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A new low density oral contrast for computed tomography
426
CLINICAL RADIOLOGY
D O E S I O D I N A T E D CONTRAST MEDIA P R E D I S P O S E TO A U T O - I M M U N E T H Y R O I D DISEASE? C. J. O C C L E S H A W , D. J. M O N A G H A N , R. L. K E N N E D Y , A. P R I C E and M. G H A N D I
C T A P P E A R A N C E S OF D E S M O I D T U M O U R S IN F A M I L I A L A D E N O M A T O U S POLYPOSIS: F U R T H E R O B S E R V A T I O N S A. P. BROOKS, R. H. R E Z N E K , K. N U G E N T * , R. PHILLIPS* and J T H O M P S O N *
Departments of Radiology and Clinical Chemistry, Royal Hallamshire/Northern GeneralHospitals, Sheffield
Department of'Diagnostic Radiology and *Surgery, St Bartholomew's. and St Mark's Hospitals', London
Thyroid dysfunction following iodinated contrast media is well documented. Iodine intake affects the development of thyroid autoimmune disease, and amiodarone, an iodine-containing antiarrhythmic, is reported to cause autoantibody development as well as frank thyroid dysfunction. Forty-eight patients undergoing elective intravenous urography had venous blood samples taken before a n d on up to four occasions over the next 6 m o n t h s following the procedure. Samples were analysed for thyroid hormone levels, and thyroglobulin and thyroid microsomal antibodies. Patients with a history of thyroid disease were excluded. Thyroid function was unchanged in the 48 patients, and no significant change was seen in the levels of antibody titres. Nine patients had thyroid autoantibodies before contrast administration; three of these showed changes in antibody titres, the largest a 20-fold increase. Iodinated contrast media does not cause the development of autoanti- ' body production, but the changes in antibody titres in those in w h o m they are already present implies that the contrast media has affected the interaction between thyroid tissue and the i m m u n e system. The longterm implications of this are unknown.
Intra-abdominal desmoid t u m o u r s represent a major cause of morbidity and mortality in patients with familial adenomatous polyposis (FAP), and such patients are also liable to develop musculoskeletal desmoids. We have reviewed the CT appearances of 44 desmoid lesions in 20 patients with FAP. We found a considerable heterogeneity in the CT appearance of desmoids, with respect to their density, definition, and change in size or density on follow-up, not only between different patients but also in single patients With multiple lesions (musculoskeletal, intra-abdominal or both) Who rarely showed identical appearances of all lesions. At least in some cases, mesenteric tumours may initially present as illdefined soft tissue infiltration of mesenteric fat, becoming larger and more mass-like with time, O n medical treatment, shrinkage was seen infrequently in musculoskeletal desmoids, not at all with mesenteric lesions. CT evidence of bowel involvement by intra-abdominal lesions was frequent, most commonly appearing as 'tethering' or encasement of bowel loops. The presence o f large mesenteric mass ( > 10 em diam.), multiple mesenteric masses, extensive small bowel involvement and/or bilateral hydronephrosis were associated with ultimate death. This relatively large series of an unusual condition provides a comprehensive analysis of the varied appearances, evolution and differential response to treatment of desmoid tumours in patients with FAP.
H O W T O I M A G E B U T T O C K M A S S E S , A REVIEW OF 20 CASES M. McPHILLIPS and B. D A L Y
Department of Diagnostic Radiology and Organ Imaging, Prince of Wales Hospital/Chinese University of Hong Kong, Hong Kong Masses in the buttocks can cause problems in diagnosis and assessment of extent. Many imaging modalities m a y be used in their investigation. We saw 20 patients with buttock masses, 13 males and seven females. The age range was 1 day to 80 years, eight being under 16 years of age. Most patients were investigated using plain radiography, ultrasound and CT. Selected patients required isotope studies, angioigraphy or magnetic resonance imaging. Ultrasound and CT were the most useful imaging modalities. Ultrasound was usually performed initially, and could characterize the internal structure of the mass more clearly than CT. CT was helpful in delineating the extent and precise location of the mass and in assessing any bony involvement. The pathology was varied. Five masses associated with neural tube defects were seen, five abscesses/bursa, six malignant tumours, two benign tumours and two vascular malformations. The usefulness of various imaging modalities in assessing buttock masses will be illustrated.
