- Email: [email protected]
Imaging in Prostate Cancer—A Reply
88
CLINICAL RADIOLOGY
On direct questioning the patient gave a history of recently having taken linseeds as a treatment for constipation. She had taken four tablespoons each morning before starting her pre-enema fasting period. Linseeds have the same morphology as the filling defects in her large and distal small bowel (see Figs 1 and 2), leading us to the conclusion that the patients dietary supplement of linseeds was responsible for the filling defects demonstrated on the DCBE. A search of the internet revealed that linseeds are recommended as a natural remedy for a wide range of conditions including the menopause, polycystic ovary disease, inflammatory joint disease and constipation. They are therefore likely to be a relatively common dietary supplement. The radiological appearance of linseeds have not previously been described, although a description of obstruction secondary to a linseed bezoar has been published [1]. The appearance is very similar to polyposis and, had fewer been present at the time of examination, could have been a
source of diagnostic error. They certainly made the exclusion of small polyps difficult in this case. It is noteworthy that they persisted in such large numbers in spite of an adequate starvation period and compliance with bowel preparation.
doi:10.1053/crad.2003.1149, available online at www.sciencedirect.com
doi:10.1053/crad.2003.1150, available online at www.sciencedirect.com
IMAGING IN PROSTATE CANCER
IMAGING IN PROSTATE CANCER—A REPLY
SIR – We write concerning the recent article in a Subspecialty Corner, Imaging in Prostate Cancer (Clin Radiol 2001;56:871–872) by Drs Cochlin and Evans [1]. The paper indicates that the value of periprostatic local anaesthesia is controversial. Our own experience in over 250 cases would indicate that periprostatic local anaesthesia is extremely efficacious. This is in keeping ¨ bek [2] and Nash et al. [3]. One with the conclusions of both Soloway and O paper concludes that ultrasound-guided nerve blockade before prostatic biopsy results in a more comfortable procedure for the patient, and the other that periprostatic nerve block dramatically decreases discomfort. This has been our own experience. Discomfort in those patients new to the procedure has been reduced despite taking an increased number of specimens (routinely 10–12, as opposed to six to eight). Those patients having a repeat biopsy have almost universally commented on how much more comfortable the procedure has been, unless they found it of little discomfort in the first instance. The routine taking of 10 specimens has been accomplished without a significant increase in morbidity. These findings are currently under review.
We found Dr Wright’s letter very interesting and also in line with the impressions formed by a number of other groups who are also currently using local anaesthetic for transrectal ultrasound-guided prostate biopsies. The statement about local anaesthesia in our paper reflected a review of the literature and the fact that there appear to be no studies that prove a benefit from the use of local anaesthesia. Since reading Dr Wright’s letter however, one of the authors has started to use local anaesthesia in the prostate, and he too has the initial impression that it is beneficial. We are currently completing pain scores for these patients and will compare them to a similar cohort of patients that did not receive local anaesthetic. We have some time to go before we have significant numbers but initial results are somewhat equivocal. Interestingly we have a small cohort of patients who have been re-biopsied with local anaesthesia who did not have local anaesthetic on the initial biopsy. In most of these patients, the pain score is less on the second biopsy with local anaesthesia. We have also found however, that patients being re-biopsied with no local anaesthesia on either occasion tend to have lower pain scores on the second biopsy so there is obviously a psychological element perhaps because they are less anxious on the second biopsy. This merely emphasizes the great difficulty in measuring pain scores, which is always somewhat subjective. We continue however, to keep an open mind, certainly we have not noticed any adverse effects from giving local anaesthetic, I suspect we may continue this practice.
C. H. WRIGHT D. A. PARKER
References 1 Cochlin D, Evans C. Imaging in prostate cancer. Clin Radiol 2001;56: 871–872. ¨ bek C. Periprostate local anaesthesia before ultrasound 2 Soloway MS, O guided prostate biopsy. J Urol 2000;163:172–173. 3 Indudhara R, Nash PA, Bruce E, et al. Transrectal ultrasound guided prostatic nerve blockade eases systematic needle biopsy of the prostate. J Urol 1996;155:607–609.
D. L. COCHLIN C. EVANS
1. Hardt M, Geisthovel W. Severe obstructive ileus caused by a linseed bezoar. Case report with critical comment on the use of dietary fibre. Med Klin, 1986;81:541–543.
