REFERENCES

1 . Hilts PJ. FDA seeks halt in breast implants

made of silicone. New York

Times Jan 7, 1992:A1

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1127

LETTERS

AJR:159, November 1992

2. Shermis RB, Adler DD, Smith DS, Hall JD. Intraductal silicone secondary to breast implant rupture: an unusual mammographic presentation. Breast Dis 1990:3:17-20 3. Silverstein MJ, Handel N, Gamagami P, et al. Breast cancer after augmentation mammoplasty. Arch Surg 1988:123:681-685 4. Shehi U, Pierson KK. Benign and malignant epithelial neoplasms and dermatological disorders. In: Bland KI, Copeland EM Ill, eds. The breast. Philadelphia: Saunders, 1991:224

tion. Depending on the underlying pathologic and surgical findings, simple reduction, bowel resection, or surgical correction may be indicated. In establishing the diagnosis of intussusception in an adult, sonography is of special importance because of its rapid bedside availability and lack of invasiveness. The diagnosis can readily be made on the basis of the typical appearance, enabling rapid institution of appropriate treatment. Michael E. Kuklinski Eckhart Froehlich Peter Fruehmorgen Ludwigsburg

Jejunogastric Sonographic A 51 -year-old

Intussusception: Findings man was admitted

Diagnosis

Based

on

District

Ludwigsburg,

Hospital Germany

REFERENCES

because

of central

chest pain.

On the basis of ECG and laboratory criteria, inferior myocardial infarction was diagnosed. The patient had a history of recurrent duodenal ulcers and had had a Billroth II gastrojejunostomy 1 5 years before. Two days after admission, he had acute onset of severe epigastric pain without hematemesis or melena. The epigastnium was tender to palpation, without guarding. Laboratory tests showed no cause for these symptoms. Abdominal sonography showed the fluidfilled gastric remnant containing an echogenic mass 1 0 cm in diameter that had a “target” appearance (concentric echogenic rings) in transverse section (Fig. 1 ). No peristalsis was evident. The diagnosis was jejunogastric intussusception, which was confirmed with endoscopy. Laparotomy showed intussusception of 60 cm of jejunum into the stomach. Manual reduction and jejunal fixation to the transverse colon were performed; bowel resection was not necessary. Jejunogastric intussusception is a recognized complication of gastrojejunostomy, particularly the Billroth II procedure [1 ]. The preva-

lence is reported

W 7140

to be 1 .5 per 1000 [2]. Chronic

intermittent

intus-

susceptions with spontaneous reduction occur far more frequently than does acute symptomatic intussusception, which is potentially fatal [3]. The diagnosis of jejunogastric intussusception is usually established on the basis of radiologic findings. Sonography has been a standard technique for diagnosis of intussusception in children. Reports of intussusception in adults generally have been published more recently [4]. The typical appearance consists of concentric echogenic rings (target sign), independent peristalsis of both parts on real-time scanning, and demonstration of the underlying abnormality (e.g., polyp) [4]. Treatment aims at urgent reduction, and surgery is usually required in the case of jejunogastric intussuscep-

1 . Phillips S. Disorders of gastrointestinal LH, eds. Cecil textbook of medicine, 1985: 705

2. Bradford B, Boggs JE. Jejunogastric intussusception: an unusual complication of gastric surgery. Arch Surg 1958:77:201-204 3. Burhenne HJ. Postoperative radiology: intestinal and biliary tract. In: Margulis AR, Burhenne HJ, eds. Alimentary tract radiology, vol. 1 , 3rd ed. St. Louis: Mosby, 1983:740-783 4. Brandt M. Sonographische Befunde bei der Invagination des Darmes. In: Gebel M, Majewski A, Brunkhorst A, eds. Sonographie in der Gastroenterologie. Berlin: Springer, 1988:85-87

Persistent Sonography

Pseudotumor of the Bowel on Caused by Stool in the Colon

Pseudotumors of the bowel are described as predominantly small and round, whereas large masses, particularly if irregular in outline, are said to represent solid tumors of the cul-de-sac or rectosigmoid colon [1]. A 31 -year-old woman was referred for sonography because of recurrent pelvic pain. Transabdominal (Fig. 1A) and transvaginal (Fig. 1 B) sonograms showed a complex mass 7 cm in diameter that was solid, irregular in contour, and heterogeneous in echogenicity. The

