Downloaded from www.ajronline.org by University of Florida on 11/14/15 from IP address 159.178.22.27. Copyright ARRS. For personal use only; all rights reserved
Letters
Single-Contrast/Double-Contrast In reference
to the article
“Double-blind
Study
Double Contrast Upper Endoscopy as a Control”
Gastrointestinal [1], the many
into
a valid
such
a study
prevent
Reply
GI of Single
The purpose of our paper was to evaluate the accuracy of the double-contrast examination of the stomach and duodenum if performed as the only examination of the upper gastrointestinal
and
Examinations Using variables which enter
conclusion.
In fact,
tract and trointestinal
it is indeed
not logical for one who has not personally conducted the fluoroscopic examination to be responsible for an informative and accurate interpretation of spot films and overhead films. Attempts to interpret radiographs without the most important aspect of the examination is a corner into which we sometimes paint ourselves. Certainly any properly conducted so-called ‘single-contrast examination” should find sufficient gas in the stomach to produce a double-contrast study of the antrum and of the duodenum. It is agreed that distension of the stomach with gas in some instances adds materially to the examination, but that should be “dealer’s choice.” I would safely state that an experienced examiner doing a meticulous upper gastrointestinal study can outperform the advocates solely relying on the doublecontrast method, as Montagne et al. report. But the idea of blind interpretation of only those films presented to an interpreter without his own insight and know-how is fraught with
the films of the singlehaving examiners who
1075
York,
New
examination
has
been
AR: Double-blind
and
over
its value
all the other
many
using
technical
years,
fluoros-
advantages
but demonstrate that by results will be improved.
with our findings and expertise
Albert A. Moss Alexander R. Margulis Jean-Philippe Montagne University of California San Francisco, California 94143
Lymphography As stated
in the paper
Detecting
lntraabdominal
in
phoma”
of Computed
and
be
specific,
when
results
should not have been lumped into Hodgkin’s and non-Hodgkin’s
ence
CT of Lymphomas Pelvic
Tomography
Adenopathy
in
Lym-
has a significant role in the workup with lymphoma. However, it is questionable if at this the answers are in and if it is yet time to draw based on such a limited sample of patients.
point all conclusions To
vs
“Accuracy
[1], CT undeniably
of patients
in the presenting
Non-Hodgkin’s clinical stages,
lymphomas therefore
mor,
or
where
CT
stage
were
into
between
usually frequently
ultrasound
presented,
one group lymphomas.
are
lymphomas
but subdivided There is a differ-
these
two
subgroups.
present in more advanced appearing as a bulky tuprobably
of
much
value.
In
5%-10% of patients with Hodgkin’s lymphoma, one finds only minimal or no enlargement of nodes which are diseased. However, the structural changes in these nodes can easily be recognized lymphography but, because their size is essentially normal, not by CT. Since therapy depends on extent of the dis-
10028
study
documented
substantiate
We are very grateful that Dr. Marshak agrees and conclusions and feel that his experience further contribute to the validity of the paper.
REFERENCE AA, Margulis
contrast
The endoscopist may not be the ultimate arbiter no matter what his expertise or experience, but the only ultimate arbiter is autopsy and we were not skillful enough to be able to design a study based on autopsy proof.
Avenue
York
and do the
separately. This obviously put the single-contrast exat a disadvantage, but since the value of the single-
single- or double-contrast examination, using the advantages of each, overall
H. Marshak Park
examinations, the patients
We did not review the films on the 100 patients twice, since the purpose of the study was not to examine the reliability of the examiners against themselves, but to duplicate as much as possible the clinical situation in which the films are read and reported. Our results do not detract from the value of either the
The article by Montagne et al. [1] substantiates the findings which I have published on many occasions in letters and articles. There is no reason when performing a gastrointestinal series, that both air studies and the ordinary barium meal examination with high kilovoltage and compression cannot be used. My results over the years have been excellent. Air studies alone will frequently miss obvious lesions. There is no question, however, that this method is best for superficial ulcers and gastritis. Historically, it may be of interest that for many years Dr. Crohn inserted a Levin tube for gastric analysis as an office procedure and then sent the patient to me for films. Utilizing the nasogastric tube, I performed air studies with high-density barium followed by conventional upper gastrointestinal series.
JP. Moss
double-contrast not familiar with
John H. Walker Mason Clinic Washington 98111
Richard
gasour
readings amination
copy with compression that may be possible.
