discomfort

this

are taped to the view is ob-

view,

two

visualized

the routine

the

anterior

craniocaudal

tissue

has

to

This techto localize

but

we

of breast

have

tissue

to quantify

in these noted

this

women

any

to

increased

anterior this

tissue has

been

wrinkling

REFERENCES 1 . Sickles EA. Practical bring the examination.

usually

of the

is not

a major

is not distorted

signif-

imaged

optimally

view. Judith

G. Farrell North

D

solutions to common mammographic AJR 1988:151 :31-39

2. Yagan A, Weisen E, Bellon EM. Mammographic

breast

already

that is not identified on craniocaudal view (B). C and D, Tegaderm traction helps localize mass on mediolateral (C) and craniocaudal (D) views. Pathologic examination showed an 8mm infiltrating ductal carcinoma.

corn-

is used.

may produce the

A and

0.9 cm

when

lesions,

it is difficult

patients

procedure

because

deep

use Tegaderrn

our

Fig. 1.-Breast traction mammography. B, Standard mediolateral view (A) shows a suspicious mass in upper quadrant

in

of which

On average,

the amount

Although

mammographically,

problem and

of

the Tegaderm

as visualized

interpretive icantly,

None

when

Commonly, skin

we now

and

breast.

in detecting

added

C

B

A

stretched

views. This was equivalent

in maximizing

visible

‘

of

It was successful

was

to the

advantages

this technique

.4

St. Paul, MN), a on the superior sheets then are adherent sheets

approximately 12% more tissue imaged (range, 0.0-24%). nique also has reduced the number of exposures required lesions,

‘I-‘I

l

amount

breast

then

depicting five deep lesions on the craniocaudal biopsy subsequently proved were carcinomas. (range,

‘Ii.

and the craniocaudal in 28 patients.

technique

‘

on the breast

a greater

These two of the two

Tegaderm

is applied,

this

mammo-

traction

visualize

1). Tegaderm

breast the

The apposed

cassette, tamed. We

nipple.

technique

identify

1 0 x 1 2 cm, is placed

dressing,

‘

plane.

and inferior surfaces of the breast. apposed, leaving several centimeters traction

available

help

vs-’!

:‘.4

.,,1

to conceptualize

readily to

orthogonal

view

adhesive

difficult

equipment

involves

craniocaudal

often

a simple,

special

abnormalities

the

are

We describe

require

Our technique on

and

I

:

Florida

Regional

M. Yancey

McNeely

Richard E. Kinard Medical Center

Gainesville,

FL 32605

on

lesions

seen in only one view.

Adenoid Cystic MR Findings

tai-

needle localization

of

AJR 1985; 144:911-916

Carcinoma

Adenoid cystic carcinoma tracheal tumor and accounts

problems:

of the

Airway:

is the second most common primary for the majority of tracheobronchial

gland neoplasms Ii 1, Characteristically seen at bronchoscopy as a submucosal mass protruding into and obstructing the larger airways, the

tumor

tends

to grow

along

the

submucosa

and

invade

the

1322

LETTERS

adjacent

mediastinal

structures.

Evaluation

with

conventional

raphy and CT is limited because these techniques define

accurately

ment

of adjacent

extent

of

submucosal

infiltration

structures

and infection.

tomog-

cannot be used to and

[2]. Multiplanar

ing has

usually more

accurate

bronchus

influence

lobe

and

(Fig.

areas

just

diagnosis

of adenoid

MR imaging

of atelectasis

and

distal

proximal

left main

left

paratracheal

carina.

cystic

carcinoma.

bronchus

images,

on

to the

regions.

Ti -weighted

the preoperative

CT scan

The

patient

carinal

resection

cystic

in the

tumor

mass

signal

on

(Figs.

had

infiltration

subsequently

had

left

axial

and

signal

1 C).

of the

course

fourth

or

of recurrent

of the airway

leads

fifth

decade

respiratory to recurrent

of

life

and

complaints. episodes

variably

multiple

of tumor

and

size

and

of

better

can

invasion

diagnosis allows

definition

of its

characterization

define

better,

The

planes

Tumor

sequences

local

time

of the airway.

anatomic

structures.

weighted

infiltration

the

the

extent

findings

that

of

may

resectability. Dean Robin Trip/er

J. Shanley

Daum-Kowalski

Army

L. Embry

Medical

Center

Honolulu,

and

and

1991

to smok-

Ronald

HI 96859

on bright with

REFERENCES 1 . Cleveland

of MR for involve-

pneumonectomy

RH,

(cylindroma)

2. Spizarny adenoid

and

Nice

CM,

Ziskind

of the trachea.

DL, Shepard cystic

J. Primary

JO, McLoud

carcinoma

adenoid

cystic

carcinoma

1977:122:597-600 TC, Grillo HC, Dedrick CG. CT of

Radiology

of the trachea.

AJR

1986; 146:1129-1132

airway.

Most adenoid cystic carcinomas arise centrally within the trachea or main bronchi and gradually occlude the airway. Patients are usually in their

with

submucosal

from

mediastinal

at

the lumen

coronal

intensity

and mediastinal

a left

MR

through

Comparison

the superiority

or

a

the subcarinal images,

images

determination

to other

MR

CT,

a large mass obstructing to provide

relationship with

or relationship

main

confirmed

invasion

low

1 B and

showed

reconstruction

into

balanced

left lower

area

showed

extension

limitations,

of the

Preoperative

of submucosal with

change of this

sequences

clearly

these

occlusion

Biopsies

and

images

the extent

ment.

The higher

T2-weighted

overcome

showed

at 1 .5 T with various

the

depicting

can

1A). Bronchoscopy

bronchus

signal

sequences

tomography,

shows

thereby providing important diagnostic information. A 34-year-old man had had intermittent cough and hemoptysis for 3 years and recently had had two episodes of respiratory distress. Chest radiograph at admission showed narrowing of the left main

weighted

sex predilection

June

found.