M R I O F THE AORTA AFTER REPAIR OF TYPE A DISSECTION N. R. M O O R E , B. T. D I C K E N S O N , R. P1LLAI and S. W E S T A B Y
Departments qf Radiology and Cardiothoracic Surgery, John Radcliffe Hospital, Oxford Repair of aortic dissection can be life saving, but survivors m a y succumb to late rupture. Magnetic resonance imaging (MRI) was performed in 23 patients (18 male; age range 40 76 years (mean 60.4 years)) following repair of type A aortic dissection (dacron graft ± aortic valve resuspension or replacement). Imaging was performed 3-47 m o n t h s after surgery. Coronal and axial gated T1 spin echo images were obtained from the proximal head and neck vessels to the mid pelvis. Axial or oblique gradient echo images were also obtained (breathhold G R A S S in 8, cine G R A S S in 20) to assess luminal patency. Residual dissection was very c o m m o n ; ascending aorta 18/23; transverse arch 17/23; descending aorta 17/23; abdominal aorta 13/23. There was extension into the aortic arch branches in 12, and into the c o m m o n iliac arteries in nine, of 22 patients examined. In all patients with a residual dissection part or all of the false lumen was patent. In six patients the thoracic aorta was aneurysmal (range 5.0 8.7 cm, mean 6.0 cm). Two patients have required reoperation following M R I findings (for redissection involving the aortic valve, and aneurysm formation respectively). Two patients have suspected confined aortic root rupture (one thrombosed, one patent) and are being observed. M R I is an accurate non-invasive method of monitoring the aorta after surgery. This m a y allow early recognition of major complications.
DOMICILIARY R A D I O G R A P H Y : AN I M P O R T A N T SERVICE? R. H. S A W Y E R , U. P A T E L and A. W. H O R R O C K S
Department of Radiology, WythenshaweHospital, Manchester Methods': A survey of 159 local GPs was performed to assess the value of domiciliary radiography. A retrospective review of 50 examinations was made with a judgement of the likely impact of the report provided. The eostings for the service as provided were calculated as well as for all alternative ways of imaging immobile patients. Results: 72% of G P s were aware of the service and 79 % would object to it being withdrawn. Twenty-five per cent requested more than five examinations per year. T h o u g h 98% recognized that a chest X-ray was suitable 45% thought domiciliary ultrasound was performed and 53% considered a lumbar spine technically feasible. Sixty-three per cent thought that a domiciliary examination was cheaper. Reports suggesting major or fundamental changes in management were provided in 48 % of cases while 2% provided no help. One case with AIDS should not haved been imaged. Costings ranged from £25 assuming a radiographer provided by the service to the current cost of about £80 when done by a radiologist. Allowing for the cost of an ambulance, a departmental film costs £70. The domiciliary service is valuable but could be provided in cheaper ways. A N E W L O W DENSITY O R A L C O N T R A S T F O R C O M P U T E D TOMOGRAPHY D. W A L K E R , N. H A C K I N G and R. B L A Q U I E R E
Department of Radiology, Southampton General Hospital, Southampton Computed tomography of the upper abdomen has usually required opacification of the bowel with a high density oral contrast agent such as a 3% solution of iodine, made up by diluting one of the standard ionic contrast agents. We describe an alternative preparation of a 50% emulsion of long chain triglycerides (Calogen: Scientific Hospital Supplies) which although developed as a nutritional supplement has proved a reliable hypodense contrast agent in the upper bowel. Five hundred ml of Calogen is administered orally with routine images obtained 40 rain later. The contrast has been well tolerated by patients and the cost per case is £4.50. It has a C T number of - 7 0 Hounsfield units (Hu) and this provides a gradient of approximately 100 H u between the luminal contents and the bowel wall and allows the bowel wall thickness to be shown at conventional soft tissue window settings (level 40 Hu; width 400 Hu). M a n y of the artifacts seen with iodinated contrast are abolished. There is excellent demonstration of the site and size of t h e pr!mary
ABSTRACTS turnout particularly in oesophageal and gastric neoplasms. Invasion into adjacent fat and regional lymph node metastases are demonstrated with greater clarity even in cachectic patients. Advantages have also been shown in staging patients with pancreatic tumours a n d in assessment of metastatic deposits in the liver.