The study should probably have included another control via examining either the same or an additional 100 patients twice by the same method. In other words, 100 patients by the contrast method at two intervals closely related and another 100 by the conventional method on two successive similar intervals. I realize that all of this is difficult, but otherwise the study lacks validity. It is well known that the endoscopist is not the ultimate arbiter no matter what his expertise or experience.
1 . Montagne
and were
we did not elect to again
error.
New
this with the single-contrast upper To equalize the two examinations,
approach was to compare the two as much in a double-blind fashion as possible. Therefore the protocol called for separating
‘
Seattle,
to compare series.
of
single and double contrast upper gastrointestinal examinations using endoscopy as a control. Am J Roentgenol
ease,
130:1041-1045,
positive
it is important
The paper
1978 1116
does
CT scans
to identify
these
not specify belonged
patients.
how many
to the
Hodgkin’s
of the patients and
how
many
with to
1117
Downloaded from www.ajronline.org by University of Florida on 11/14/15 from IP address 159.178.22.27. Copyright ARRS. For personal use only; all rights reserved
LETTERS the non-Hodgkin’s group. Nor is there any mention extensive the disease was. Did most have significantly nodes? Was the entire retroperitoneum involved? single nodes or nodal groups involved? As far as the accuracy of the so-called “normal”
as to how enlarged Were only
concerned,
The claims
clinical
staging
is not accurate
enough.
group
is
The 84% is simply a percentage of agreement between the CT scan and the lymphangiogram in the 37 patients who had both CT and lymphangiography but no surgical staging procedure.
Nowhere in our paper does the statement “that lymphography has no real advantage over CT when following patients,...” appear. We did state that “lymphangiography has only a tran-
that clinical follow-up can be used as a proof that interpretation is correct reminds me of papers published in the 1960s regard-
sient
advantage
more
valuable
ing accuracy of lymphography. True accuracy of lymphography was only established after the results of the methodical studies, including staging laparotomies done by the Stanford group, were published. Only then were we able to learn the true criteria
residual
for
interpretation
should
of the
be applied
to CT before
I must take issue with no
real
advantage
instances
lymphograms.
over
sufficient
conclusions
the statement CT when
contrast
Similar
rigid
medium
patients.
remains
has In most
in the node
allow recognition of nodal changes for at least a year, longer. During that time a single plain film of the abdomen that is needed to compare with previous studies. This
simpler,
cheaper,
scan at intervals giography.
and less time-consuming of 2-3 months
as is usually
than repeating done
after
most
in
are drawn.
following
contrast
to
if not is all is far
a CT
lymphan-
the
patients
nodes
for
[1].
It is doubtful
have
sufficient
lymph
significant
contrast
had
insufficient
contrast
firm
diagnostic
opinion
lating
after
it is probably
true
medium film
up
percentage
medium
remaining or,
unchanged
when,
The
6 months
of patients
will
time.
of these
cases
overall
accuracy
of
proven
phangiography 92% [2]. The
that
the
whereas chance
worse, fact,
Having
cases
may
to allow
in order CT
CT
size in other
to press
in lymphoma
is 90%.
have
this
demon-
locations no residual of accumu-
point
in our
The overall
for a
deceptively
subsequent
in node
in lymphoma in the series difference between CT and
former
nodes appeared
or other nodes which had them. We are in the process
a series
surgically
in
increase
such as the mesentery contrast material within
in the
even
further.
series
accuracy
of
31
of lym-
of Castellino et al. is lymphangiography is
a 14%-15%
false
negative
rate,
the latter may have up to a 25% false positive rate. The that CT will miss an involved node is no greater than
lymphangiography
over-calling
a hyperplastic
lymph node. Joseph K. T. Lee Robert J. Stanley
Stuart S. Sagel Robert G. Levitt Institute of Radiology
of Utah Medical Center Salt Lake City, Utah 84132 Mallinckrodt
St. Louis,
REFERENCE JKT, Stanley RJ, Sagel SS, Levitt RG: Accuracy of computed tomography in detecting intraabdominal and pelvic adenopathy in lymphoma. Am J Roentgenol 131 :311315, 1978
retained
to
by that
P. Ruben Koehler University
of
nodes
contrast
abdominal
is a
amount
worked with CT for 3 years in patients who have had both CT and lymphangiography, we have been impressed with the large number of cases in which the follow-up abdominal film either
ultrasound be used for staging of lymphomas. Accuracy of 84% is not acceptable. It is the patient with minimal involvement that we want to find early; it is easy to identify the one with obvious disease. It is questionable if one needs lymphography if the the limited information available, that the negative CT reliably reflects the stage of the disease? Are we willing to accept a small error in correct staging of potentially curable patients? These questions must also be answered before one discards the tedious, but fairly reliable lymphography.
