Search

Pancreatic adenocarcinoma is a highly aggressive malignancy with a poor prognosis secondary to late presentation with metastases, challenging resection, and limited alternative therapies. Standard treatment strategies for pancreatic cancer include surgery, chemotherapy, and radiation therapy. These options can extend survival and/or relieve symptoms but are seldom curative. Thermal ablative therapies have been utilized in pancreatic cancer mostly in an open surgical setting. Irreversible electroporation (IRE) is a nonthermal ablative option for pancreatic cancer that uses high voltage, low energy direct current to induce cell death. IRE technology has been shown to spare critical structures such as blood vessels and bile ducts. The safety and efficacy of the percutaneous IRE in Stage 3 pancreas cancer has been studied and there is currently a Food and Drug Administration approved, randomized, controlled trial, and registry enrolling patients in the United States. Recent animal studies have also demonstrated that the advantages of IRE may extend beyond the local tumor effect. In addition to this local ablative option, a phase 3 trial is studying a transarterial option in the management of pancreatic cancer.

(CHEST 2005; 127:1433–1436) A 70-year-old man presented with progressive mild dyspnea on exertion, cough, and low-grade fevers. He had a long history of atrial fibrillation, recurrent despite multiple cardioversions, and antiarrhythmics, and was currently rate controlled with amiodarone, 200 mg po tid. He also had a history of coronary artery disease documented by coronary angiography, asthma, and prior transurethral resection of prostate for benign prostatic hyperplasia. He was a lifelong nonsmoker with no occupational exposures. Physical examination revealed an elderly man in no acute distress. Heart rate was 82 beats/min, BP was 150/80 mm Hg, respiratory rate was 16 breaths/ min, and temperature was 37.1°C. Auscultation of the chest revealed mildly diminished breath sounds with otherwise normal lungs. The remainder of the physical examination was normal. Laboratory data were unremarkable, with a normal CBC, serum chemistry and liver function test results, and erythrocyte sedimentation rate. The chest radiograph (not shown) demonstrated a hazy mass at the peripheral aspect of the right lung base. The cardiac size was normal. CT scan of the thorax revealed subcarinal lymph node enlargement (Fig 1) and masses in the left upper, left lower, right lower, and right middle lobes (Fig 2), each approximately 1 cm in size. There was focal ground-glass opacity in the azygoesophageal recess (Fig 3). At bronchoscopy, there was no evidence of endobronchial lesions. Bronchial washings were negative for acid-fast bacilli and fungi, with rare atypical keratinizing squamous cells.

To retrospectively determine the accuracy of sonography in helping to distinguish soft-tissue lipomas from other soft-tissue masses by using histologic proof as the reference standard.Institutional review board approval was obtained, and informed consent was waived. Thirty-nine patients who underwent sonographic evaluation of a soft-tissue mass followed by biopsy or resection were retrospectively evaluated. Two musculoskeletal radiologists (readers 1 and 2) reviewed the sonographic images, characterized the masses, and rated the level of confidence in the diagnosis of lipoma by using a five-point scale. A level of confidence was also rated for the prospective sonographic report, which was reviewed and designated as reader 3. Receiver operating characteristic (ROC) curves, including 95% confidence intervals, were generated, and the area under the ROC curve (A(z)) was calculated for each reader. Sensitivity, specificity, and accuracy for each reader were calculated by using a confidence rating of 4 or 5 as positive for lipoma. Weighted kappa analysis was also performed to assess for interobserver variability.Histologic examination yielded 25 lipomas and 14 nonlipomas. The echogenicity of lipomas ranged from hypoechoic to hyperechoic relative to muscle, although most were isoechoic or hyperechoic. A(z) values were 0.79 for reader 1, 0.56 for reader 2, and 0.77 for reader 3. There was no significant difference between the A(z) for each reader and for chance. Interobserver agreement was fair, with a kappa value of 0.35 among the three readers. Sensitivities were 52%, 40%, and 52%, and accuracies were 64%, 49%, and 64% for readers 1, 2, and 3, respectively.Sonography demonstrates low accuracy in the diagnosis of soft-tissue lipomas.

The purpose of our study was to review the MDCT urography appearance of pathologically proven transitional cell carcinomas of the renal collecting system and ureter and to correlate the MDCT urography findings with pathology findings.Of 370 MDCT urography examinations performed over an 18-month period, 18 patients were diagnosed with 27 renal collecting system or ureteral urothelial neoplasms at endoscopic biopsy (n = 8) or surgery (n = 19). Initial MDCT reports were reviewed to determine the sensitivity of original reviewers in detecting these neoplasms. Two radiologists also retrospectively reviewed these scans and characterized the CT appearance of the neoplasms on both axial CT and 3D reformatted images. Findings at retrospective review were correlated with pathology results to determine whether any CT features could be used to predict tumor grade.Eighteen of 27 neoplasms were prospectively identified on MDCT urography, and an additional six neoplasms were detected on retrospective review. Three ureteral neoplasms could not be visualized. The 24 retrospectively detected neoplasms had three distinct MDCT appearances: circumferential urothelial wall thickening (n = 14), small masses (5 mm in maximal diameter) (n = 5), and large masses (5 mm in maximal diameter) (n = 5). All detected lesions could be seen on axial excretory phase images provided wide window settings were reviewed; however, only six were detected on 3D reconstructions. MDCT urography appearance did not correlate with tumor grade.MDCT urography is a promising technique for detecting upper urinary tract neoplasms. The static 3D reconstructions used in this study are insufficient for visualization. Axial image review remains essential for tumor identification.

To retrospectively compare the effects of abdominal compression, intravenous saline hydration, and two imaging delays on both distention and opacification of the intrarenal collecting system and ureter during multi-detector row computed tomographic (CT) urography.Institutional review board approval for reviewing images and medical records of the patients was obtained; informed patient consent was not required. Excretory phase images obtained from multi-detector row CT urography in 85 patients (57 men, 28 women) were reviewed. Examinations were performed by using one of four techniques: abdominal compression and intravenous hydration with 250 mL of normal saline, compression only, intravenous hydration with saline only, and neither compression nor saline hydration. Excretory phase imaging was performed at 300 and 450 seconds for each patient. Two reviewers measured urinary tract distention on transverse images and graded opacification and image quality on volume-rendered images. Effects were compared by using statistical mixed models with repeated-measures analysis of variance.Saline hydration significantly improved opacification (P = .02) and overall image quality (P.001) of the intrarenal collecting system and proximal ureter. Delayed excretory phase image acquisition of 450 seconds significantly increased distention of the intrarenal collecting system and proximal ureter (P.001). No significant effects involving the lower segment of the ureter were seen with any technique; however, there were fewer nonvisualized distal ureteral segments with the longer imaging delay.Compression does not significantly improve distention or opacification of the urinary tract. Saline hydration is effective in improving opacification of the proximal urinary tract. Longer imaging delays improve distention of the proximal urinary tract and may aid in visualization of the lower segment of the ureter.

OBJECTIVE. We have found variability in the sonographic appearance of peripheral nerve sheath tumors. The purpose of this study was to characterize the sonographic appearances of pathologically proven peripheral nerve sheath tumors.CONCLUSION. Peripheral nerve sheath tumors are often hypoechoic with posterior acoustic enhancement and so may simulate a ganglion cyst. The presence of intrinsic blood flow on color Doppler sonography and peripheral nerve continuity suggests the diagnosis of peripheral nerve sheath tumor. Sonography cannot reliably distinguish neurofibromas from schwannomas.