CT R A D I O L O G Y OF T H E P A R A N A S A L S I N U S E S IN W E G E N E R ' S G R A N U L O M A T O S I S AND T H E C H U R G STRAUSS SYNDROME - A COMPARATIVE STUDY W. L. W O N G , D. D ' C R U Z , K. ENTWISLE, E. LOVEDAY, G. H U G H E S and A. B. A Y E R S
Department of Clinical Radiology and Rheumatology, St Thomas's Ho~spital, London The systemic vasculitides encompass a range of diseases, including Wegener's granulomatosis and the Churg-Strauss Syndrome. Patients with both Wegener's granulomatosis and the Chnrg-Strauss Syndrome m a y experience upper respiratory tract symptoms but involvement of the paranasal sinuses (PNS) and nasopharynx can also result in radiological changes of these regions. The purpose of this study is to document the CT changes within the PNS and nasopharynx in these two groups of patients to see if they can aid the differential diagnosis. We reviewed the paranasal sinus CT changes in 23 patients with Wegener's granulomatosis and in six patients with the Churg-Strauss Syndrome. Sixteen cases of Wegener's granulomatosis showed negative or non-specific changes. In the remaining seven cases (30%) bony destruction was seen. The radiological changes varied from a normal appearance through paranasal sinuses full of soft tissue to bony sclerosis and destruction of the nasal septum and sinus walls. In contrast, in the Churg-Strauss Syndrome negative or non-specific findings were present in five cases with only one case demonstrating bony destruction. The bony destruction as well as being less extensive was not associated with a perforated nasal septum. Our study suggests that the difference in radiologieal pattern in Wegener's and Churg-Strauss is one of degree only. Bony destruction although very unusual in Churg-Strauss can however be present, so it may not be possible on PNS C T alone to distinguish between the two conditions.
D Y N A M I C C O N T R A S T - E N H A N C E D M R I O F T H E LIVER A N D PORTAL VENOUS SYSTEM J. W A R D , D. M A R T I N E Z , A. G. C H A L M E R S , J. R I D G W A Y and P. J. R O B I N S O N
Department of Radiology and Medical Physics, St James's University Hospital, Leeds The aim of the study was to test the efficiency of rapid sequential acquisitions following G d - D T P A in demonstrating the a n a t o m y of portal venous system in 40 patients, mainly candidates for liver resection or transplantation. Four consecutive acquisitions were obtained in the coronal plane using a multislice T u r b o F L A S H sequence ( T R - 1 0 0 ms, T E = 4 ms). The short echo time of this sequence allows a relatively high n u m b e r of slices to be acquired within an acceptable breathhold period. Eleven slices of 5 m m each were acquired in 19 s with the patient breathholding. The slices from each acquisition were combined using a m a x i m u m intensity algorithm to include all the vessels on a single image. All patients also had axial T2-weighted spin echo (SE) imaging and in 10 patients coronal Tl-weighted SE images were also obtained. The clarity of vessel a n a t o m y was compared and scored for all sequences by two radiologists. Vessel patency, the conspicuity of mass lesions, and the spread o f t u m o u r to adjacent structures was also scored. The coronal Tl-weighted SE images were non-contributory. The main and right portal veins were significantly better seen on dynamic images whilst the left portal vein is equally well seen on T2-weighted SE images and dynamic images. Vessel patency was more clearly shown after G d - D T P A . Lesion conspicuity was improved on dynamic images.
