- Email: [email protected]
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Also, it is well known that adrenal androgen secretion decreases dramatically with age. If, as the authors speculate, flutamide is blocking the influence of adrenal androgens, then one would have anticipated the effect to be more pronounced in younger than in older patients. If so, should only younger patients be treated with flutamide and if not, why not? In addition, patients with a severe performance status (in bed more than 50% of the waking hours) who received flutamide had progression more rapidly and had a shorter survival than patients in the placebo group. Should these patients be given flutamide? Finally, this year at the annual meeting of the American Urological Association 2 large studies were reported from Europe that failed to confirm these findings. 2 • 3 If total androgen ablation prolongs life, then all patients should have the opportunity to benefit from this medical advance. However, before we reach this conclusion important questions need to be answered. Patrick C. Walsh, M.D. 1. Trachtenberg, J., Beland, G., Elhilali, M. M., Fradet, Y.,
Laroche, B., Ramsey, E. W. and Venner, P. N.: A randomized trial of total androgen ablation vrs orchiectomy in patients with metastatic prostatic cancer. J. Urol., part 2, 141: 347A, abstract 712, 1989. 2. Denis, L., De Moura, C., Smith, P., Newling, D., Sylvester, R. and Members of the EORTC GU Group: Zoladex and flutamide versus orchidectomy: first final analysis of EORTC 30853. J. Urol., part 2, 141: 311A, abstract 565, 1989. 3. Altwein, J. E., Klippel, K.-F., Holdaway, I. M., Lunglmayr, G., Tyrrell, C. J. and Varenhorst, E.: A multicentre randomised trial comparing the LHRH agonist "Zoladex" with "Zoladex" in combination with flutamide in the treatment of advanced prostate cancer. J. Urol., part 2, 141: 310A, abstract 564, 1989.
Treatment of Complicated Benign Prostatic Hyperplasia With LHRH-Analogues in Aged Patients
S.
BIANCHI, G. GRAVINA, A. PODESTA., D. BARLETTA, F. FRANCHI, P. KICOVIC AND M. LUISI, Endocrine Research
Unit of the CNR, Pisa University, Pisa, Italy Int. J. Androl., 12: 104-109, 1989 The effect of administration of an LHRH-analogue (LHRHa) was evaluated in 11 patients with benign prostatic hyperplasia (BPH) in whom there were contraindications for surgery. These patients, who already had impaired potency due to age or serious illness, were given 1500 µg LHRH-a in the first week and 1200 µg from the eighth day onwards. They all improved significantly (P <0.001) with regard to their urological symptoms on day 60 of treatment. Our results demonstrate the influence of androgen in maintaining established BPH, the effectiveness of LHRH-a therapy in selected patients with BPH and the usefulness of a salivary testosterone assay for the follow-up of treatments expected to lower the bioavailability of androgen to target tissues.
Clinical Experience: Symptomatic Management of BPH With Terazosin DUNZENDORFER, Maingau Krankenhaus, Frankfurt, Frankfurt am Main, West Germany
U.
Universitiit
Urology, suppl. 6, 32: 27-31, 1988 Several reports in the literature have suggested that alphareceptor blockade may have therapeutic value in treating the
symptoms of patients with benign prostatic hypertrophy (BPH). Terazosin is an alpha-1 adrenergic blocking agent currently marketed as an antihypertensive. A multicenter study to evaluate the safety and efficacy of terazosin in the treatment of patients with BPH was initiated. Preliminary results in 15 patients showed that terazosin significantly improved peak as well as mean flow rates, and improved obstructive symptoms in patients with BPH (P < 0.001). The results at four months of a six-month study support the conclusion that terazosin is beneficial for treatment of symptoms in patients with benign prostatic hypertrophy.