any
residual
or
with
Although
that
enough
a significant
to conclude,
is quite variable. a diagnostic
normal
but is it justified
The
in the
have
and the latter
follow-up.”
later (1 year sounds a bit long to us), only less than one-half of the relapses in Hodgkin’s disease occur in the first 15 months, whereas the rest of the recurrences occur within the first 5 years
strated
are positive,
patients
long-term
remaining
will
While time may prove that CT and ultrasound are as sensitive or more sensitive than lymphography, the limited experience available now does not justify suggesting that CT or
CT or ultrasound
CT in following for
medium
lymphangiography that
criteria
that lymphography
over tool
Missouri
63110
I . Lee
1 . Weller
SA, Glatstein E, Kaplan HS, Rosenberg SA: Initial relapses in previously treated Hodgkin’s disease. Cancer 37:2840-2846, 1976 2. Castellino RA, Billingham M, Dorfman RF: Lymphographic
accuracy
Reply It is true that 5%-10% of patients with Hodgkin’s lymphoma may have minimal or no enlargement of nodes which, in fact, are diseased. We did not encounter such a case during the time of the study which was reported. Recently, we saw a patient who had a ‘normal” CT scan despite an inguinal node biopsy positive for Hodgkin’s disease. Lymphangiography was recommended in that instance and showed replaced but normal-sized lymph nodes. It is cleanly stated in the discussion of our paper that “lymph nodes which are normal in size but replaced with
tumor
REFERENCES
will not be distinguished
as abnormal
by CT.”
We agree with Dr. Koehler that clinical staging is not accurate enough and cannot be relied upon as the final proof for the socalled “normal” group. In our paper, the accuracy of CT is computed only on the cases with surgical or autopsy proof. The overall accuracy in our series is 90% and not 84% as alluded to.
with
a note
in Hodgkin’s on the
false-positive 1974
‘ ‘
disease
reactive
lymphograms.”
Ultrasound
of Tumor
and malignant
lymphoma
lymph node as a cause of most Invest Radiol 9 : 1 55-1 65,
Extension
to IVC
I read with interest the article entitled “Ultrasonic Detection of Renal Tumor Extension into the Inferior Vena Cava” [1]. The authors felt that ‘ ‘only one previous case of intracaval tumor extension demonstrated by ultrasonography has been reported in the
English
language
literature.”
I wish
to point
out
an article
written by me entitled ‘ ‘The Inferior Vena Cava: Mass Effects,” in the March 1978 issue of the AJR [2]. In that article, six patients were presented with mass effects on the vena cava from a variety of tumors. In one of these patients, with renal cell
LETTERS
Downloaded from www.ajronline.org by University of Florida on 11/14/15 from IP address 159.178.22.27. Copyright ARRS. For personal use only; all rights reserved
1118
carcinoma, the tumor mass could be seen to extend through the right renal vein into the lumen of the vena cava. The five cases presented by Goldstein et al. are certainly a valuable addition to the literature. This will encourage all of us to be certain to perform supine scans in the search for caval extension and hepatic metastases, once a hypernephroma has
been identified. University
Barbara B. Gosink of California School of Medicine San Diego, California 92161
REFERENCES 1 . Goldstein
HM, Green B, Weaver RM Jr: Ultrasonic of renal tumor extension into the inferior vena Roentgenol 130:1083-1085, 1978
detection cava. Am J
2. Gosink BB: The inferior Roentgenol 130:533-536,
vena 1978
cava:
mass
effects.
Am
J
Reply We are aware of and enjoyed Dr. Gosink’s article in the March 1978 issue, which indeed includes a patient with renal cell
cancer
extending
to the lumen
of the inferior
vena
cava.
It
would have been our pleasure to acknowledge her case; however, as clearly indicated in the footnotes on the first page of our article, our manuscript was submitted, revised, and accepted well before publication of Dr. Gosink’s article.