PEROPERATIVE CHOLANGIOGRAPHY DURING LAPAROSCOPIC CHOLECYSTECTOMY U. PATEL, R. F. McCLOY, R. G. N A I R and S. H. LEE
Pancreatico-biliary Unit and Department of Radiology, Manchester Royal Infirmary, Manchester M a n y recent papers discuss the rote ofpre-operative imaging in patients undergoing laparoscopic cholecystectomy. In our unit, peroperative
427
cholangiography (POC) is routinely attempted in all such patients. Other units favour either pre-operative intravenous cholangiography (IVC), selective POC, or selective endoscopic retrograde cholangiography (ERC) to determine a n a t o m y and to detect the presence of bile duct stones. We present the findings in 46 consecutive, unselected patients undergoing POC during laparoscopic cholecystectomy. Successful POC via cystic duct cannulation was obtained in 35/46 (76%) of patients. Two radiographs were taken in the supine position following injection of 5 ml and 20 ml of contrast. The films were subsequently assessed for anatomical detail and the presence of bile duct calculi. The reasons for failed cystic duct cannulation are discussed. N o patient required conversion to open cholecystectomy. We believe that POC is of prime importance in demonstrating bile duct a n a t o m y during laparoscopic cholecystectomy, as it is during open cholecystectomy, and that pre-operative 'road-map' imaging by IVC or E R C is unlikely to prevent bile duct injury. The presence of clinically suspected bile duct stones is of secondary importance as several means are available for their subsequent removal.
UTILITY OF R A D I O L O G I C A L I N T E R V E N T I O N F O R BILIARY O B S T R U C T I O N IN T R A N S P L A N T E D LIVERS J. S H E R I D A N , E. Y E U N G , C. S. H O and W. T H U R S T O N
Department of Radiology, The Toronto Hospital, Toronto General Division, Toronto, Canada Of 183 liver transplants performed over a 6 year period, radiological intervention for suspected biliary obstruction was requested in nine patients. All cases presented with either cholangitis or biochemical evidence of biliary obstruction. The interval since transplantation ranged from 2 8 months. Eight patients had biliary strictures, five anastomotic and three nonanastomotic strictures. All strictures were treated initially by percutaneous transhepatic biliary drainage (PTCD). One patient had a normal percutaneous transhepatic cholangiogram and no further intervention was performed. The eight patients with strictures subsequently underwent a variety of interventional procedures including: stricture dilatation, removal of biliary sludge and stone and choledoscopy. Six patients eventually required further surgery, three had anastomotic revisions and three were re-transplanted. In our experience, biliary intervention for strictures in the transplanted liver has a vital role in defining the site and extent of stricture and managing cholangitis. In patients requiring re-transplantation, it temporizes until a new liver becomes available.
A C O M P A R I S O N OF T H E M A M M O G R A P H I C F E A T U R E S OF INVASIVE L O B U L A R VERSUS INVASIVE D U C T A L C A R C I N O M A O F T H E BREAST E. J. C O R N F O R D , M. G A L E A , I. O. ELLIS, C. W. ELSTON, E. J. R O E B U C K , R. W. B L A M E Y and A. R. M. W I L S O N
Breast Screening Training Centre, City Hospital, Nottingham The mammograpic features of 86 invasive lobular and 86 invasive carcinomas of no special type (ductal NST) have been reviewed. Abnormalities consistent with carcinoma were present in 78% of patients with lobular carcinoma and 83% of patients with ductal N S T carcinoma. A mass was present in 6l (71%) patients with lobular carcinoma and 66 (82.5%) patients with ductal carcinoma. There were no differences between the two groups in the characteristics of these masses, the m a m m o g r a p h i c size, background patterns or the frequency of secondary m a m m o g r a p h i c features. Microcalcification was present more frequently in association with ductal NST carcinoma (44%) than with lobular carcinoma (25.6%). In the classical lobuIar subtype underlying anatomic structures tend to be preserved while the mixed subtype is associated with a marked desmoplastic response. Some correlation has been demonstrated between the m a m m o g r a p h i c features and these histopathological subtypes. N o m a m m o g r a p h i c abnormality was present in eight cases, six of which were of the classical lobular type. The masses demonstrated in six of 39 women with classical lobular carcinoma showed no evidence of spiculation while all masses in women with mixed lobular tumours demonstrated this appearance. The majority of invasive lobular carcinomas show detectable abnormalities which are indistinguishable from ductal carcinoma. Although numbers are small, impalpable lobular cancers m a y be more likely to be of the 'classical' lobular type.