Editorial Comment: Two different approaches are presented for the medical management of benign prostatic hyperplasia: 1) decreasing prostate size and 2) decreasing prostate tone. Treatment with the luteinizing hormone-releasing hormone analogue decreased prostatic size by 29% at 6 months and improved symptoms by 40%. Treatment with the al-adrenergic blocking agent also improved total symptom score by 48%. An important question yet to be answered is whether there would there be synergy if these agents are given together. Patrick C. Walsh, M.D.
IMAGING Small Renal Neoplasms: Clinical, Pathologic, and Imaging Features
E. LEVINE, M. HUNTRAKOON AND L. H. WETZEL, Departments of Diagnostic Radiology and Pathology, Bell Memorial Hospital, University of Kansas Medical Center, Kansas City, Kansas AJR, 153: 69-73, 1989 Small renal neoplasms are being found more often because of the widespread use of abdominal CT and sonography. Little is known about their natural history. We therefore retrospectively reviewed clinical, pathologic, and imaging findings in 22 patients with surgically confirmed solitary renal neoplasms that were 3 cm or less in diameter. Eighteen lesions were first found by CT, three by sonography, and one by IV urography. Three lesions were discovered because the patients had hematuria. Nineteen were incidental radiologic diagnoses in patients without renal symptoms. Of 22 neoplasms, 15 (68%) were renal cell carcinomas, six (27%) were oncocytomas, and one (5%) was a lymphoma. Fourteen (93%) of the 15 carcinomas were confined to the kidney, and one showed microscopic capsular invasion. Metastases did not develop in any patient with carcinoma, indicating that small carcinomas usually have good prognoses. Patients with carcinomas had a mean follow-up of 42 months. All neoplasms were visible on CT. However, characterization of these lesions sometimes required a combination of CT and sonography and occasionally angiography. The carcinomas, oncocytomas, and solitary renal lymphoma could not be distinguished radiologically. Small renal neoplasms are most often found incidentally by CT performed in patients without renal complaints. Most are low-stage carcinomas, and some are oncocytomas.
Editorial Comment: With the advent of our newest imaging modalities, smaller and smaller neoplasms of the kidney, symptomatic and asymptomatic, are being
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demml§trated. As expected, the prognosis for these §maHer and often asymptomatic lesions is better. There is a bias to this series in the fact that 5 of the patients with renal cell carcinoma had either Von HippelLindau\; (4) or acquired cystic kidney disease (1). At the moment, the authors advocate radical nephrectomy for these lesions; referring to a 9 to 13% frequency of local tumor recurrence with partial nephrectomy. However, many of these small lesions ultimately were benign oncocytomas in this series (26%). We all certainly would prefer not to remove a kidney with a benign process. One could suggest performing partial nephrectomy on these smaller lesions and await the histological findings before deciding whether nephrectomy is appropriate. We still are unclear as to the need for total nephrectomy for small peripheral renal cell carcinoma and will have to await further studies in this regard. Stanford M. Goldman, M.D. Gadolinium-DTP A Enhanced Dynamic MR Imaging in the Evaluation of Cisplatinum N ephrotoxicity J. A. FRANK, P. L. CHOYKE, M. E. GIRTON, H. A. AUSTIN, C. 8IEVENPIPER, S. W. INSCOE, J. L. BLACK, M. J. CARVLIN AND A. J. DWYER, Diagnostic Radiology Department, Warren Grant Magnuson Clinical Center, and Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland; Departments of Radiology and Medicine, Georgetown University Medical Center, Washington, D. C., and General Electric Company, Milwaukee, Wisconsin J. Comput. Assist. Tomogr., 13: 448-459, 1989 Gadolinium diethylenetriamine pentaacetic acid (Gd-DTP A) enhanced dynamic magnetic resonance (MR) imaging was used to monitor the nephrotoxic effects of cis-platinum (cis-diamminedichloroplatinum; CDDP), a chemotherapeutic agent that produces