Letters

to the

U Ductal Carcinoma in Situ: Mammographic Appearances

From:

Daniel

Department Box 3808,

C. Sullivan,

Editor Atypical

MD

of Radiology, Duke Durham, NC 27710

University

Medical

Center

Editor: In the September 1989 issue of Radiology, Drs Ikeda and Andcrsson reported interesting and useful statistics on atypical mammographic appearances of ductal carcinoma in situ (DCIS) (1). They suggest that their data arc more representative of the relative frequency of various radiographic patterns because they reviewed the data on all patients with DCIS who also underwent mammography (italics mine) at their hospital, whereas many previous studies reviewed only cases detected with mammography (ic, some of the cases of Drs Ikeda and Andersson

were

detected

clinically

or incidentally).

This

cer-

tamnly adds value to their findings, but they omit two pieces of information that would be helpful in placing their findings in perspective: First, how many patients with and without mammograms received a diagnosis of DCIS during the study penod of January 1976 and March 1988? Second, what time intervals occurred between mammography and the diagnostic procedures? Their article suggests, but does not state, that most or all of the patients with DCIS at their hospital during the 12year study period had undergone mammography immediately prior

to diagnosis

of DCIS.

Clarification

of these

Reference

Drs

Ikeda DM, mographic

Ikeda

Andersson appearances.

and

I.

Ductal carcinoma Radiology 1989;

Andersson

in situ: atypical 172:661-666.

mam-

respond:

The answer to Dr Sullivan’s first question about our recent antide (1) is that all patients who received a diagnosis of DCIS during the period in question also underwent mammography. In answer to the second question, most women (176 of 190 [93%]) underwent surgery about or within 3 months of mammography (83% within 2 months of breast imaging). Of the remaining 14 women who underwent surgery 4 months or longer after mammography (7% of the 190 patients), seven had calcifications; of these women, four underwent resection 4_41/2 months after imaging, and two underwent surgery 7 months after imaging. Of the other seven women who underwent surgery and were included in the noncalcified study group, six had negative mammographic studies. Three patients were operated on at about 4 months for newly diagnosed Paget disease of the nipple, one patient developed bloody discharge (with positive galactographic findings) and underwent resection at 31/2 months, and one patient was operated on at 81/2 months for a nodule that was palpable at the time of a normal mammographic study and that had been followed up clinically. The latter patient had a region of spiculation seen at radiography but deferred surgery for 6 months after mammography. No calcifications were reported in the pathologic specimens of any of these patients. Dr Sullivan did not ask about the incide.tcc of DCIS in the

Volume

175

#{149} Number

1

ferning

physicians

screening

or found

at mammography

outside

the

trial.

References 1.

Ikeda DM, mographic

Andersson appearances.

2.

Andersson

I, Aspegren

points

would help us assess how representative their group of 190 women with DCIS who had undergone mammography might be of the larger group of all women with DCIS, which would make their interesting article more informative.

1.

Swedish population studied. Here are the incidences of DCIS (per 100,000 women per year) for the city of Malm#{246}for some of the years studied: i976, 4.7; 1977, 8.8; 1978, 15.1; 1979, 13.8; i980, 10.6; 1981, 16.4; i982, 12.4; 1983, 13.2; 1984, 12.4. These figures include cases with a combination of DCIS and lobular carcinoma in situ (LCIS) but not cases of LCIS alone. As would be intuitively surmised, the number of noninvasive carcinomas seen in this population is related to the amount of mammographic activity in the city, in this case in part related to the Malm#{246}Mammographic Screening Trial (2), which began in 1976. This would shift some of the percentage of DCIS tumors (found in a “normal” population by means of palpation or report of bloody discharge) to a larger number of cases that arc nonpalpable and arc detected radiographically. For example, the incidence of DCIS in the control group of the screening trial was approximately 20 per 100,000 women pen year, whereas 35 cases per 100,000 women per year were seen in the invited group. The DCIS cases described in our article (1) were originally referred for surgery from a variety of sources and included cases from both the invited and the control portions of the screening trial, as well as cases found in the community by re-

ing and screening

mortality trial.

I.

from Br Med

Debra M. Ikeda, MD Department of Radiology, 1500 East Medical Center Ingvar Andcrsson, MD Department of Radiology, S-21301 Malm#{246},Sweden

Ductal carcinoma Radiology 1989; K, Janzon

in situ: atypical 172:661-666.

L, et al.

breast cancer: the J 1988; 297:943-948.