Conventional

involve-

MA imaging

of MA

variably

No significant

been

ability

with

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the

mediastinal

AJR:156,

have

a prolonged

The insidious of pneumonitis,

clinical

obstruction

Emphysematous Modification of Diffuse Centrilobular Lesions Due to Staphylococcal Pneumonia

atelectasis, In patients

with

areas of the lungs of Kohn,

and

involves filled, lung

that

the

pattern

the

[2].

to

becomes

aureus Here

we

the

of the pores

[1 ]. When

the dilated

emphysematous

of consolidation

emphysema,

bed, absence

structure

lobe,

that high-resolution

lesions

capillary

is confined

the

Staphylococcus

pulmonary

bronchiolar

exudate

surround

previously lobular

distorted

an emphysematous

and

with

preexisting

have a sparse

the foci.

pneumonia

air spaces

relatively Thus,

disorganized

[1].

describe

showed a case

We

widespread

of staphylococcal

monia that had an atypical pattern of diffuse centrilobular

are

areas

of

emphysema,

CT of immunocompromised pneumonia

rarely

normal with

affected

reported

patients centripneu-

lesions that

was due to preexisting pulmonary emphysema. A 70-year-old man had shortness of breath, low-grade fever, cough, and yellowish-green sputum. He had smoked at least two

packs of cigarettes

Fig. 1.-Adenoid cystic carcinoma of the airway. A, Chest radiograph shows narrowing of left main bronchus (arrow) evidence of volume loss in left hemithorax. B and c, Ti-weighted (882/18, B) and T2-weighted coronal MR images show a large tumor mass causing obstruction of left main bronchus.

and

(2903/180, C) nearly complete

each day for more than 30 years. He had received

Fig. i.-5taphylococcal pneumonia in a 70-year-old man with preexisting pulmonary emphysema. A, Chest radiograph shows nodular or patchy consolidation, especially in right lower lobe of lung. B, High-resolution CT scan shows widespread rounded, poorly defined nodules interrupted by air-filled spaces and smaller emphysematous foci outlined by consolidation.

LETTERS

AJR:156, June 1991

interferon

gamma

carcinoma 74%

neutrophils.

ophils.

The

of arterial mm,

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because 17%

level

Hg,

the

partial

pH

was

7.55.

drawn

consolidation,

rupted by

(Fig.

growth

showed

of

disease

previously

that

uniform

(Fig.

sputum

1A).

inter-

foci

outlined

in pure

and

and

later

condition.

parenchymal

changes

High-reso-

started,

patient’s

the

persistent

lung

within

the

within

the

diseases,

lobules

pain

can

be

less

was

confluent

associated

opacities

with

lesions.

and respiratory

(panlobular ular

Because

bronchiole

emphysema

lesions

caused

the

central

portions

are destroyed

is extremely

by

of the

lung

in centrilobular

rare

staphylococcal

in Japan),

In conclusion,

sematous

foci

our

interfere

case

with

suggests

that

lobule

be

centrilobular

inter-

on high-resolution

lesions. Jiro

Fujita

Katashi

the

neck,

showed

headache,

confusion,

anorexia,

and

abdominal

tenderness

chemotherapy

led to a complete

Medical

Sato

the

goat’s

disease

milk or cheese [2]. The systemic

usually

Japan

predominate

over

the

Low-density

masses

in the

peritoneum

associated

with

pancreatic dilated

woman

had cyst

loops

had severe

diabetes and

and

adhesions

of small

vomiting

was

persisted.

had

a splenectomy. intestine

plaques on the left peritoneal omy was performed because of

abdominal

previously

divided. On

with

CT fluid

pain, fever, had

of levels,

abdomen ascites,

and

Use of a Condom to Cover Enema Rectal Tip

(FDA)

and

Postoperatively,

readmission

1 month

the after

patient’s surgery.

one

(E-Z-EM,

retention

tions,

many

of which

nodular

to the

FDA

(personal

logical

Health).

fever she

of

the

Inc.,

problem.

Dev Biol

Stand

the Balloon

tract

of a Barium

a

To

avoid

and

cuff

of the

had

cuff

and

the

cuff.

this barium rectal

major

manufacturers

Westbury,

of

NY) suggests

barium

enema

Thus

a possible is the soluble proteins present in the latex far, nine deaths and about 1 50 complica-

were

anaphylactic

source of these reactions in the

margin (Fig. 1). An exploratory laparotof small-bowel obstruction, and a band

as a world

BMJ 1969;1 :612-614 3. Young EJ. Human brucellosis. Rev Infect Dis i983;5:821-842 4. Mohamed AS, Madkour MM, Talukder MS. Al-Karawi MA. Alimentary presentation of brucellosis. Ann Saudi Med 1986:6 :27-31

showed

for

T. Brucellosis

2. Williams E. Brucellosis.

tion

and vom-

a laparotomy

the

tuberculosis

Kuwait University Safat, 13 1 10 Kuwait

equipment

peritonitis. She

com-

Because of increasing concern about serious allergic reactions associated with the use of rectal tips with latex balloons, radiologists have been forced to abandon the use of such tips for barium enema examinations. Evidence reviewed by the Food and Drug Administra-

CT Findings

Human brucellosis is a major health problem worldwide Ii]. I report the CT findings of abdominal brucellosis in a patient with brucellar A 53-year-old

manifestations

gastrointestinal

REFERENCES

1 . Ziskind MM, Schwarz Ml, George RB, et al. Incomplete consolidation in pneumococcal lobar pneumonia complicating pulmonary emphysema. Ann Intern Med 1970:72:835-839 2. Fujita J. Sato K, Hata Y, et al. Diffuse centrilobular lesions of the lung caused by Staphylococcus aureus in two immunocompromized patients (letter). AJR 1990:155:652-653 3. Murata K, Itoh H, Todo G., et al. Centrilobular lesions of the lung: demonstration by high-resolution CT and pathologic correlation. Radiology 1986:161 :641 -645

iting.

CT after

have been described. Irregular masses with nodular configurations have been described in malignant mesothelioma of the peritoneum and in peritoneal metastases, but the CT features of each of these are distinctly different from those of the case described here. Fareed Mohamed Denath

1 . Matyas Z, Fujikura i989;56:3-20

Brucellosis:

of

School

761-07,

REFERENCES

Abdominal

weight.

stiffness

Follow-up

and colleagues Kagawa,

of

and

recovery.