Fig. 1.-Persistent

pseudotu-

mor of bowel caused by stool in colon. A and B, Transabdominal (A) and transvaginal (B) sonograms of pelvis show large, solid mass (between calipers) with an irregular contour and a heterogeneous

echogenlcity. Fig. 1.-Jejunogastric intussusception in an aduft. A, Abdominal sonogram shows fluid-filled gastric remnant with echogenic 7 x 10 cm mass with a “target” sign. B, Longitudinal sonogram shows echogenic mass within stomach; no peristalsis is evident.

motility. In: Wyngaarden JB, Smith 17th ed. Philadelphia: Saunders,

C, CT

scan

of pelvis

shows

rectosigmoid colon (solid arrows) distended with stool and displaced uterus (open arrow).

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1128

LETTERS

mass, which could not be distinguished as an entity separate from the ovary, was posterior to the uterus, displacing the uterus to the right. No peristalsis was detected within the mass, and the configuration of the mass did not change over time. The patient said she had normal bowel movements. Differential diagnosis included ovarian neoplasm, a solid tumor of the cul-de-sac, and possible pedunculated leiomyoma of the uterus. The diagnosis of pseudotumor was considered but thought highly unlikely because of the size and irregular contour of the mass, the complete lack of peristalsis, and the lack of change in appearance over time. The patient had repeat transvaginal sonography the next morning after a bowel movement. The mass was unchanged. CT scans with oral, rectal, and IV contrast material showed a significant amount of stool distending the rectosigmoid colon and displacement of the uterus to the right, but no mass (Fig. 1C). The patient evacuated the colon, and transvaginal and transabdominal sonograms were obtamed, which again showed the pelvic mass. Although the mass did not appear to change considerably in size or configuration, the CT results suggested a pseudotumor. Transvaginal sonography combined with a water enema was then performed. The water took several seconds to enter the mass, but soon showed that the mass was stool. The size of this mass, its irregular contour, and the complete lack of change in size or configuration during the course of several studies led us to think that the mass was a neoplasm. According to current literature [2), this mass fit in the category of solid tumor of the culde-sac or rectosigmoid colon. Its persistence led to several radiologic studies. The most reliable for diagnosis was a combination of transvaginal sonography and water enema. Rita A. Perrella Bruce McLucas University

of California,

Los

Angeles,

School

Los Angeles,

of Medicine

CA 90024

REFERENCES 1 . Kurtz

AB, Rubin CS, Kramer

posterior

FL, et al. Ultrasound evaluation of the 1979:132:677-682 New York: Churchill Livingstone,

pelvic compartment. Radiology 2. Taylor KJW. Atlas of ultrasonography. 1985:97

AJR:159, November 1992

Fig. 1.-Osteoclast-type

giant-cell

tumor of the pancreas.

A, Transverse sonogram shows large epigastric mass with mixed echogenicity anterior to aorta and superior mesenteric artery. B, Contrast-enhanced CT scan at level of porta hepatis shows large

pancreatic mesenteric

mass

with several

artery

(arrow)

areas

surrounded

of low attenuation. by fat, without

Note superior

evidence

of tumoral

involvement.

cell tumor have revealed pancreatic masses with areas of low attenuation consistent with necrosis (1 , 3]. In one case [1], mesenteric vessels were encased by tumor, which showed retropancreatic extension toward the aorta, but no metastases were detected. In our case, the tumor was a large mass in the body and tail of the pancreas. The tumor showed irregular enhancement after administration of contrast material and had low-density areas corresponding to hemorrhagic necrosis. Portal and splenic vein thrombosis resulting in severe portal hypertension is a finding previously not reported for this tumor. In contradistinction to this marked portal infiltration, retropancreatic extension toward the aorta and thickening of the superior mesenteric artery were not detected, and the surrounding fat was preserved. In conclusion, the findings in our case enlarge the spectrum of radiologic findings in this tumor, but the usefulness of CT and sonography in the preoperative diagnosis of this entity is uncertain. Isabel Gil-Garcia Carlos Valls Ana Sanchez-Marquez Isabel