University Drive, Ann

Mammographic

of Michigan Hospitals Arbor, MI 48109-0326

Malm#{246}General

Hospital

in Primary

From: Hcrmann

MD, Gent Judmaicr,

Kathrein,

Vogel, MD of Internal Medicine, 35, A-6020 Innsbruck,

screen-

Malm#{244}mammographic

U Lymphadenopathy CT Observations

Wolfgang Department Anichstrassc

mam-

Innsbruck Austria

Biliary

Cirrhosis: MD, and

University

Editor: We read with interest the article by Outwater et a! on computed tomographic (CT) observations of lymphadenopathy in primary biliary cirrhosis (1), which appeared in the June 1989 issue of Radiology. In a prospective ultrasound study in 234 paticnts of the significance of enlarged lymph nodes in the porta hepatis for the diagnosis of liver disease, we found similan results (2). Of 112 patients with inflammatory liver discase, 29 (26%) showed lymph node enlargement in the porta hepatis. Malignancy had been excluded in all these patients. The highest percentage of lymph node enlargement (72%) was found in patients with acute hepatitis. Patients with chronic hepatitis of different causation (all biopsy proved) were found to have a lower percentage of lymph node enlargement (17%). Of 19 patients with histologically proved

Radiology

#{149} 285

primary biliary cirrhosis (stages I-Ill), five were found to have lymph nodes enlarged to over 1.0 cm in diameter. We speculate that the lower percentage of patients with lymph node enlargement in our study might reflect earlier stages of disease. Furthermore, none of the remaining 122 patients with metabolic or noninflammatory liver disease (eg, steatosis, hemochromatosis, and a-l-antitrypsin deficiency) had enlarged lymph nodes in the porta hepatis. Finally, in our experience, it has never been a problem to distinguish vascular structures from enlarged lymph nodes, particularly with the help of duplex sonography. We were glad to learn that the conclusion made in our study, namely, that enlargement of lymph nodes in the porta hepatis can be a sign of inflammatory liver disease after exclusion of malignant disease, was confirmed in a CT investigation.

neum

of the

fossa,

the

clips.

The

stone

vantage

that

in pri171:731-

1.

Martin

H,

lymph

Vogel

node

er disease.

W,

Dietze

B, Judmaier

enlargement

in

Ultraschall

1989;

the

G.

liver

hilum

The in

significance

2.

EC,

Percutaneous System

Transjejunal

RN,

Access

to the

3.

RN,

Adam

hilar

and

puncture

in

with

rates patients

recurrent

of Roux-en-Y

calculi

after

radiologic

with

primary

jejunal

AG,

tern

colonized

obstructed

mation. Our lems

by

segments,

or strictures.

dilation

are

sclerosing

own

approach

generally

tion

of the

286

#{149}

bacteria and

efferent

Radiology

(4), may

The

5.

Gibson

limb

R.

skin

the ad-

with

infection,

Percutaneous

system.

the

and

the

A,

transjejunal

Radiology

A, Czerniak

1989;

A, et al.

and

Yeung

Benign

biliary

strictures:

management.

Percutaneous

Aust

techniques

J Intervent

strictures.

ap-

172:1031-1034.

radiological

E, et a!.

intrahepatic

Cotton

PB,

1988;

108:546-553.

RN.

J, et a!.

Rode

a light

In:

Louis:

by

and

in

Radiol

ed.

1990;

stent

1988;

blockage

microscopy

radiology

JT,

Mosby,

Biliary

electron

Interventional

Ferrucci

for

Advances

in

benign

with

study.

Ann

biliary

stric-

hepatobiliary

In-

radiology.

St

395-412.

of Increased Lung Scans

Tank

and

complex access

Roux-en-Y

U

for stone biliary

by

superficial

loop

to the

Oxford,

the

OX3

interest

the

authors’

9DU,

England

by

perfusion

microaggregated size only. Thus,

of a pulmonary

segment

on

Hospital

Meignan

issue

et al (1), I was

of Radiology.

criterion (“hot

selection

of increased

tion of injected on is based on

Radcliffe

1989

for excluding spots”) caused

at least

two

views

which surprised

ap-

artifactual by aggrega-

human albumin. hot spots smaller

all

on

BAO

John

article

October

Spots)

This cnitenithan 25%

are

dismissed

as

artifactual and excluded from consideration. This, I believe, might be rather inaccurate. Work by Duffy et al (2) emphasizes that since aggregates of radiopharmaceutical vary in radioactivity and distance from the radiation detector, estimation of their size with lung scintigraphy is difficult. Indeed, many of the hot spots illustrated in that article are certainly larger than 25% of a pulmonary segment. These hot “clots” (3) might

be

more

peripheral

appropriately

location

suspected

(4)

and

focal

basis of their size. In fact, as circular areas of increased ure).