Shozo Irino Kagawa

lethargy,

loss

plaints despite the ease with which brucellosis is transmitted via the oral route. Limited reports 13, 4] on the gastrointestinal manifestations and complications have been published. To my knowledge, peritonitis associated with brucellosis has not been described before. The CT scan showed ascites and nodular plaques on the peritoneal surface.

CT, the pattern of diffuse centrilobular lesions of the lung caused by S. aureus may be distorted by underlying emphysema, because emphyrupted.

vomiting, of

studies showed WBCs and proteins in the CSF, tests of blood and CSF and enzyme-linked assays of CSF were positive for brucellosis. Antibru-

pasteurized

centrilob-

should

examination

cellosis

of

emphysema

diffuse

pneumonia

side

1 month of therapy showed no ascites and no nodular plaques. Human brucellosis usually is associated with consumption of un-

the

affected lung parenchyma 121. However, as we report here, although the findings on plain chest radiographs were similar to those seen when emphysema was not present, the findings on high-resolution CT scans were quite different from the typical pattern of diffuse centrilobular

Physical

repeated

right

immunosorbent a

throughout

fever,

in the

the neck. Laboratory and microagglutination

[3J. We reported

lobule

pneumonia

Abdominal CT scan shows dilated loops of small bowel with fluid 1evels, ascites (straight arrow), and nodular plaques (curved arrow) on peritoneum.

patchy

nodules

resulted was

and

or

chest radiography and standard high-resolution permits the local-

processes of

Hg,

emphysematous

in the

staphylococcal

dissemination

mm

defined

therapy

helpful ization

lobe

of certain

lOb eosin-

nodular

poorly

of

(3]. Although conventional CT provide little such information,

27

Fig. 1. brucellosis.

cell

with

A specimen oxygen (3 1/ was 55 mm

of oxygen

lower

Antibiotic

of pathologic

and

breathing

was

renal

cells/ph,

mg/dl.

showed

right

Culture

diagnosis

localization

was

pressure

and smaller

1 B).

25.0

dioxide

improvement

differential

accurate

patient

rounded,

of S. aureus.

radiographs In the

in the

spaces

consolidation

monocytes,

radiography

widespread

by air-filled

heavy

chest

from

was 10,800

was

partial

of carbon

especially

CT showed

the

the

pressure

8%

protein

while that

Plain

count

lymphocytes,

showed

metastases

The WBC

of C-reactive

blood,

nasally),

lution

of pulmonary

(clear cell type).

1323

reactions,

communication,

problem, enema mucosa.

we tip

use

Center a condom

to prevent Flexi-Cuff,

direct

that

have for

Devices

to cover contact

a commercial

been

reported

and the

retention

between barium

Radio-

the enema

1324

LETTERS

Fig.

1.-Condom

AJA:156, June 1991

is

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placed over retention cuff of barium enema tip to prevent direct contact between latex cuff and rectal mucosa.

retention

tip (E-Z-EM,

reservoir

tip

Inc.)

of the

is covered

condom

is cut

with off,

a condom

and

as follows.

a rubberband

The

is used

to

secure the condom firmly in place over the rectal tip. The other end of the condom is inverted overthe inflatable cuff(Fig. 1). This modified tip is lubricated with a standard commercial gel and inserted into the

rectum, and the balloon cuff is inflated. We have used this technique in more

30 patients

than

complications. This

and have observed

The condom

technique

has remained

is based

on the

are made of latex,

do not cause

a

are

billion

condoms

assumption

serious

manufactured

condom

reactions

or

that

allergic

each

condoms,

reactions.

year

in the

(personal

United

half

States

communication

manufacturer).

an anaphylactic

However, reported.

no deaths

reaction

associated

Universit#{233} Paris

Medical

VI, HOpital Broussais Paris 75014, France

have been

REFERENCES

K. Sadriah Affairs

probably was caused by trauma. The diagnosis was delayed because the appearance of the tumor was similar to that of a hematoma [2]. J. L. Bouillot A. Hernigou M. Ch. Plainfosse J, H. Alexandre

after vaginal and oral intercourse. with the use of condoms

J. Jamshidian Veterans

Fig. 1.-Liver cell adenoma discovered after blunt hepatic injury. A, Initial enhanced CT scan shows large blood-containing mass in liver. B, Gadolinium-enhanced Ti-weighted spin-echo MR image shows mass in liver 6 months after injury.

which

About

A number of reports suggest that condoms can cause contact dermatitis and urticaria i , 2j. One report [31 suggests that a condom

caused

B

in place in every case.

and are used at the rate of 1 2 per second with

no adverse

A

Center, Wadsworth Los Angeles,

1 . Leese

Division CA 90073

T, Farges

experience

0,

Bismuth

H. Liver

from a specialist

cell adenomas:

hepato-biliary

a 1 2-year surgical Surg 1988:208:

unit. Ann

558-564

2. Foley WD, Cates JD, Kellman GM, et al. Treatment role of CT. Radiology

of blunt hepatic injuries:

1987; 1 64 :635-638

REFERENCES 1 . Turjanmaa K, Reunala T. Condoms as a source of latex allergen and cause of contact urticaria. Contact Dermatitis 1989:20:360-364 2. Rademaker M, Forsyth A. Allergic reactions to rubber condoms. Genitourin Med 1989;65:194-195

3. Taylor JS, Cassettari J, Wagner W, Helm T. Contact urticaria and anaphylaxis to latex. J Am Acad Dermatol 1989;21 :874-877

Hepatic

Sarcoidosis:

One case report [1 1 describing the sarcoidosis has been published. However, findings

in this

liver

black woman

Liver Cell Adenoma Injury

Discovered

After

Blunt

Hepatic

MR Findings

disease

have

with stage

admitted

because

Physical

examination

jaundice.