CLINICAL RADIOLOGY
D O E S I O D I N A T E D CONTRAST MEDIA P R E D I S P O S E TO A U T O - I M M U N E T H Y R O I D DISEASE? C. J. O C C L E S H A W , D. J. M O N A G H A N , R. L. K E N N E D Y , A. P R I C E and M. G H A N D I
C T A P P E A R A N C E S OF D E S M O I D T U M O U R S IN F A M I L I A L A D E N O M A T O U S POLYPOSIS: F U R T H E R O B S E R V A T I O N S A. P. BROOKS, R. H. R E Z N E K , K. N U G E N T * , R. PHILLIPS* and J T H O M P S O N *
Departments of Radiology and Clinical Chemistry, Royal Hallamshire/Northern GeneralHospitals, Sheffield
Department of'Diagnostic Radiology and *Surgery, St Bartholomew's. and St Mark's Hospitals', London
Thyroid dysfunction following iodinated contrast media is well documented. Iodine intake affects the development of thyroid autoimmune disease, and amiodarone, an iodine-containing antiarrhythmic, is reported to cause autoantibody development as well as frank thyroid dysfunction. Forty-eight patients undergoing elective intravenous urography had venous blood samples taken before a n d on up to four occasions over the next 6 m o n t h s following the procedure. Samples were analysed for thyroid hormone levels, and thyroglobulin and thyroid microsomal antibodies. Patients with a history of thyroid disease were excluded. Thyroid function was unchanged in the 48 patients, and no significant change was seen in the levels of antibody titres. Nine patients had thyroid autoantibodies before contrast administration; three of these showed changes in antibody titres, the largest a 20-fold increase. Iodinated contrast media does not cause the development of autoanti- ' body production, but the changes in antibody titres in those in w h o m they are already present implies that the contrast media has affected the interaction between thyroid tissue and the i m m u n e system. The longterm implications of this are unknown.
Intra-abdominal desmoid t u m o u r s represent a major cause of morbidity and mortality in patients with familial adenomatous polyposis (FAP), and such patients are also liable to develop musculoskeletal desmoids. We have reviewed the CT appearances of 44 desmoid lesions in 20 patients with FAP. We found a considerable heterogeneity in the CT appearance of desmoids, with respect to their density, definition, and change in size or density on follow-up, not only between different patients but also in single patients With multiple lesions (musculoskeletal, intra-abdominal or both) Who rarely showed identical appearances of all lesions. At least in some cases, mesenteric tumours may initially present as illdefined soft tissue infiltration of mesenteric fat, becoming larger and more mass-like with time, O n medical treatment, shrinkage was seen infrequently in musculoskeletal desmoids, not at all with mesenteric lesions. CT evidence of bowel involvement by intra-abdominal lesions was frequent, most commonly appearing as 'tethering' or encasement of bowel loops. The presence o f large mesenteric mass ( > 10 em diam.), multiple mesenteric masses, extensive small bowel involvement and/or bilateral hydronephrosis were associated with ultimate death. This relatively large series of an unusual condition provides a comprehensive analysis of the varied appearances, evolution and differential response to treatment of desmoid tumours in patients with FAP.
H O W T O I M A G E B U T T O C K M A S S E S , A REVIEW OF 20 CASES M. McPHILLIPS and B. D A L Y
Department of Diagnostic Radiology and Organ Imaging, Prince of Wales Hospital/Chinese University of Hong Kong, Hong Kong Masses in the buttocks can cause problems in diagnosis and assessment of extent. Many imaging modalities m a y be used in their investigation. We saw 20 patients with buttock masses, 13 males and seven females. The age range was 1 day to 80 years, eight being under 16 years of age. Most patients were investigated using plain radiography, ultrasound and CT. Selected patients required isotope studies, angioigraphy or magnetic resonance imaging. Ultrasound and CT were the most useful imaging modalities. Ultrasound was usually performed initially, and could characterize the internal structure of the mass more clearly than CT. CT was helpful in delineating the extent and precise location of the mass and in assessing any bony involvement. The pathology was varied. Five masses associated with neural tube defects were seen, five abscesses/bursa, six malignant tumours, two benign tumours and two vascular malformations. The usefulness of various imaging modalities in assessing buttock masses will be illustrated.