Osteoclast-Type

Giant-Cell

Tumor

of the Pancreas

Hospital 08907

A 41 -year-old woman was hospitalized tric mass

for evaluation

a smooth

Barcelona,

Spain

of an epigas-

and pain in the left upper quadrant. Physical examination palpable mass in the epigastnum and mild hepatosplenomegaly. Sonography showed a large mass in the pancreatic body with mixed echogenicity (Fig. 1A), marked splenomegaly, and portal and splenic thrombosis. CT showed a bulky mass in the body and tail of the pancreas, which had irregular areas of enhancement after bolus administration of contrast material (Fig. 1B), portal and splenic vein thrombosis, and marked splenomegaly. Retroperitoneal extension and encasement of mesentenic vessels were not detected. At surgery, the mass could not be resected because of involvement of vascular structures. Intraoperative fine-needle aspiration was performed, and histologic examination showed osteoclast-type giant-cell carcinoma of the pancreas. Osteoclast-type giant-cell carcinoma is a rare pancreatic neoplasm histologically indistinguishable from skeletal giant-cell tumor [1]. It must be distinguished from the more usual giant-cell neoplasms of the pancreas that contain atypical pleomorphic giant cells [1-3]. Microscopic examination shows numerous multinucleated osteoclastlike giant cells within a stroma of oval, polygonal, or plump spindleshaped mononuclear cells with various degrees of pleornorphism [2]. CT scans obtained in three cases of pancreatic osteoclast-type giant-

showed

Catala

de Bellvitge

REFERENCES

1 . Berendt AC, Shnitka TK, Wiens E, Manickavel V. Jewell LD. The osteoclast-type giant cell tumor of the pancreas. Arch Pathol Lab Med 1987: 111:43-48 2. Friedman AC, Edmonds PR. Rare pancreatic malignancies. Radio! C!in North Am

1989:29:177-190

3. Trepeta AW, Mathur B, Lagin S. Livosi A. Giant cell tumor (“osteoclastoma’) of the pancreas: a tumor of epithelial origin. Cancer 1981:48: 2022-2028

Tiny

Echogenic

Foci in the Liver

In the January 1992 issue of the AJR, Bray et al. [1] describe multiple tiny echogenic foci in the liver and kidneys of a patient with AIDS. Their illustration in Figure 1 in the paper brought to mind a similar appearance that my colleagues and I [2] described in patients with miliary tuberculosis of the liver. Virtually identical echogenic nodules were present. As our patients were infected with Mycobacterium tuberculosis and their patient was infected with Mycobacterium avium-intracellulare, the similarity is not surprising. As miliary tuber-

culosis can involve a compromised such an echo pattern could include

host, the differential miliary tuberculosis.

diagnosis

of

W. K. Andrew Eugene

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Pretoria

0038,

Marais

Republic

Hospitaal

of South Africa

REFERENCES

1 . Bray HJ, Lail VJ, Cooperberg PL. Tiny echogenic foci in the liver and kidney in patients with AIDS: not always due to disseminated Pneumocystis carinii. AJR 1992:158:81-82 2. Andrew WK, Thomas AG, Gollach BL. Miliary tuberculosis of the liver: another cause of the ‘bright liver’ on ultrasound examination. S Afr Med J 1982:62:808-809

Testicular

Reply

My colleagues and I thank Kutcher et al. for their interest in our article [1]. We agree that testicular neoplasm and testicular microlithiasis can coexist. Indeed, we described three such cases in our article, and we found that the microlithiasis did not interfere with sonographic visualization of the tumors. However, only a few cases of testicular microlithiasis have been described in the literature to date, and we think that no conclusions can be made about whether patients with this disorder are at increased risk for testicular neoplasm. We concluded that clinical or sonographic surveillance may be prudent, and we think that the suggestion of Kutcher et al. regarding annual sonography is reasonable. We wish to emphasize our belief that the typical sonographic appearance of testicular microlithiasis is not by itself a justification for orchiectomy or testicular biopsy.