A sonogram

not

CT appearance to our

been

II sarcoidosis

of recent

onset

showed

a normal

the

no therapy

fatigue,

and

and

was

jaundice.

hepatomegaly gallbladder

MR

A 43-year-old

requiring

moderate

showed

described.

of dyspnea,

of hepatic

knowledge,

and

slight

common

bile

establish an accurate diagnosis of the lesion. A 32-year-old man complained of pain in the right upper quadrant 2 days after a skiing accident caused severe closed abdominal injury.

duct and a diffusely heterogeneous liver with poorly defined interlacing hyper- and hypoechoic areas. CT showed an enlarged liver with diffuse, small, irregular hypodense foci amid preserved areas of normal-appearing parenchyma. Axial proton-density (2000/20 [TA/ TE]) and T2-weighted (2000/i 20) MA images were obtained with a 1 .5-T MR unit. The proton-density images showed multiple, small,

Sonography

closely packed nodularfoci

Trauma-induced

right

hemorrhage

and CT showed

into

a tumor

a 1 3-cm

may

make

heterogeneous

lobe of the liver (Fig. 1A). The diagnosis

it difficult

mass

to

in the

was intrahepatic

throughout

the liver, with normal to slightly

showed that the mass was still present but smaller. MR showed that the lesion was composed of tissue and blood (Fig. 1 B). A partial hepatectomy was performed 7 months after the initial injury. Histo-

increased signal intensity (Fig. 1A). T2-weighted images showed that all areas of liver were decreased in signal (Fig. 1 B). No foci of increased signal were seen on T2-weighted images. A percutaneous liver biopsy showed the cholestatic form of hepatic sarcoidosis. Sarcoidosis has many different manifestations. The acute form of the disease, frequently limited to the thorax, has a high prevalence of spontaneous remission. Chronic sarcoidosis has a highly variable

logic

clinical

course

indicate

that

hematoma. servatively.

showed

The patient was clinically stable and was treated Sonographically guided biopsy performed 2 months

only necrotic

examination

cells. CT performed

showed

a liver

6 months

cell adenoma.

The

conlater

after the injury

patient’s

recovery

has been unremarkable. Liver

women. tumor

cell

adenomas

are

rare

benign

tumors

seen

mainly

in young

The tumor often is discovered when hemorrhage into the causes pain [1 ]. In our case, hemorrhage into the lesion

sarcoidosis, with die

the

and in the

use

of their

can

nearly disease

be two

insidiously thirds

eventually

of corticosteroid disease

[2j.

patients

is cured

therapy; Hepatic

progressive. of

who

either

reports

have

chronic

spontaneously

approximately

involvement

Some

of clinical

3%

of patients significance

or

AJR:156,June

LETTERS

1991

1325

Fig. 1.-Transverse

sonogram

of mid abdomen shows multiple fluid-filled loops of small bowel floating in large amounts of asci-

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tic fluid.

Fig. i.-Hepatic sarcoidosis. A, Proton-density MR image shows liver has diffuse nodular appearance and normal to increased intensity. B, T2-weighted MR image shows decreased intensity throughout liver parenchyma. Note heterogeneity of spleen.

cm,

and

with

occurs

in this

case [1 1; multiple, throughout

the

5%

of cases.

Hepatic

case

are similar

to those

in the previously

small,

irregular,

diffusely

scattered,

liver.

These

findings

failure

are

occurs

rarely.

The

relatively

with

foci

nonspecific

and

parenchyma

on proton-density

ing foci of hypointensity on

12-weighted

images

matory disease such

on T2-weighted effectively

because

these

images

images. excludes

diseases

and

at

external

rest.

bobbing

The

of an object

floating

collapsed

small

bowel.

fluid in the somewhat

fluid

the

lateral

This

abdominal

have hyperintense

displaced

peritoneal

wall

wavelike motion. This fluid wave floating on the ascitic fluid.

a similar

and

rebounded,

displaced

Cornell

Shore

setting

signal on

up

a

the small bowel A. Javors

University

University

inflam-

amount

The displaced

Bruce North

images.

and

cyclical,

waves.

cavity.

markedly

We think the finding or

applied was

on ocean

filling

elastic

correspond-

metastases

being

movement

for this movement was the rapid filling (approximately 1 00 mI/mm) of the previously

ofascitic hit

compression

to-and-fro

likely explanation

methylcellulose

partially

suggest diffuse metastases, widespread inflammatory disease, or, possibly, regions of scarring in a nodular, regenerating liver. MR in our case was useful in the differential diagnosis because the liver had multiple, diffuse, densely packed islands of isointense or slightly hyperintense

the

The most

published

hypodense

without

patient

mimicking

in less than

CT findings

it occurred

the

Hospital

Medical

College

Manhasset,

NY

11030

abdominal

diseases,

REFERENCES

Fred W. Flickinger Eric Medical

College

Augusta,

1 . Frimann-Dahl

A. Pfeifer

GA

J. Roentgen

examinations

in acute

ed. Springfield, IL: Thomas, 1974:59-77 2. Hulnick DH, Megibow AJ. Computed tomography Herlinger H, Maglinte D, eds. Clinical radiology Philadelphia: Saunders, 1989:190

of Georgia 30912-3910

3rd

of the small bowel. In: of the small intestine.

REFERENCES 1 . Nakata K, Iwata K, Kojima K, Kanai K. Computed tomography of liver sarcoidosis. J Comput Assist Tomogr i989;13:707-708 2. Israel H, Karlan P, Menduke H, DeLisser 0. Factors affecting the outcome of sarcoidosis: influence of race, extrathoracic involvement, and initial radiographic lung lesions. Ann NY Acad Sci i986;465 :609-617

Stage D2 Transitional Cell Carcinoma Bladder in a 36-Year-Old Woman

A 36-year-old woman had had right-sided flank pain and dysuria for 1 week and had been having episodes of gross hematuria intermittently

A New

of the

Sign of Ascites

for

1 month.

exposure

to chemical

indurated

palpable

She

had

no

history

of cigarette

smoking

or

Pelvic

examination

showed

an

carcinogens.

mass

anterior

to

the

vagina.