M R I O F THE AORTA AFTER REPAIR OF TYPE A DISSECTION N. R. M O O R E , B. T. D I C K E N S O N , R. P1LLAI and S. W E S T A B Y
Departments qf Radiology and Cardiothoracic Surgery, John Radcliffe Hospital, Oxford Repair of aortic dissection can be life saving, but survivors m a y succumb to late rupture. Magnetic resonance imaging (MRI) was performed in 23 patients (18 male; age range 40 76 years (mean 60.4 years)) following repair of type A aortic dissection (dacron graft ± aortic valve resuspension or replacement). Imaging was performed 3-47 m o n t h s after surgery. Coronal and axial gated T1 spin echo images were obtained from the proximal head and neck vessels to the mid pelvis. Axial or oblique gradient echo images were also obtained (breathhold G R A S S in 8, cine G R A S S in 20) to assess luminal patency. Residual dissection was very c o m m o n ; ascending aorta 18/23; transverse arch 17/23; descending aorta 17/23; abdominal aorta 13/23. There was extension into the aortic arch branches in 12, and into the c o m m o n iliac arteries in nine, of 22 patients examined. In all patients with a residual dissection part or all of the false lumen was patent. In six patients the thoracic aorta was aneurysmal (range 5.0 8.7 cm, mean 6.0 cm). Two patients have required reoperation following M R I findings (for redissection involving the aortic valve, and aneurysm formation respectively). Two patients have suspected confined aortic root rupture (one thrombosed, one patent) and are being observed. M R I is an accurate non-invasive method of monitoring the aorta after surgery. This m a y allow early recognition of major complications.
DOMICILIARY R A D I O G R A P H Y : AN I M P O R T A N T SERVICE? R. H. S A W Y E R , U. P A T E L and A. W. H O R R O C K S
Department of Radiology, WythenshaweHospital, Manchester Methods': A survey of 159 local GPs was performed to assess the value of domiciliary radiography. A retrospective review of 50 examinations was made with a judgement of the likely impact of the report provided. The eostings for the service as provided were calculated as well as for all alternative ways of imaging immobile patients. Results: 72% of G P s were aware of the service and 79 % would object to it being withdrawn. Twenty-five per cent requested more than five examinations per year. T h o u g h 98% recognized that a chest X-ray was suitable 45% thought domiciliary ultrasound was performed and 53% considered a lumbar spine technically feasible. Sixty-three per cent thought that a domiciliary examination was cheaper. Reports suggesting major or fundamental changes in management were provided in 48 % of cases while 2% provided no help. One case with AIDS should not haved been imaged. Costings ranged from £25 assuming a radiographer provided by the service to the current cost of about £80 when done by a radiologist. Allowing for the cost of an ambulance, a departmental film costs £70. The domiciliary service is valuable but could be provided in cheaper ways. A N E W L O W DENSITY O R A L C O N T R A S T F O R C O M P U T E D TOMOGRAPHY D. W A L K E R , N. H A C K I N G and R. B L A Q U I E R E
Department of Radiology, Southampton General Hospital, Southampton Computed tomography of the upper abdomen has usually required opacification of the bowel with a high density oral contrast agent such as a 3% solution of iodine, made up by diluting one of the standard ionic contrast agents. We describe an alternative preparation of a 50% emulsion of long chain triglycerides (Calogen: Scientific Hospital Supplies) which although developed as a nutritional supplement has proved a reliable hypodense contrast agent in the upper bowel. Five hundred ml of Calogen is administered orally with routine images obtained 40 rain later. The contrast has been well tolerated by patients and the cost per case is £4.50. It has a C T number of - 7 0 Hounsfield units (Hu) and this provides a gradient of approximately 100 H u between the luminal contents and the bowel wall and allows the bowel wall thickness to be shown at conventional soft tissue window settings (level 40 Hu; width 400 Hu). M a n y of the artifacts seen with iodinated contrast are abolished. There is excellent demonstration of the site and size of t h e pr!mary
ABSTRACTS turnout particularly in oesophageal and gastric neoplasms. Invasion into adjacent fat and regional lymph node metastases are demonstrated with greater clarity even in cachectic patients. Advantages have also been shown in staging patients with pancreatic tumours a n d in assessment of metastatic deposits in the liver.