Microlithiasis

We read with interest “Testicular Clinical Features,’ by Janzen et al. AJR. We have studied two patients testicular microlithiasis. Both had a no evidence of calcification within otherwise healthy young men, 27 Neither had a history of abnormal abnormality, or any known fertility speckled

1129

LETTERS

AJR:159, November 1992

calcifications

Microlithiasis: Sonographic and [1] in the May 1992 issue of the in the past year who have had unilateral seminoma (Fig. 1A) with the lesion. Both patients were and 35 years old, respectively. testicular descent, chromosomal problem. One had classic minute

in the epididymis

(Fig. 1B). Epididymal

Medical

Center/Albert

Einstein

Rosalyn Kutcher Ruth Rosenblatt Sarah Kremer College of Medicine Bronx, NY 10467

REFERENCE 1 . Janzen DL, Mathieson JR, Marsh JI, et al. Testicular microlithiasis: graphic and clinical features. AJR 1992:158: 1 057-1 060

sono-

.,-c.:l-:’..-

Fig. 1.-Testicular

microlithiasis

in a 35-year-old

Vancouver,

B.C.,

John R. Mathieson of British Columbia Canada

V6Z

1 Y6

REFERENCE 1 . Janzen DL, Mathieson JR. Marsh JI, et al. Testicular graphic and clinical features. AJR 1992:158:1057-1060

microlithiasis:

sono-

involve-

ment has not been previously reported. We agree with Janzen et al. that testicular microlithiasis is uncommon and apparently asymptomatic, and that the occurrence of a malignant tumor may be coincidental. However, the occurrence of neoplasms in our two patients suggests that yearly follow-up sonography in patients with testicular microlithiasis is justifiable.

Montefiore

University

man.

A, Right tranverse sonogram shows a large intratesticular mass compressing normal testicular parenchyma involved with microllthiasls. B, Longitudinal sonogram of left testicle shows typical microlithiasis, with speckled calcification in caput of epididymis also.

Abdominal

Aortic

Aneurysm

With the liberal use of diagnostic techniques such as sonography and CT, physicians are increasingly confronted with patients who have asymptomatic abdominal aortic aneurysm; therefore, knowledge of current treatment strategy is mandatory. The true mortality rate from ruptured abdominal aortic aneurysm is high (more than 80%) [1]. The operative mortality is between 29 and 52% [2]. As the rate for elective repair is now less than 5% in most centers, the chances for survival of patients with abdominal aortic aneurysm can be improved by early detection and elective repair of suitable cases. The only reliable predictor of rupture is the diameter of the aneurysm, although even small ones may rupture. Apart from the diameter, the age and general health of the patient are important when elective surgery is considered. It is generally accepted that every asymptomatic abdominal aortic aneurysm needs, at the least, serial follow-up with sonography every 6 months. Elective repair is usually considered when the diameter of the aneurysm exceeds 50 mm, although some [3] advocate surgery for all patients who have asymptomatic abdominal aortic aneurysm. After treatment, expected long-term survival is comparable to that of matched population control subjects 141. To study the diameter of abdominal aortic aneurysms at the time of rupture or shortly before (within the preceding year), we reviewed the records of all 91 patients who had been admitted to our hospital with rupture of an abdominal aortic aneurysm between 1983 and 1 990. In 43 cases (38 men, five women) the maximum anteroposterior diameter was measured by using either sonograms or CT scans. In 25 cases, this was done on admission and in 17 cases within the preceding year (mean, 4.1 months). The latter 17 all had vital contraindications for planned surgery. The mean diameter was 69 mm (range, 40-90 mm). We found no important differences between findings in men and women. In 35 cases (81 %) the diameter exceeded 60 mm, and in 41 cases (95%) it exceeded 50 mm. The diameter of almost all the abdominal aortic aneurysms that ruptured

1130

LETTERS

exceeded size.