Harvey Southwest
M. Goldstein
Texas Methodist Hospital San Antonio, Texas 78229
Letters
Single-Contrast/Double-Contrast In reference
to the article
“Double-blind
Study
Double Contrast Upper Endoscopy as a Control”
Gastrointestinal [1], the many
into
a valid
such
a study
prevent
Reply
GI of Single
The purpose of our paper was to evaluate the accuracy of the double-contrast examination of the stomach and duodenum if performed as the only examination of the upper gastrointestinal
and
Examinations Using variables which enter
conclusion.
In fact,
tract and trointestinal
it is indeed
not logical for one who has not personally conducted the fluoroscopic examination to be responsible for an informative and accurate interpretation of spot films and overhead films. Attempts to interpret radiographs without the most important aspect of the examination is a corner into which we sometimes paint ourselves. Certainly any properly conducted so-called ‘single-contrast examination” should find sufficient gas in the stomach to produce a double-contrast study of the antrum and of the duodenum. It is agreed that distension of the stomach with gas in some instances adds materially to the examination, but that should be “dealer’s choice.” I would safely state that an experienced examiner doing a meticulous upper gastrointestinal study can outperform the advocates solely relying on the doublecontrast method, as Montagne et al. report. But the idea of blind interpretation of only those films presented to an interpreter without his own insight and know-how is fraught with
the films of the singlehaving examiners who
1075
York,
New
examination
has
been
AR: Double-blind
and
over
its value
all the other
many
using
technical
years,
fluoros-
advantages
but demonstrate that by results will be improved.
with our findings and expertise
Albert A. Moss Alexander R. Margulis Jean-Philippe Montagne University of California San Francisco, California 94143
Lymphography As stated
in the paper
Detecting
lntraabdominal
in
phoma”
of Computed
and
be
specific,
when
results
should not have been lumped into Hodgkin’s and non-Hodgkin’s
ence
CT of Lymphomas Pelvic
Tomography
Adenopathy
in
Lym-
has a significant role in the workup with lymphoma. However, it is questionable if at this the answers are in and if it is yet time to draw based on such a limited sample of patients.
point all conclusions To
vs
“Accuracy
[1], CT undeniably
of patients
in the presenting
Non-Hodgkin’s clinical stages,
lymphomas therefore
mor,
or
where
CT
stage
were
into
between
usually frequently
ultrasound
presented,
one group lymphomas.
are
lymphomas
but subdivided There is a differ-
these
two
subgroups.
present in more advanced appearing as a bulky tuprobably
of
much
value.
In
5%-10% of patients with Hodgkin’s lymphoma, one finds only minimal or no enlargement of nodes which are diseased. However, the structural changes in these nodes can easily be recognized lymphography but, because their size is essentially normal, not by CT. Since therapy depends on extent of the dis-
10028
study
documented
substantiate
We are very grateful that Dr. Marshak agrees and conclusions and feel that his experience further contribute to the validity of the paper.
REFERENCE AA, Margulis
contrast
The endoscopist may not be the ultimate arbiter no matter what his expertise or experience, but the only ultimate arbiter is autopsy and we were not skillful enough to be able to design a study based on autopsy proof.
Avenue
York
and do the
separately. This obviously put the single-contrast exat a disadvantage, but since the value of the single-
single- or double-contrast examination, using the advantages of each, overall
H. Marshak Park
examinations, the patients
We did not review the films on the 100 patients twice, since the purpose of the study was not to examine the reliability of the examiners against themselves, but to duplicate as much as possible the clinical situation in which the films are read and reported. Our results do not detract from the value of either the
The article by Montagne et al. [1] substantiates the findings which I have published on many occasions in letters and articles. There is no reason when performing a gastrointestinal series, that both air studies and the ordinary barium meal examination with high kilovoltage and compression cannot be used. My results over the years have been excellent. Air studies alone will frequently miss obvious lesions. There is no question, however, that this method is best for superficial ulcers and gastritis. Historically, it may be of interest that for many years Dr. Crohn inserted a Levin tube for gastric analysis as an office procedure and then sent the patient to me for films. Utilizing the nasogastric tube, I performed air studies with high-density barium followed by conventional upper gastrointestinal series.
JP. Moss
double-contrast not familiar with
John H. Walker Mason Clinic Washington 98111
Richard
gasour
readings amination
copy with compression that may be possible.