I believe

that

distribution these more

such

hot

the

basis

(2,4)

than

clots

of their on

the

are represented

radiopharmaceutical uptake investigation of radiopharmaceutical

any

on lung definite

most

on

character

perfusion characteristics

scans

should of artifactual

take

(Fig-

into account hot clots.

References 1.

Meignan

M,

creased

perfusion

with 2.

Palmer

pulmonary

Duffy

GJ,

EL,

(hot

AC,

GL,

pulmonary

Strauss

on perfusion

arteriograms.

DeNardo

dioactive

Waltman

spots)

Radiology Abington

emboli

in

Origin

Zones

scans:

1989;

RB. man.

HW.

lung

of in-

correlation

173:47-52. and

Radiology

evolution

1968;

of ra-

91:1175-

3.

Neumann

4.

tilation-perfusion Johnson PM. Semin

RD.

NucI

Sostman

HD,

Gottschalk

A.

imaging. Semin NucI role of lung scanning

The Med

1971;

Current

Med 1980; in pulmonary

status

of yen-

10:198-217. embolism.

1:161-184.

reg-

formasupare

of infection

a nidus

be

with

radiologic

of the

a source

MB, BCh,

of Radiology,

in the

(Hot

1180.

over

(3).

a

Perfusion

F. Massoud,

with

zones

reported

19%-34%

cholangitis

are

well

in patients

is to create

Bixon

biofilm: Med

peared

loops

Martin et al argue that long-term access by means of tube is preferable in at least some patients, since it allows ular flushing, which may help prevent recurrent stone tion. As they point out, there are as yet no good data to port this. Furthermore, tubes placed in the biliary tract rapidly

has

catheter

3:125-130. Speer

Editor: I read

when the loop has not been fixed surgically to the anterior abdominal wall. The second message, which is implicit, is that fixation of Roux-en-Y jejunal loops should be considered at the time of hepaticojejunostomy, especially when dealing with complex biliary problems. It is vital that interventional radiologists encourage our surgical colleagues to do so, in order that simple long-term percutaneous transjejunal biliary access is provided for subsequent stricture dilation or stone extraction, as required. As Martin et al emphasize, the use of both radiologic and surgical approaches to complex biliary strictures can be invaluable. The techniques can be combined in a number of ways (2), but one of the major requirements is the availability of safe and easy long-term radiologic access to the biliary tract. Repeated radiologic procedures are needed in many pa-

50%

Adam

benign

Department

The article by Martin et al (1), which appeared in the Septemben 1989 issue (RSNA-SCVIR special series) of Radiology, contains two important messages for biliary interventional radiologists. The first is the description of a number of innovative techniques for gaining access to the biliary system by means

to deal

KJ, biliary

Gibson

From:

Biliary

Editor:

restenosis

dilation

approach

liv-

Robert N. Gibson, MD,’ Neil A. Collier, MD,2 and Antony G. Speer, MD3 Departments of Radiology,’ Surgery,2 and Gastroenterology,3 Royal Melbourne Hospital Parkvillc, Victoria, Australia 3050

tients

percutaneously

This

leakage, (5).

iliac

of surgical

stricture

drainage

combined surgical 1987; 57:361-368.

Headington,

percutaneous

punctured and

external

right

ring

10:127-131.

From:

of direct

Laffey

a proposed NZ J Surg

U Zones Perfusion

U

be

as necessary. is no

to the

Gibson

of

non-malignant

removal

proaches

tures.

Kathrein

then

the

a

by

References

733. 2.

can

toward

cholangiography

there

bacterial

Lymphadenopathy Radiology 1989;

marked

inherent problems of bile need for regular replacement

References Outwater E, Kaplan MM, Bankoff MS. mary biliary cirrhosis: CT observations.

wall

being

loop

follow-up

and/or

abdominal

of fixation

jejunal

to allow

4.

1.

anterior

site

in

forprobfixa-

penito-

Dr Strauss We

read

difference

responds: with in

interest the

the patients in our al, the artifacts due shown while of the

the

hot

spots

letter

from

Dr

identified

article is the to microsphere

in the figure accompanying those seen in our patients borders of bronchopulmonary

in

shape

Massoud. his

of the clumping

Dr usually

letter

A major and

those

lesions. In are round

Massoud’s followed segments.

in

gener(as

letter), at least part Clearly, when

April

1990