CT R A D I O L O G Y OF T H E P A R A N A S A L S I N U S E S IN W E G E N E R ' S G R A N U L O M A T O S I S AND T H E C H U R G STRAUSS SYNDROME - A COMPARATIVE STUDY W. L. W O N G , D. D ' C R U Z , K. ENTWISLE, E. LOVEDAY, G. H U G H E S and A. B. A Y E R S
Department of Clinical Radiology and Rheumatology, St Thomas's Ho~spital, London The systemic vasculitides encompass a range of diseases, including Wegener's granulomatosis and the Churg-Strauss Syndrome. Patients with both Wegener's granulomatosis and the Chnrg-Strauss Syndrome m a y experience upper respiratory tract symptoms but involvement of the paranasal sinuses (PNS) and nasopharynx can also result in radiological changes of these regions. The purpose of this study is to document the CT changes within the PNS and nasopharynx in these two groups of patients to see if they can aid the differential diagnosis. We reviewed the paranasal sinus CT changes in 23 patients with Wegener's granulomatosis and in six patients with the Churg-Strauss Syndrome. Sixteen cases of Wegener's granulomatosis showed negative or non-specific changes. In the remaining seven cases (30%) bony destruction was seen. The radiological changes varied from a normal appearance through paranasal sinuses full of soft tissue to bony sclerosis and destruction of the nasal septum and sinus walls. In contrast, in the Churg-Strauss Syndrome negative or non-specific findings were present in five cases with only one case demonstrating bony destruction. The bony destruction as well as being less extensive was not associated with a perforated nasal septum. Our study suggests that the difference in radiologieal pattern in Wegener's and Churg-Strauss is one of degree only. Bony destruction although very unusual in Churg-Strauss can however be present, so it may not be possible on PNS C T alone to distinguish between the two conditions.
D Y N A M I C C O N T R A S T - E N H A N C E D M R I O F T H E LIVER A N D PORTAL VENOUS SYSTEM J. W A R D , D. M A R T I N E Z , A. G. C H A L M E R S , J. R I D G W A Y and P. J. R O B I N S O N
Department of Radiology and Medical Physics, St James's University Hospital, Leeds The aim of the study was to test the efficiency of rapid sequential acquisitions following G d - D T P A in demonstrating the a n a t o m y of portal venous system in 40 patients, mainly candidates for liver resection or transplantation. Four consecutive acquisitions were obtained in the coronal plane using a multislice T u r b o F L A S H sequence ( T R - 1 0 0 ms, T E = 4 ms). The short echo time of this sequence allows a relatively high n u m b e r of slices to be acquired within an acceptable breathhold period. Eleven slices of 5 m m each were acquired in 19 s with the patient breathholding. The slices from each acquisition were combined using a m a x i m u m intensity algorithm to include all the vessels on a single image. All patients also had axial T2-weighted spin echo (SE) imaging and in 10 patients coronal Tl-weighted SE images were also obtained. The clarity of vessel a n a t o m y was compared and scored for all sequences by two radiologists. Vessel patency, the conspicuity of mass lesions, and the spread o f t u m o u r to adjacent structures was also scored. The coronal Tl-weighted SE images were non-contributory. The main and right portal veins were significantly better seen on dynamic images whilst the left portal vein is equally well seen on T2-weighted SE images and dynamic images. Vessel patency was more clearly shown after G d - D T P A . Lesion conspicuity was improved on dynamic images.