50 mm,

which

underlines

the importance

of this

George

J. M. Akkersdijk

Pieter Minnee B. C. M. Puylaert

Julien

Alexander

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critical

C. de Vnes

Westeinde The Hague,

Hospital

The Netherlands

AJR:159, November 1992

not indicate additional sites of disease. A lateral transthoracic approach to the spine was used for resection and stabilization. Because of the mediastinal

was possible.

extension

RAP, Ashton HA, Kay DN. Abdominal aortic aneurysm in 4237 screened patients: prevalence, development and management over 6

1 . Scott

years. BrJSurg

1991:78:1122-1125

2. Callam MJ, Haiart D, Murie JA, Ruckley CV, Jenkins aortic aneurysms: 1126-1129

a

proposed

classification.

Br

AMcL. Ruptured J

Surg

1991:78:

3. Pasch AR, Ricotta JJ, May AG, Green RM, DeWeese JE. Abdominal aortic aneurysm: the case for elective resection. Circulation 1984:7olsuppl I]: 1-4 4. Fielding JWL, Black J. Ashton F, Slaney G, Campbell DJ. Diagnosis and management of 528 abdominal aortic aneurysms. Br Med J 1981:283: 355-359

Primary Neuroblastoma Location for a Variant Tumor of Bone

of a Vertebra: An Unusual of Primitive Neuroectodermal

paraparesis

and a Ti 0 sensory

level deficit.

Because of his rapid neurologic deterioration, emergent CT myelography was performed. An expansive soft-tissue mass destroying the anterior and posterior elements of Ti 0 was seen. The mass also caused encasement of the spinal cord and extended into the posterior mediastinum, destroying the heads of both 1 0th ribs (Fig. 1A). These findings were compatible with a nonspecific aggressive metastatic neoplasm or a primary skeletal sarcoma. An extensive workup did

resection

(Fig. 1B) and

immuno-

primary tumor [2-41. Several recent reports

[3-5] have described cases of primary malignant neoplasms of peripheral soft tissue and bone that either strongly resemble or are indistinguishable from classical neuroblastoma. These small, roundcell neoplasms of bone have recently been recognized by some investigators as a distinct category of PNET occurring in the skeleton

[3, 5]. The three most common

sites of involvement

of PNET of bone

are the extremities, pelvis, and scapula. The prognosis is uniformly poor; the tendency is early development of metastases and incomplete response to therapy. Despite the lack of specific radiologic findings, this case is particularly noteworthy because of the unusual site of origin of this type of neoplasm and its differentiation into classical neuroblastoma. To our knowledge, a primary neuroblastoma (or primitive neuroectodermal tumor) of the vertebra has not been previously reported. John C. Chaloupka University

of California,

Los

Angeles,

Medical

Los Angeles,

Primary primitive neuroectodermal tumor (PNET) of bone is a rare neoplasm that occurs in children and young adults. Its true prevalence is unknown because of the infrequency of reported cases and the current controversy in distinguishing it from Ewing’s sarcoma [1 ]. We report a particularly unusual case of a PNET of bone. Excruciating back pain and leg weakness developed abruptly in a previously healthy 31 -year-old man. On arrival at the hospital, he had

a rapidly progressive

only a subtotal

histochemical studies of a surgical specimen were consistent with a PNET of bone with neuroblastic differentiation. Until recently it has been maintained that osseous involvement with classical neuroblastoma is always a manifestation of metastatic

disease from a visceral REFERENCES

of the tumor,

The results of histopathologic

Memorial

Hospital,

University

of North

Center CA

90024

Mauricio Castillo Carolina School of Medicine Chapel Hill, NC 27514

REFERENCES 1 . Ushigome S. Shimoda T, Takaki K, et al. Immunocytochemical and ultrastructural studies of the histogenesis of Ewings sarcoma and putatively related tumors. Cancer 1989:64 : 52-62 2. Willis RA. Metastatic neuroblastoma in bone presenting as the Ewing syndrome, with discussion of ‘Ewing’s sarcoma.’ Am J Patho! 1940:16: 31 7-322 3. Hashimoto H. Enjoji M, Takashi N, et al. Malignant neuroepithelioma (peripheral neuroblastoma): a clinicopathologic study of 15 cases. Am J Surg Pathol 1984:7:309-318 4. Pritchard DJ. Small round cell tumors. Orthop C!in North Am 1989: 20:367-375 5. Jafte A, Santamaria M, Yunis EJ, et al. The neuroectodermal tumor of bone. Am J Surg Patho! 1984;8:885-898