Urinalysis

showed

25-50 WBC/,I. An excretory urogram ing system consistent with obstruction.

showed a dilated right collectDelayed films showed a large,

presence of ascites.

irregular,

bladder

1 A).

A 55-year-old man with a history of unexplained gastrointestinal bleeding had a double-contrast enteroclysis examination of the small

extensive

papillary lesion involving

While

performing

observed

a new,

a small-bowel previously

bowel.

During instillation

and-fro

movement

Subsequently, obtained.

examination, undescribed

of the barium-filled

a history

of the ascites

include

bulging

flanks,

loops

of cirrhosis

imaging

effects

fluoroscopic

of the methylcellulose,

The latter was confirmed

Conventional

my colleagues

of ascites

on the bowel

sign

marked

of bowel

with sonography is based

and adjacent

obscuration

of organ

for

I

the

cyclic, to-

was observed.

and concomitant

usually

and

ascites (Fig. 1).

on the

organs.

outlines,

secondary

may

separation

of

the liver from the lateral abdominal wall, separation of opacified bowel loops, and central gathering of the small-bowel loops floating in the ascites 11], In malignant ascites, the loops of small bowel may be tethered [21. In our small

case,

bowel

double-contrast

exaggerated occurred

during

examination.

movement the

instillation

The

range

of the of of the

barium-filled

loops

methylcellulose movement

of

for was

was

5-7

a

performed,

men showed grade the lamina propria. compatible

These

defect

(Fig.

Cystoscopy

showed

the trigone with extension

an

to the

posterior and lateral walls. Both ureteral orifices were obscured, and the mass extended distally into the mid urethra. A limited transurethral resection

was

filling

ment,

the

Bladder

with

metastatic

patient

died.

carcinoma

years old. It accounts majority

and

of patients,

pathologic

1 -2 transitional Technetium-99m disease

is uncommon

(Fig.

is the

1 B). One

in patients

for an estimated hematuria

examination

of the

cell carcinoma bone scan

1% initial

speci-

with invasion of showed findings month

after

treat-

who are less than 40

of bladder

tumors.

complaint.

Male

In the predomi-

nance is the usual finding, with male to female ratios as high as 8:1. More than 50% have a history of cigarette smoking [11. Accurate staging is important in defining the management and assessing the prognosis of bladder carcinoma. At the time of diagnosis, transitional cell carcinoma is localized to the mucosa in 48%,

i 326

LETTERS

AJR:156,

increased permit

resistive any

index

differential

may indicate diagnosis

renal disease,

between

various

June 1991

but they do not causes

of

renal

dysfunction.

We reviewed

eight recent reports

on the use of Doppler sonograindex in the evaluation of kidneys (seven reports

phy and the resistive

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on transplanted only

two

kidneys

of these

[1

and one on 2j

,

consider

native

kidneys)

possible

intra-

and or

found

that

interobserver

The errors reported were less than 1 O% or 6.5-i 2.0%, respectively. In no report were the errors determined by using color Doppler equipment. For this reason and because, in our own experimental studies, we found that the range of interobserver error was ±7.5% and the range of intraobserver error was ±7% [3], we undertook a test with our color Doppler equipment (Quad 1 , Quantum, lssaquah, WA). One errors.

volunteer Fig. 1.-Transitional cell carcinoma of bladder in a 36-year-old woman. A, Excretory urogram shows irregular defect in bladder and hydronephrosis of right kidney. B, Bone scan shows areas of abnormal uptake of radionuclide and hydronephrosis.

at

medium

(five or

into the muscle layer of the bladder wall. These studies are subject to errors in understaging, with rates between 40% and 50%. invasion

Excretory cases, and finding

urography can detect bladder tumors in only 45-60% the postvoid film provides the most information.

of ureteral

obstruction

implies

at least T3 [3]. Ureteral obstruction

that

the

stage

has the same

of the

of The

disease

is

prognostic significance as an abnormal lymphangiogram. CT has limited usefulness in staging because the normal bladder wall, muscular hypertrophy, and infiltrating tumor may have similar attenuations. CT is helpful in showing

nodal

metastasis.

but it may detect sonography

follow-up

invasion

can

be used

information

cell carcinoma

MR

is not

of perivesical to assess

after

resection.

of the bladder

liver, brain, urethra, abdominal

local

poor

significantly

better

fat more readily. tumor

on

lung,

(7

mm/sec,

and made

each

kidney).

were

between

used the 3-mHz

according

to

1 0 determinations

The

indexes

the

and from

bone,

selected

0.5 and 0.8; 34 of 40 measurements

Brooklyn,

ation

whenever

the

index

is used

for evaluation

of renal

S. Kessler C. Honeyman

Janice

Jun

V. Kaude

Jeffrey A. Longmate University

of Florida

College

Gainesville,

of Medicine

FL 32610-0374

REFERENCES 1 . Schwaighofer B, Kainberger F, Fruehwald F, et al. Duplex normal renal allografts. Acta Radiol 1989;30 : 53-56

2. Townsend

Center

AR, Tomlanovich

and morphologic Ultrasound Med

11219

3. Cazenave

sonography

of

SJ, Goldstein RB, Filly RA. Combined Doppler

sonographic evaluation i990;9: 199-206

of renal

transplant

rejection.

J

CT, Sievers KW, Kaude JV, Williams JL, Bush D, Wright PG.

Pulsatile flow index for qualitative measurements ultrasound: an experimental study. Eur J Radiol

REFERENCES RJ, Lindner A, deKemion JB. Transitional cell carcinoma of the in the first four decades of life. Urology 1982;20:582-584 2. Choyke PL, Thickman D, Kressel HY, et al. Controversies in the radiologic diagnosis of pelvic malignancies. Radiol Clin North Am 1985;23 :531-549

disease.