damage in the proximal convoluted tubule. Ten New Zealand white rabbits (NZWs) were divided into two groups and were evaluated at two clinically relevant doses of CDDP. Group 1 (four NZWs) received CDDP intravenously at 125 mg/ m 2 over 1 h. Rabbits in Group 2 (six NZWs) were infused with CDDP at 40 mg/m 2 each day for 5 consecutive days. Dynamic MR images were performed in the axial plane at 1.5 T using a gradient recalled acquisition in the steady state sequence with an echo time of 11 ms, a repetition time of 20 ms, and a flip angle of 10° after a bolus injection of Gd-DTP A 0.1 mmol/kg. Thirty-two sequential post Gd-DTPA images (5.12 s/image) were obtained over 2 min 45 s at a single location. All rabbits underwent baseline normal and serial post CDDP Gd-DTPA enhanced dynamic MR scans. Analysis of the alterations in the normal pattern of renal enhancement caused by CDDP was facilitated by using a stacked profile image and quantitative region of interest measurements of signal intensity. Normally, after the injection of Gd-DTP A, a dark band promptly appears in the outer cortex of the kidneys and migrates centripetally toward the papilla, reflecting the tubular concentration of GdDTP A. In Group 1 rabbits, nephrotoxicity due to CDDP was observed as early as 9 h after administration of the drug, with a complete disappearance of the dark band by 7 days. In Group 2 rabbits, the band disappeared gradually and reappeared 2-10 days after the completion of CDDP treatment, indicative of tubular damage and recovery with return of the concentrating ability of the kidney. These results illustrate the feasibility of
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using Gd-DTP A MR as a sensitive mor,itor of induced alterations of renal function.
Editorial Comment: Experimentally induced nephrotoxicity with cis-plathmm was :monitored m1ccessfo.lly using Gd-DTPA-enhanced dynamic magnetic resonance l.magi.ng (MRI). Gd-DTP A, an approved MRI contrast enhancement agent, is excreted renally. N ephrotoxicity was demonstrated as early as 9 hours, even before Hght microscopic changes were observed. If confirmed in the future, MRI may be invaluable to follow patients being treated with potentially nephrotoxic agents for early signs of renal damage. Stanford M. Goldman, M.D. Prostatic Carcinoma and Benign Prostatic Hyperplasi.a: Correlation of High-Resolution MR and Histopathologic Findings M. L. SCHIEBLER, J. E. TOMASZEWSKI, M. BEZZI, H. M. POLLACK, H. Y. KRESSEL, E. K. COHEN, H. G. ALTMAN, W. B. GEFTER, A. J. WEIN AND L. AXEL, Departments of Radiology, Pathology and Urology, University of Pennsylvania School of Medicine and Hospital, Philadelphia, Pennsylvania; Department of Radiology, University of North Carolina Medical School, Chapel Hill, North Carolina, and Department of Radiology, Mount Sinai uc,0µaicc", Toronto, u11,w,,,,..,, Canada
Radiology, 172: 131-137, 1989 High-resolution magnetic resonance (MR) imaging of 24 fresh radical prostatectomy specimens was performed on an experimental 1.9-T system. Direct correlation between the findings in 7-µm-thick macrosections and their corresponding MR images was possible. Fourteen patients had macroscopic evidence of cancer. In all 14 cases, the carcinoma nodules appeared as areas of low signal intensity on images obtained with a repetition time of 2,500 msec and an echo time of 80 msec. Ten of 14 nodules had well-defined margins and consisted of packed glandular elements, which displaced the surrounding normal glandular material of higher signal intensity. Ten specimens displayed benign prostatic hyperplasia The MR characteristics of this entity were quite variable but relatively predictable, depending on the distribution and size of the glandular elements, as well as the ~v,m,,v~cc,vu of the surround" ing stroma. In BPH, the changes began in the central of the gland. The areas of highest to dilated glandular elements of lowest signal intensity <>ffr>'~,,mrm to collagen and fibromuscular stroma. Nodules of mixed glandular BPH and fibromuscular BPH were found to have intensities similar to those of well-differentiated nodules of prostatic adenocarcinoma.