Recurrent Adult-Type MR Appearance

Pharyngeal

Rhabdomyoma:

A 64-year-old man had had an intraoral mass sensation for 6 months. He had had a left-sided pharyngeal rhabdomyoma removed 25 years earlier. Physical examination showed a large, soft, nonfluctuant left-sided oronasopharyngeal mass with involvement of the soft

palate and encroachment

on the airway. No involvement

of the larynx

and hypopharynx was noted. MR imaging showed a large, lobulated, well-defined, homogeneous mass lesion involving the left lateral wall of the nasopharynx and oropharynx. The lesion extended to the soft

A

B Fig. 1.-Primitive

neuroectodermal

tumor of bone.

A, Axial CT myelogram

at level of T10 shows a destructive soft-tissue mass involving anterior and posterior vertebral elements and adjacent ribs. Note circumferential thecal encasement with severe compression of spinal cord. B, Photomicrograph shows a mildly pleomorphic small-cell neoplasm

surrounded by a thick fibrovascular type rosettes are present (arrows).

stroma. A few irregular Homer-Wright(H and E, original magnification x485)

palate and the adjacent

parapharyngeal

and masticator

spaces and

bulged into the airway. It appeared slightly hyperintense relative to muscle on both short TR/TE (533.3/i 6) and long TRITE (2500/80) images (Figs. 1A and 1 B) and enhanced slightly after administration of IV gadopentetate dimeglumine (Fig. i C). The larynx, hypopharynx, and ipsilateral base of the tongue were not involved. No enlargement of lymph nodes was detected. The tumor was resected without complication. Histopathologic examination showed adult-type extracardiac rhabdomyoma.

1131

LETTERS

AJR:159, November 1992

The adult type occurs almost exclusively in adults, with a marked male predilection of about 5:1 . The tumors involve primarily the head and neck. The oral cavity and oropharynx are the most frequent sites;

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next are the larynx,

Fig. 1.-Recurrent A, Short

TR/TE

pharyngeal

rhabdomyoma

in an adult.

shows large, well-defined, homogeneous mass lesion (M) involving left lateral wall of oropharynx. Mass extends into adjacent parapharyngeal (solid arrow) and masticator spaces (open arrow) and bulges into oropharyngeal airway. Mass is slightly hy-

perintense

(533.3/16)

(2500/80)MR

Thomas

Jefferson Jefferson

image

shows

relative to muscle. C, MR image obtained after administration shows

Macroscopically,

MR image

relative to muscle.

B, Long TR/TE

mine

neck, and nasopharynx.

mild enhancement

lesion

is slightly

hyperintense

of IV gadopentetate

sclerosis

[1

College PA

19107

REFERENCES

of lesion.

, 2]. Extracardiac

Medical

Philadelphia,

1 . Robbins SL, Cotran AS, Kumar V. Pathologic

rare and most likely represent solitary and have been divided

Van Thong Ho Vijay M. Rao University Hospital

dimeglu-

Rhabdomyomas are rare benign tumors of skeletal or cardiac muscle. Cardiac rhabdomyomas are the most common type and are considered to be hamartomas, which are often associated with tuberous

the

tumors appear lobulated and well encapsulated [1]. Histologically, they are composed of large round to oval cells with granular and eosinophilic cytoplasm containing peripheral glycogen-filled vacuoles. The cell nuclei are eccentric. Cross-striations are an essential feature for diagnosis [2]. The fetal type of extracardiac rhabdomyoma occurs mainly in children 3 years old and younger, with a male predominance. The tumors are usually found subcutaneously in the head and neck, most frequently in the posterior auricular area [1 , 3]. Fetal-type rhabdomyomas may arise in adults, particularly in the vulvovaginal region. Macroscopically, the tumors are not encapsulated and appear well circumscribed. Histologically, they are composed of spindle fetal myoblasts with various degrees of skeletal differentiation [1]. Extracardiac rhabdomyomas are well-circumscribed nonenhancing tumors that appear isodense with muscle on CT [4]. In our case, the tumor was slightly hyperintense relative to muscle on both short and long TR/TE spin-echo MR images. In addition, slight enhancement of the rhabdomyoma occurred after the administration of contrast material. The only treatment for extracardiac rhabdomyoma is complete excision [1 -3]. Recurrence is rare and is thought to be associated with incomplete resection. In our case, the recurrence became clinically obvious 25 years after the initial surgery. To our knowledge, this is the longest reported period between the initial excision of rhabdomyoma and its recurrence. No known case of benign rhabdomyoma has turned malignant.