Larry

transitional

NY

were 0.6

The analysis of these values according to statistical variance gave the following results: interobserver variation, 6.4%; intraobserver variation, 9.6%; total variation, 1 1 .5%. To this variation, the transducer/vessel angle error should be added, which according to our experimental study may vary up to ±8% in the angle range of 40#{176} to 80#{176} [3]. Even assuming no or minimal inherent error for equipment software calculations, we may face a total error of 1 5_20% in index determinations. This error may change many borderline cases from normal to abnormal, or vice versa, making the resistive index even less reliable. At least, the error factors must be taken into consider-

mediastinum,

Medical

index

intrarenal

0.7.

to provide

Gilbert J. Wise and colleagues

transducer

manufacturer’s

of the Pourcelot

in randomly

CT,

nodes, and extrapleural space. Ronald G. Frank Perry S. Gerard

Maimonides

level

of renal disease was the test subject.

sonographers

Transurethral

invasion

Metastases

may involve

than

flow

specifications), vessels

to the lamina propria in 3i%, and to the muscle in 21% of cases [2]. Current imaging techniques may not show accurately the degree of

who had no history

Each of four experienced

of blood flow with duplex i989;9 :42-43

1 . Cherrie, bladder

3. Greiner A, Skaleric C, Veraguth P. The prognostic significance of ureteral obstruction in carcinoma of the bladder. Int J Radiat Oncol Biol Phys 1977;2:1095-i

100

Broadband Ultrasound in Osteoporosis

Measurements

Aesch et aI. [1 1 report that broadband ultrasound attenuation measurements of the calcaneus have “relatively low sensitivity” in the diagnosis

Intra- and Interobserver Variations Blood-Flow Indexes with Doppler

Attenuation

in Determining Sonography

Several authors have suggested that renal blood-flow indexes based on analysis of Doppler spectra are useful in determining the presence of renal parenchymal disease, particularly in the differential diagnosis of renal transplant dysfunction. However, recent reports on this issue have been more critical. Changes in Doppler curves and

of osteoporosis.

In contrast,

my colleagues

and

I [2-4]

and

others [5, 6] have shown that broadband ultrasound attenuation is a sensitive and specific discriminator of axial osteopenia, is predictive of hip fracture [7], and has the added advantages free and inexpensive. The discrepancy between from

inappropriate

use

of the

term

“normal

range”

of being radiationthe findings arises by

Resch

et al.

For quantities that vary with age, a normal range refers to the 95% confidence limits for a population of a given age (e.g. , women who all are 63 years old). Aesch et al. studied either 23 (according to the

LETTERS

AJA:156, June 1991

text

in

1 age

45-81 specific

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) or

21

(according

to the

figures)

“normal”

women

applicable

whose

63 years and whose age range was approximately years (my calculation, based on the standard error). The age-

mean

was

normal

range

of this

linear regression

analysis

9S#{176}/o confidence

limits

population

can

of bone density

for

the

line

so

be computed

by using

as a function

obtained

are

a

of age; the

calculated

after

removing variation due to age. Reporting the mean ± 2 SD for a small group of women with a mean age of 63 years and an age range of four decades as the normal range will mislead many. Resch et al. simply should have stated that they were calculating the means ± 2 SD of their populations of control subjects and patients. If this is done, all three techniques, single-photon absorptiometry, quantitative CT, and broadband ultrasound attenuation, give values that are significantly lower in patients who have osteoporosis. I suggest that Resch et al. use all three techniques on separate groups of women (50 women per group) from each decade from 40 to 80 years, determine

the

95% confidence ancies between

linear

regression,

and

calculate

the

decade-specific

limits. The added precision will remove the discreptheir results [1 ] and the results of others [2-7].

Daniel T. Baran University

of Massachusetts

Medical

Worcester,

Center

MA

01655

REFERENCES 1 . Aesch H, Pietschmann P, Bernecker P. Krexner E, Willvonseder A. Broadband ultrasound attenuation: a new diagnostic method in osteoporosis. AJR 1990:155:825-828

2. Baran DT, Kelly AM, Karellas A, et al. Ultrasound attenuation calcis in women with osteoporosis and hip fractures. Calcif

CK, Leahey D, Lew A. Broadband

normal values. As we gave a clear description

obtained

our

normal

range

in our

Patients

and

of how we

Methods

section,

do not think that our conclusion will mislead the readers In contrast to other studies [2-5] that used broadband attenuation

in osteoporotic

our report, in the

allowing

patients

patients,

a direct

and

the

we

comparison

control

presented Defining

ultrasound

scattergrams

of individual

subjects.

we

of AJR. in

measurements

a normal

range

as

the mean ± 2 SD and using the values for the normal subjects studied by Baran et al. [2], we established the normal range as 35-90.2 db/ MHz. Although in this study no data on individuals are presented, the

mean broadband given given

ultrasound

as 40.3 db/MHz, as 32.3 db/MHz.

range as defined values

previously,

of the control

attenuation

value for “osteoporotics”

is

and the mean value of hip fracture patients is When these values are related to the normal subjects

a considerable and those

overlap

between

of the patients

seems

the to be

evident. In this context, it should be emphasized that a similar overlap has been reported [6] between patients with osteoporosis when single-photon

absorptiometry

and

quantitative

CT

were

used

to

measure bone density. In conclusion, we think that broadband ultrasound attenuation may become an interesting tool in the clinical management of osteoporosis. However, further technical improvements are necessary before this method can be recommended for general clinical practice. H. Resch and colleagues Krankenhaus

der Barmherzigen BrUder A-1020 Wien, Austria

of the os

mt i988;43: 138-1 42 3. Agren M, Karellas A, Leahey D, Marks 5, Baran D. tJtrasound attenuation of the calcaneus: a sensitive and specific discriminator of osteopenia in postmenopausal women. Calif Tissue Int i99i;48:240-244

4. Baran DT, McCarthy

1327

Tissue

ultrasound

atten-

uation of the calcaneus predicts lumbar and femoral neck density in Caucasian women: a preliminary study. Osteoporosis mt i99i;i :110-113 5. Poll V, Cooper C, Crawley Ml. Broadband ultrasonic attenuation in the os

calcis and single photon absorptiometry in the distalforearm: a comparative study. Clin Phys Physiol Meas i986;7:375-379 6. McCloskey EV, Murray SA, Miller C, et al. Broadband ultrasound attenuation in the os calcis: relationship to bone mineral at other skeletal sites. Clin Sci i990;78:227-233 7. Porter AW, Miller CG, Grainger D, Palmer SB. Prediction of hip fracture in elderly women: a prospective study. BMJ 1990;301 :638-641