PEROPERATIVE CHOLANGIOGRAPHY DURING LAPAROSCOPIC CHOLECYSTECTOMY U. PATEL, R. F. McCLOY, R. G. N A I R and S. H. LEE
Pancreatico-biliary Unit and Department of Radiology, Manchester Royal Infirmary, Manchester M a n y recent papers discuss the rote ofpre-operative imaging in patients undergoing laparoscopic cholecystectomy. In our unit, peroperative
427
cholangiography (POC) is routinely attempted in all such patients. Other units favour either pre-operative intravenous cholangiography (IVC), selective POC, or selective endoscopic retrograde cholangiography (ERC) to determine a n a t o m y and to detect the presence of bile duct stones. We present the findings in 46 consecutive, unselected patients undergoing POC during laparoscopic cholecystectomy. Successful POC via cystic duct cannulation was obtained in 35/46 (76%) of patients. Two radiographs were taken in the supine position following injection of 5 ml and 20 ml of contrast. The films were subsequently assessed for anatomical detail and the presence of bile duct calculi. The reasons for failed cystic duct cannulation are discussed. N o patient required conversion to open cholecystectomy. We believe that POC is of prime importance in demonstrating bile duct a n a t o m y during laparoscopic cholecystectomy, as it is during open cholecystectomy, and that pre-operative 'road-map' imaging by IVC or E R C is unlikely to prevent bile duct injury. The presence of clinically suspected bile duct stones is of secondary importance as several means are available for their subsequent removal.
UTILITY OF R A D I O L O G I C A L I N T E R V E N T I O N F O R BILIARY O B S T R U C T I O N IN T R A N S P L A N T E D LIVERS J. S H E R I D A N , E. Y E U N G , C. S. H O and W. T H U R S T O N
Department of Radiology, The Toronto Hospital, Toronto General Division, Toronto, Canada Of 183 liver transplants performed over a 6 year period, radiological intervention for suspected biliary obstruction was requested in nine patients. All cases presented with either cholangitis or biochemical evidence of biliary obstruction. The interval since transplantation ranged from 2 8 months. Eight patients had biliary strictures, five anastomotic and three nonanastomotic strictures. All strictures were treated initially by percutaneous transhepatic biliary drainage (PTCD). One patient had a normal percutaneous transhepatic cholangiogram and no further intervention was performed. The eight patients with strictures subsequently underwent a variety of interventional procedures including: stricture dilatation, removal of biliary sludge and stone and choledoscopy. Six patients eventually required further surgery, three had anastomotic revisions and three were re-transplanted. In our experience, biliary intervention for strictures in the transplanted liver has a vital role in defining the site and extent of stricture and managing cholangitis. In patients requiring re-transplantation, it temporizes until a new liver becomes available.
A C O M P A R I S O N OF T H E M A M M O G R A P H I C F E A T U R E S OF INVASIVE L O B U L A R VERSUS INVASIVE D U C T A L C A R C I N O M A O F T H E BREAST E. J. C O R N F O R D , M. G A L E A , I. O. ELLIS, C. W. ELSTON, E. J. R O E B U C K , R. W. B L A M E Y and A. R. M. W I L S O N
Breast Screening Training Centre, City Hospital, Nottingham The mammograpic features of 86 invasive lobular and 86 invasive carcinomas of no special type (ductal NST) have been reviewed. Abnormalities consistent with carcinoma were present in 78% of patients with lobular carcinoma and 83% of patients with ductal N S T carcinoma. A mass was present in 6l (71%) patients with lobular carcinoma and 66 (82.5%) patients with ductal carcinoma. There were no differences between the two groups in the characteristics of these masses, the m a m m o g r a p h i c size, background patterns or the frequency of secondary m a m m o g r a p h i c features. Microcalcification was present more frequently in association with ductal NST carcinoma (44%) than with lobular carcinoma (25.6%). In the classical lobuIar subtype underlying anatomic structures tend to be preserved while the mixed subtype is associated with a marked desmoplastic response. Some correlation has been demonstrated between the m a m m o g r a p h i c features and these histopathological subtypes. N o m a m m o g r a p h i c abnormality was present in eight cases, six of which were of the classical lobular type. The masses demonstrated in six of 39 women with classical lobular carcinoma showed no evidence of spiculation while all masses in women with mixed lobular tumours demonstrated this appearance. The majority of invasive lobular carcinomas show detectable abnormalities which are indistinguishable from ductal carcinoma. Although numbers are small, impalpable lobular cancers m a y be more likely to be of the 'classical' lobular type.