rhabdomyomas

are extremely

true neoplasms [1 ]. They are usually histologically into adult and fetal types.

basis of disease 3rd and 4th eds. Philadelphia: Saunders, 1984:1314, 1989:1375 2. Andersen CB, Elling F. Adult rhabdomyoma of the oropharynx recurring three times within thirty-five years. APMIS 1986:94:281-284 3. Pradhan SA, Rajpal AM. Shrikhande 55. Extracardiac rhabdomyoma: a report of two cases. J Surg Oncol 1986:33:69-71 4. Dillon WP. The pharynx and oral cavity. In: Head and neck imaging. St. Louis: Mosby-Year Book, 1991:460-462

Letters are published at the discretion of the Editor and are subject to editing. Letters to the Editor must not be more than two double-spaced, typewritten pages. One or two figures may be included. Abbreviations should not be used. Limit the number of authors to four, or we will list only the first three and add “and colleagues’ to the end of the list. See Author Guidelines. Material being submitted or published elsewhere should not be duplicated in letters, and authors of letters must disclose financial associations or other possible conflicts of interest. Letters concerning a paper published in the AdA 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.

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1132

Review

of Current

Literature

;,#{149}‘#{149}#{149}#{149}#{149}#{149}

Initials and addresses of corresponding authors are provided in parentheses for each article so that the reader can obtain reprints

directly.

The

Abstracts

New

Magnetic

are printed verbatim

England

Journal

resonance

imaging

from each journal.

of Medicine of angiographically

occult

runoff

vessels in peripheral arterial occlusive disease. Owen RS, Carpenter JP, Baum RA, Perloff Li, Cope C (CC, Dept. of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104). N EngI J Med 326(24):i577-1581 , June 1992 Background.

become cular

Bypass

standard

disease.

grafting

surgical

Its

to arteries

management

success

of the

of advanced

depends

on

identifying

lower

leg

peripheral suitable

has

vasdistal

vessels. Preoperative preparation includes imaging of the arteries of the lower leg, usually by conventional contrast arteriography. An alternative procedure, magnetic resonance (MA) angiography, has been successfully employed in patients with various cardiovascular diseases, but its possible value in patients with peripheral vascular disease has received little attention. Methods. We used both conventional and MR angiography in preoperative studies of the lower-leg vessels of 23 patients (25 legs) with

peripheral arteriosclerosis and arterial insufficiency, and developed independent therapeutic plans based on the information provided by each technique. When the plans differed, the interventional procedure judged more likely to save the limb was performed. The

findings

of conventional

operative

arteriography,

operative

exploration. MR angiography

Results.

tional tect

angiography,

and MR angiography postinterventional

whereas

detected

were verified by intraarteriography,

or direct

all vessels identified by convenarteriography failed to de-

conventional

22 percent of the runoff vessels identified by MR angiography.