D. L. COCHLIN C. EVANS
CLINICAL RADIOLOGY
On direct questioning the patient gave a history of recently having taken linseeds as a treatment for constipation. She had taken four tablespoons each morning before starting her pre-enema fasting period. Linseeds have the same morphology as the filling defects in her large and distal small bowel (see Figs 1 and 2), leading us to the conclusion that the patients dietary supplement of linseeds was responsible for the filling defects demonstrated on the DCBE. A search of the internet revealed that linseeds are recommended as a natural remedy for a wide range of conditions including the menopause, polycystic ovary disease, inflammatory joint disease and constipation. They are therefore likely to be a relatively common dietary supplement. The radiological appearance of linseeds have not previously been described, although a description of obstruction secondary to a linseed bezoar has been published [1]. The appearance is very similar to polyposis and, had fewer been present at the time of examination, could have been a
source of diagnostic error. They certainly made the exclusion of small polyps difficult in this case. It is noteworthy that they persisted in such large numbers in spite of an adequate starvation period and compliance with bowel preparation.
doi:10.1053/crad.2003.1149, available online at www.sciencedirect.com
doi:10.1053/crad.2003.1150, available online at www.sciencedirect.com
IMAGING IN PROSTATE CANCER
IMAGING IN PROSTATE CANCER—A REPLY
SIR – We write concerning the recent article in a Subspecialty Corner, Imaging in Prostate Cancer (Clin Radiol 2001;56:871–872) by Drs Cochlin and Evans [1]. The paper indicates that the value of periprostatic local anaesthesia is controversial. Our own experience in over 250 cases would indicate that periprostatic local anaesthesia is extremely efficacious. This is in keeping ¨ bek [2] and Nash et al. [3]. One with the conclusions of both Soloway and O paper concludes that ultrasound-guided nerve blockade before prostatic biopsy results in a more comfortable procedure for the patient, and the other that periprostatic nerve block dramatically decreases discomfort. This has been our own experience. Discomfort in those patients new to the procedure has been reduced despite taking an increased number of specimens (routinely 10–12, as opposed to six to eight). Those patients having a repeat biopsy have almost universally commented on how much more comfortable the procedure has been, unless they found it of little discomfort in the first instance. The routine taking of 10 specimens has been accomplished without a significant increase in morbidity. These findings are currently under review.
We found Dr Wright’s letter very interesting and also in line with the impressions formed by a number of other groups who are also currently using local anaesthetic for transrectal ultrasound-guided prostate biopsies. The statement about local anaesthesia in our paper reflected a review of the literature and the fact that there appear to be no studies that prove a benefit from the use of local anaesthesia. Since reading Dr Wright’s letter however, one of the authors has started to use local anaesthesia in the prostate, and he too has the initial impression that it is beneficial. We are currently completing pain scores for these patients and will compare them to a similar cohort of patients that did not receive local anaesthetic. We have some time to go before we have significant numbers but initial results are somewhat equivocal. Interestingly we have a small cohort of patients who have been re-biopsied with local anaesthesia who did not have local anaesthetic on the initial biopsy. In most of these patients, the pain score is less on the second biopsy with local anaesthesia. We have also found however, that patients being re-biopsied with no local anaesthesia on either occasion tend to have lower pain scores on the second biopsy so there is obviously a psychological element perhaps because they are less anxious on the second biopsy. This merely emphasizes the great difficulty in measuring pain scores, which is always somewhat subjective. We continue however, to keep an open mind, certainly we have not noticed any adverse effects from giving local anaesthetic, I suspect we may continue this practice.
C. H. WRIGHT D. A. PARKER
References 1 Cochlin D, Evans C. Imaging in prostate cancer. Clin Radiol 2001;56: 871–872. ¨ bek C. Periprostate local anaesthesia before ultrasound 2 Soloway MS, O guided prostate biopsy. J Urol 2000;163:172–173. 3 Indudhara R, Nash PA, Bruce E, et al. Transrectal ultrasound guided prostatic nerve blockade eases systematic needle biopsy of the prostate. J Urol 1996;155:607–609.
D. L. COCHLIN C. EVANS
1. Hardt M, Geisthovel W. Severe obstructive ileus caused by a linseed bezoar. Case report with critical comment on the use of dietary fibre. Med Klin, 1986;81:541–543.
D. L. COCHLIN C. EVANS