The study should probably have included another control via examining either the same or an additional 100 patients twice by the same method. In other words, 100 patients by the contrast method at two intervals closely related and another 100 by the conventional method on two successive similar intervals. I realize that all of this is difficult, but otherwise the study lacks validity. It is well known that the endoscopist is not the ultimate arbiter no matter what his expertise or experience.
1 . Montagne
and were
we did not elect to again
error.
New
this with the single-contrast upper To equalize the two examinations,
approach was to compare the two as much in a double-blind fashion as possible. Therefore the protocol called for separating
‘
Seattle,
to compare series.
of
single and double contrast upper gastrointestinal examinations using endoscopy as a control. Am J Roentgenol
ease,
130:1041-1045,
positive
it is important
The paper
1978 1116
does
CT scans
to identify
these
not specify belonged
patients.
how many
to the
Hodgkin’s
of the patients and
how
many
with to
1117
Downloaded from www.ajronline.org by University of Florida on 11/14/15 from IP address 159.178.22.27. Copyright ARRS. For personal use only; all rights reserved
LETTERS the non-Hodgkin’s group. Nor is there any mention extensive the disease was. Did most have significantly nodes? Was the entire retroperitoneum involved? single nodes or nodal groups involved? As far as the accuracy of the so-called “normal”
as to how enlarged Were only
concerned,
The claims
clinical
staging
is not accurate
enough.
group
is
The 84% is simply a percentage of agreement between the CT scan and the lymphangiogram in the 37 patients who had both CT and lymphangiography but no surgical staging procedure.
Nowhere in our paper does the statement “that lymphography has no real advantage over CT when following patients,...” appear. We did state that “lymphangiography has only a tran-
that clinical follow-up can be used as a proof that interpretation is correct reminds me of papers published in the 1960s regard-
sient
advantage
more
valuable
ing accuracy of lymphography. True accuracy of lymphography was only established after the results of the methodical studies, including staging laparotomies done by the Stanford group, were published. Only then were we able to learn the true criteria
residual
for
interpretation
should
of the
be applied
to CT before
I must take issue with no
real
advantage
instances
lymphograms.
over
sufficient
conclusions
the statement CT when
contrast
Similar
rigid
medium
patients.
remains
has In most
in the node
allow recognition of nodal changes for at least a year, longer. During that time a single plain film of the abdomen that is needed to compare with previous studies. This
simpler,
cheaper,
scan at intervals giography.
and less time-consuming of 2-3 months
as is usually
than repeating done
after
most
in
are drawn.
following
contrast
to
if not is all is far
a CT
lymphan-
the
patients
nodes
for
[1].
It is doubtful
have
sufficient
lymph
significant
contrast
had
insufficient
contrast
firm
diagnostic
opinion
lating
after
it is probably
true
medium film
up
percentage
medium
remaining or,
unchanged
when,
The
6 months
of patients
will
time.
of these
cases
overall
accuracy
of
proven
phangiography 92% [2]. The
that
the
whereas chance
worse, fact,
Having
cases
may
to allow
in order CT
CT
size in other
to press
in lymphoma
is 90%.
have
this
demon-
locations no residual of accumu-
point
in our
The overall
for a
deceptively
subsequent
in node
in lymphoma in the series difference between CT and
former
nodes appeared
or other nodes which had them. We are in the process
a series
surgically
in
increase
such as the mesentery contrast material within
in the
even
further.
series
accuracy
of
31
of lym-
of Castellino et al. is lymphangiography is
a 14%-15%
false
negative
rate,
the latter may have up to a 25% false positive rate. The that CT will miss an involved node is no greater than
lymphangiography
over-calling
a hyperplastic
lymph node. Joseph K. T. Lee Robert J. Stanley
Stuart S. Sagel Robert G. Levitt Institute of Radiology
of Utah Medical Center Salt Lake City, Utah 84132 Mallinckrodt
St. Louis,
REFERENCE JKT, Stanley RJ, Sagel SS, Levitt RG: Accuracy of computed tomography in detecting intraabdominal and pelvic adenopathy in lymphoma. Am J Roentgenol 131 :311315, 1978
retained
to
by that
P. Ruben Koehler University
of
nodes
contrast
abdominal
is a
amount
worked with CT for 3 years in patients who have had both CT and lymphangiography, we have been impressed with the large number of cases in which the follow-up abdominal film either
ultrasound be used for staging of lymphomas. Accuracy of 84% is not acceptable. It is the patient with minimal involvement that we want to find early; it is easy to identify the one with obvious disease. It is questionable if one needs lymphography if the the limited information available, that the negative CT reliably reflects the stage of the disease? Are we willing to accept a small error in correct staging of potentially curable patients? These questions must also be answered before one discards the tedious, but fairly reliable lymphography.