The detection by MR angiography of vessels not identified by conventional angiography altered the surgical management of the disorders of four patients (1 7 percent) and guided successful bypass procedures. Conclusions.

greater tooting sive

MR

sensitivity distal

runoff

angiography

is a noninvasive

than conventional vessels

in patients

contrast

technique

arteriography

with peripheral

arterial

with

for deocclu-

disease.

course of pulmonary embolism. Carson JL, Kelley MA, Duff A, et al. (JLC, Division of General Internal Medicine, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, 97 Paterson St., New Brunswick, NJ 08903). N EngI J Med 326:1240-1245, May 1992 The clinical

Background. Pulmonary embolism is a potentially fatal disorder. about the outcome of clinically recognized pulmonary embolism is sparse, particularly given that new treatments for more seriously ill patients are now available. Methods. We prospectively followed 399 patients with pulmonary embolism diagnosed by lung scanning and pulmonary angiography, who were enrolled in a multicenter diagnostic trial. We reviewed all hospitalizations, all new investigations of pulmonary embolism, and Information

all deaths among the patients within one year of diagnosis. Results. Of the 399 patients, 375 (94 percent) received

treatment for pulmonary embolism, usually conventional anticoagulation. Only 10 patients (2.5 percent) died of pulmonary embolism; 9 of them had clinically suspected recurrent pulmonary embolism. Clinically apparent pulmonary embolism recurred in 33 patients (8.3 percent), of whom 45 percent died during follow-up. Ninety-five patients with pulmonary embolism (23.8 percent) died within

one year.

The conditions

associated

cancer (relative risk, 3.8; 95 percent left-sided

congestive

fidence interval,

heart

failure

with these

confidence

(relative

1 .5 to 4.6), and chronic

interval,

deaths

risk, 2.7; 95 percent

lung disease

were

2.3 to 6.4), (relative

con-

risk,

2.2; 95 percent confidence interval, 1.2 to 4.0). The most frequent causes of death in patients with pulmonary embolism were cancer (in 34.7 percent), infection (22.1 percent), and cardiac disease (16.8 percent).

Conclusions. When properly diagnosed and treated, clinically apparent pulmonary embolism was an uncommon cause of death, and it recurred in only a small minority of patients. Most deaths were due to underlying diseases. Patients with pulmonary embolism who had cancer, congestive heart failure, or chronic lung disease had a higher risk of dying within one year than did other patients with pulmonary embolism. Endoscopic for bleeding

sclerotherapy esophageal

as compared with endoscopic ligation varices. Stiegmann GV, Goff JS, Michal-

etz-Onody PA, et al. (GVS, C-3i 3, University of Colorado Health Sciences Center, 4200 E. 9th Ave., Denver, CO 80262). N EngI J Med 326(23):1527-i532,

1992

Endoscopic sclerotherapy is an accepted treatment for bleeding esophageal varices, but it is associated with substantial local and systemic complications. Endoscopic ligation, a new form of endoscopic treatment for bleeding varices, may be safer. We compared the effectiveness and safety of the two techniques. Methods. In this randomized trial we compared endoscopic sclerotherapy and endoscopic ligation in 129 patients with cirrhosis who had proved bleeding from esophageal varices. Sixty-five patients were treated with sclerotherapy, and 64 with ligation. Initial treatment Background.

for acute vances.

which

bleeding The

patients

we determined

was followed were

by elective

followed

the incidence

retreatment to eradicate of 1 0 months, during of complications and recurrences for a mean

AJR:159, November

REVIEW

1992

OF

CURRENT

Downloaded from www.ajronline.org by 197.255.203.159 on 10/13/15 from IP address 197.255.203.159. Copyright ARRS. For personal use only; all rights reserved

of bleeding, the number of treatments needed to eradicate varices, and survival. Results. Active bleeding at the first treatment was controlled by sclerotherapy in 1 0 of 1 3 patients (77 percent) and by ligation in 12 of 1 4 patients (86 percent). Slightly more sclerotherapy-treated patients had recurrent hemorrhage during the study (48 percent vs. 36 percent for the ligation-treated patients, P = 0.072). The eradication

of varices

required

a lower mean (±SD) number

of treatments

with

ligation (4±2 vs. 5±2, P = 0.056) than with sclerotherapy. The mortality rate was significantly higher in the sclerotherapy group (45 percent vs. 28 percent, P = 0.041 ), as was the rate of complications

(22 percent therapy

vs. 2 percent,

were

P

Handgun control: a public health issue.

REFERENCES 1 . Hilts PJ. FDA seeks halt in breast implants made of silicone. New York Times Jan 7, 1992:A1 Downloaded from www.ajronline.org by 19...
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