REFERENCES 1 . Aesch H, Pietschmann

P. Bernecker P, Krexner E, Willvonseder A. Broadattenuation: a new diagnostic method in osteoporosis.

band ultrasound AJR

i990;1 55:825-828

2. Baran DT, Kelly AM, Karellas A, et al. Ultrasound attenuation of the os calcis in women with osteoporosis and hip fractures. Calcif Tissue Int i988;43: 138-142

3. Poll V, Cooper C, Crawley MI. Broadband

ultrasonic attenuation

calcis and single photon absorptiometry in the distal forearm: study. Clin Phys Physiol Meas 1986:7:375-379

4. McCloskey

EV, Murray SA, Miller C, et al. Broadband

in the os

a comparative

ultrasound

atten-

uation in the os calcis: relationship to bone mineral at other skeletal sites. C/in Sci 1990:78:227-233 5. Porter AW, Miller CG, Grainger D, Palmer SB. Prediction of hip fracture in elderly women: a prospective study. BMJ i990;301 :638-641

6. Hluck AF, Block J, Glueer CC, Steiger P. Genant HK. Mild versus definite osteoporosis: comparison of bone densitometry techniques statistical models. J Bone Mm Res i989;4 :891-900

using different

Reply

Dr. Baran suggests ultrasound attenuation

that we increase the number of broadband measurements in normal subjects. Unfortunately, the ultrasonic device used in our study [1 ] was a prototype and is no longer available to us. We are well aware of some divergent conclusions regarding the sensitivity of broadband ultrasonic attenuation measurements [2-5]. In our opinion, in clinical practice, the usefulness of a diagnostic

We read with interest the article by Van Blarcom et al. Ii I on follow-up radiographs of patients with dysbaric osteonecrosis that were obtained a minimum of 1 0 years after the patients’ last exposure to hyperbaric pressures. We report a case of dysbaric osteonecrosis of the humeral and femoral heads that occurred 10 years after

procedure

exposure

depends

on its ability to discriminate

between

normal and

pathologic conditions. Usually a normal range is defined in healthy subjects as the 5th to 95th percentile or, alternatively, the mean ± 2 SD. In our study, we tried to investigate the clinical usefulness of an ultrasonic technique in defining a “normal range” and in assessing the number of osteoporotic patients outside the normal range. As we did

not

find

attenuation did that

not

a correlation

establish

when

our number

between

age

and

values in the normal subjects normal

compared

of control

values with

the

subjects

broadband

(r

0.08,

for each

decade.

numbers

in published

is far too

We

ultrasound

.060),

p < are

well

studies

we

aware [2-4],

small to define generally

Dysbaric

Osteonecrosis

to hyperbaric

A 50-year-old earlier,

pressures.

man had a painful

he suddenly

had

had

pain

right shoulder.

in his right

shoulder.

Three months This

had

been

followed,

10 days later, by pain in the right side of the groin, which induced limping. The patient had been a skin diver for 20 years, but it had been 1 0 years since his last exposure to hyperbaric pressures. He had no significant medical history. On physical examination, the right

hip

and

shoulder

were

restricted

and

painful.

The

results

of

laboratory tests were normal. Radiographs showed osteonecrosis of the right humeral and femoral heads (Fig. 1). Scintigrams showed only a fixation

ofthose

bones.

The patient

had a total hip arthroplasty.

LETTERS

1328

AJR:156,

The case reported

June 1991

of the latent the decadeearlier cessation of exposure to hyperbaric pressures. Further prospective study of persons with exposure to hyperbaric pressures is needed because of the asymptomatic nature of the early stages of morbidity

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this

associated

by Goupille et al. is a further example with dysbaric

osteonecrosis

despite

disease.

Stephen T. Van Blarcom St. Luke’s

Medical

Milwaukee,

Center

WI 53215

REFERENCE 1 . Van Blarcom ST, Czamecki DJ, Fueredi GA, Wenzel MS. Does dysbaric osteonecrosis progress in the absence of further hyperbaric exposure? A 10-year radiologic follow-up of 15 patients. AJR i990;155:95-97 Fig.

1.-A

and B, Radiographs

show

dysbaric

osteonecrosis

of right

humeral (A) and femoral (B) heads 10 years after patient’s last exposure to hyperbaric

Primary Squamous Cell Carcinoma of the Base the Tongue with Liver and Bone Metastases

pressures.

The article by Van Blarcom and al. [1] is remarkable, and we would to make some comments: (1 ) The number and severity of the osteonecrotic lesions are influenced not only by the frequency and severity of the exposure to a hyperbaric environment but also by the depth of the dive, the antecedents of bends, and the participation in experimental dives [2]. (2) Van Blarcom et al. have compared original and follow-up radiographs, but we cannot know when the lesions seen on the radiographs became worse because only 29.4% of the lesions of dysbaric osteonecrosis are symptomatic [2]. (3) Classically, like

lesions

caused

by caisson

disease

of bone

are not seen on radio-

graphs until late in the course of the disease. The earliest a lesion was seen was 10 months after exposure to hyperbaric pressures (3]. These lesions are uncommon in the early years after the exposure and are 1 0 times more likely to be seen ifthe radiographs are obtained more than 5 years after exposure. (4) The course of the disease is unpredictable. Scintigrams obtained more than 10 years after a patient’s

exposure

to hyperbaric

pressures

may

show

fixations

with-

out radiologic lesions. Among those who have lesions seen on scintigrams, radiologic lesions develop in only 18% 5 years later [4]. Philippe Goupille Bernard Fouquet Philippe Cotty Jean-Pierre Valat