any
residual
or
with
Although
that
enough
a significant
to conclude,
is quite variable. a diagnostic
normal
but is it justified
The
in the
have
and the latter
follow-up.”
later (1 year sounds a bit long to us), only less than one-half of the relapses in Hodgkin’s disease occur in the first 15 months, whereas the rest of the recurrences occur within the first 5 years
strated
are positive,
patients
long-term
remaining
will
While time may prove that CT and ultrasound are as sensitive or more sensitive than lymphography, the limited experience available now does not justify suggesting that CT or
CT or ultrasound
CT in following for
medium
lymphangiography that
criteria
that lymphography
over tool
Missouri
63110
I . Lee
1 . Weller
SA, Glatstein E, Kaplan HS, Rosenberg SA: Initial relapses in previously treated Hodgkin’s disease. Cancer 37:2840-2846, 1976 2. Castellino RA, Billingham M, Dorfman RF: Lymphographic
accuracy
Reply It is true that 5%-10% of patients with Hodgkin’s lymphoma may have minimal or no enlargement of nodes which, in fact, are diseased. We did not encounter such a case during the time of the study which was reported. Recently, we saw a patient who had a ‘normal” CT scan despite an inguinal node biopsy positive for Hodgkin’s disease. Lymphangiography was recommended in that instance and showed replaced but normal-sized lymph nodes. It is cleanly stated in the discussion of our paper that “lymph nodes which are normal in size but replaced with
tumor
REFERENCES
will not be distinguished
as abnormal
by CT.”
We agree with Dr. Koehler that clinical staging is not accurate enough and cannot be relied upon as the final proof for the socalled “normal” group. In our paper, the accuracy of CT is computed only on the cases with surgical or autopsy proof. The overall accuracy in our series is 90% and not 84% as alluded to.
with
a note
in Hodgkin’s on the
false-positive 1974
‘ ‘
disease
reactive
lymphograms.”
Ultrasound
of Tumor
and malignant
lymphoma
lymph node as a cause of most Invest Radiol 9 : 1 55-1 65,
Extension
to IVC
I read with interest the article entitled “Ultrasonic Detection of Renal Tumor Extension into the Inferior Vena Cava” [1]. The authors felt that ‘ ‘only one previous case of intracaval tumor extension demonstrated by ultrasonography has been reported in the
English
language
literature.”
I wish
to point
out
an article
written by me entitled ‘ ‘The Inferior Vena Cava: Mass Effects,” in the March 1978 issue of the AJR [2]. In that article, six patients were presented with mass effects on the vena cava from a variety of tumors. In one of these patients, with renal cell
LETTERS
Downloaded from www.ajronline.org by University of Florida on 11/14/15 from IP address 159.178.22.27. Copyright ARRS. For personal use only; all rights reserved
1118
carcinoma, the tumor mass could be seen to extend through the right renal vein into the lumen of the vena cava. The five cases presented by Goldstein et al. are certainly a valuable addition to the literature. This will encourage all of us to be certain to perform supine scans in the search for caval extension and hepatic metastases, once a hypernephroma has
been identified. University
Barbara B. Gosink of California School of Medicine San Diego, California 92161
REFERENCES 1 . Goldstein
HM, Green B, Weaver RM Jr: Ultrasonic of renal tumor extension into the inferior vena Roentgenol 130:1083-1085, 1978
detection cava. Am J
2. Gosink BB: The inferior Roentgenol 130:533-536,
vena 1978
cava:
mass
effects.
Am
J
Reply We are aware of and enjoyed Dr. Gosink’s article in the March 1978 issue, which indeed includes a patient with renal cell
cancer
extending
to the lumen
of the inferior
vena
cava.
It
would have been our pleasure to acknowledge her case; however, as clearly indicated in the footnotes on the first page of our article, our manuscript was submitted, revised, and accepted well before publication of Dr. Gosink’s article.
Harvey Southwest
M. Goldstein
Texas Methodist Hospital San Antonio, Texas 78229