of

Distant metastases from oropharyngeal carcinomas are less common than metastases from most other head and neck primary tumors [1 -4]. When metastases occur, the lungs are the most common site [1 -4]. We present a case of bone and liver metastases from a primary oropharyngeal poorly differentiated squamous cell carcinoma. A 42-year-old man had had weight loss, general malaise, progressive neck swelling, and pain in the right hip and knee over several months. Physical examination showed bilateral matted adenopathy of the anterior and posterior chains of lymph nodes. Laryngoscopy showed an extensive tumor of the tongue base extending down to the vallecula, the lingual and laryngeal surfaces of the epiglottis, and the right lateral pharyngeal wall. CT of the neck (Fig. 1A) showed an ulcerating mass at the base of the tongue, involving the right vallecula and base of the epiglottis. The right aryepiglottic fold was thickened. Extensive bilateral necrotic matted adenopathy throughout the entire jugular chain of nodes was noted. CT of the pelvis showed a 12 x 7 x 10 cm expansile, lytic, necrotic soft-tissue mass of the right iliac wing (Fig. 1 B). CT of the abdomen showed a 6 x 4 x 6 cm necrotic mass in the right lobe of the liver. No lung or mediastinal lesions were seen on CT scans of the chest. Biopsy of the right lateral pharyngeal wall, the left side of the base of the tongue, and the iliac crest showed invasive poorly differentiated squamous cell carcinoma. According to

C. H. U. Trousseau 37044 Tours, France

REFERENCES 1 . Van Blarcom osteonecrosis

ST. Czamecki progress

DJ, Fueredi GA, Wenzel MS. Does dysbaric

in the absence

of further

hyperbaric

exposure?

A

10-year radiologic follow-up of 15 patients. AJR 1990;1 55:95-97 2. Amako T, Kawashima M, Torisu T, Hayashi K. Bone and joint lesions in decompression

sickness.

Semin

Arthritis

Rheum

i974;4:

151-190

3. Gregg PJ, Walder DN. Caisson disease of bone. CIin Orthop 43-54 4. MacLeod MA, McEwan in the early diagnosis

MB, Pearson AR, Houston of dysbaric osteonecrosis.

1986;210:

AS. Functional imaging Br J Radio! i982;55

497-500 Reply

Fig. 1.-Squamous

cell carcinoma

of base

of the tongue

with liver and

bone metastases.

The case reported delayed changes in

dysbaric

directly

to those

comparable

by Dr. Goupille et aI. is noted with interest. The osteonecrosis seen in their patient are seen

in the patients

Many of our patients

also were asymptomatic

either

or associated

articular

fracture

osteoarthritic

in our study

[1].

for many years until changes

occurred.

A, Enhanced CT scan at level of oropharynx ated mass at base of tongue (arrow) extending

shows an irregular, ulcerinto right oropharyngeal

wall. B, Enhanced

CT scan

of pelvis

shows

large,

expansile,

lytic, necrotic

soft-tissue mass of right iliac wing, which biopsy showed was a metastasis of squamous

cell carcinoma

of base

of tongue

shown

in A.

AJA:156,June

the

TNM

system

a T3N2cMI,

of the

or stage

International

Union

Against

Downloaded from www.ajronline.org by 186.67.91.98 on 11/12/15 from IP address 186.67.91.98. Copyright ARRS. For personal use only; all rights reserved

neck

laryngeal

squamous

this

was

primary site

from [1-4].

(excluding

vocal

cord),

cell

carcinomas

[1 -4].

This

and

This likely

may to

have be

a significant

associated

impact

with

cludes the stage of disease and histologic

hypopharyn-

from primary head case

sites.

is more

tumor

would

metastases

directly

correlates

with

information

may

have

its metastatic

status

ture,

is

it often

neoplasm

been

the

more

at presentation.

difficult

to

or the histologic

important In cases

determine

if the

findings

differed

Letters

are published

factors

Dale N. Estes

the

significantly

University Veterans

of letters must disclose

1 . Probert JC, Thompson AW, Bugshaw MA. Pattern of spread metastases in head and neck cancer. Cancer 1974:33:127-133

Center TN 38104

of distant

2. Memo OR, Lindberg, AD, Fletcher GH. An analysis of distant metastases from squamous cell carcinoma of the upper respiratory and digestive tracts. Cancer i977;40:145-151 3. Dennington ML, Carter DR. Meyers AD. Distant metastases in head and neck epidermoid carcinoma. Laryngoscope 1980:90:196-201 4. Papac RJ. Distant metastases from head and neck cancer. Cancer

litera-

between

i984;53:342-345

of the Editor

and are subject

double-spaced,

to editing.

typewritten

pages.

One

or two

should not be used. See Author Guidelines, page AS. elsewhere should not be duplicated in letters, and authors

financial associations

of Tennessee Medical

REFERENCES

Letters to the Editor must not be more than two figures may be included. Abbreviations Material being submitted or published

Affairs

Memphis,

primary

at the discretion

TN 38163

Jorge Salazar

the stage

in the of

of Tennessee

Memphis,

in determining

reported stage

A

on the primary

University

,

carcinoma

primary

disease.

of an oropha-

the neoplasm [2]. Studies [1 3, 4] have shown that the more locally extensive (T3, T4) lesions are more likely to metastasize. Though a positive correlation of cervical adenopathy with distant metastases has been suggested, the relationship is more equivocal 11-3]. This case was a higher T and N stage neoplasm. It also was unusual in having liver and bone metastases without detectable lung metastases, as several studies have shown that lung metastases are more common than bone and liver metastases [1-4]. The stage of the disease or the histologic features of this particular of

which

be of interest.

ryngeal carcinoma with disseminated disease illustrates one of the less likely of the head and neck carcinomas to metastasize. The rate of distant

on

disseminated

more extensive evaluation of the prevalence of distant metastases from oropharyngeal and other head and neck carcinomas that in-

head and neck carcinoma Most studies agree that

geal areas are the most likely sites of metastases and

Cancer,

IV, lesion.

Clinical detection of metastases occurs in only 5-25% of cases nasopharyngeal,

1329

LETTERS

1991

or other possible conflicts

of interest.

Letters concerning a paper published in the AJR will be sent to the authors of the paper for a reply to be published in the same issue. Opinions expressed in the Letters to the Editor do not necessarily reflect the opinions of the Editor.