Editorial Comment: groups are working intensely in an attempt to crnrrelate magnetic resonance images (MRI) of the prostate (and for that matter ultrasound images) with. th.at of the micropathology result. The authors present the on-going research. at the University of Pennsylvania to explain the image characteristics of prostatic adenocarcinoma and benign prostatic hyperplasia in relationship to the pathological findings. However, it should be noted carefully that this project was performed on a 1.9 Tesla MRI unit. It is not always possible to extrapolate the findings at one particular field strength to another. Specifically, current clinical
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imaging of the prostate usually is done at 1.5 Tesla or at less than 0.5 Tesla. The authors attempt to correlate in vivo images obtained on a 1.5 Tesla clinical unit with in vitro images performed on an experimental 1.9 Tesla unit. Presently, for example, they noted a low relative signal intensity in the peripheral zone of the prostate ex vivo (1.5 Tesla) compared to that in vivo (1.9 Tesla). The authors do not have a good explanation for this phenomenon, although they do suggest the possibility that expressible fluid was squeezed out of the glands or that devascularization may have occurred ex vivo. However, this is an important area of research that hopefully will yield clinically significant information. Stanford M. Goldman, M.D. Percutaneous N ephrostomy in Pyonephrosis F. CAMUNEZ, A. ECHENAGUSIA, M. L. PRIETO, P. SALOM, F. HERRANZ AND C. HERNANDEZ, Departments of Diagnostic Radiology and Urology, Hospital General Gregorio Maranan, Universidad Complutense, Madrid, Spain Urol. Rad., 11: 77-81, 1989 A series of 76 pyonephrotic kidneys in 73 patients were drained by percutaneous nephrostomy (PN) tube and examined to evaluate the contribution of this technique to the treatment of pyonephrosis. In 71 patients, clinical symptoms disappeared 24-48 h after the procedure. Two patients died from sepsis subsequent to anuria and underlying malignancy. Once the acute phase had remitted, interventional procedures were carried out in 39 cases, and constituted the definitive therapy in 36. In 32 cases, elective surgery was the definitive therapy, including the 3 cases not resolved after interventional procedures. Three patients in whom the obstruction cleared spontaneously following PN needed no additional treatment. Major complications included 6 cases of sepsis, all of which resolved satisfactorily with proper medical therapy.
Editorial Comment: In this large series of pyonephrotic kidneys drained percutaneously the fact that 93% of the patients had relief of symptoms within 48 hours truly is impressive. As momentous is the fact that 83.1 % of the kidneys were salvaged (59 kidneys) by percutaneous nephrostomy while radical nephrectomy ultimately was required in only 12 (16.9%). We believe that percutaneous nephrostomy should be attempted with an operation being reserved for kidneys that could not be drained successfully or when the kidney clearly cannot be salvaged. Stanford M. Goldman, M.D. The Detection of Adrenal Tumors and Hyperplasia in Patients With Primary Aldosteronism: Comparison of Scintigraphy, CT, and MR Imaging D. M. IKEDA, I. R. FRANCIS, G. M. GLAZER, M.A. AMENDOLA, M. D. GROSS AND A. M. AISEN, Departments of Radiology and Internal Medicine, Division of Nuclear Medicine, University of Michigan Medical Center, and Veterans Administration Medical Center, Ann Arbor, Michigan; Department of Diagnostic Radiology and Nuclear Medicine, Stanford University, School of Medicine, Stanford, California, and Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
AJR, 153: 301-306, 1989 We retrospectively reviewed the imaging studies in 17 proved cases of primary aldosteronism to determine the value of the procedures used to detect adrenal tumors or adrenal hyperplasia. The procedures included CT with 3-, 5-, and/or 10-mmthick sections (1 7 patients), 131 I-6/)-iodomethyl-19-norcholesterol (NP-59) scintigraphy (16 patients), and MR imaging (six patients). Proof of the adrenal abnormality was established in cases of tumor (seven adenomas, one carcinoma) by surgery and in cases of adrenal hyperplasia by surgery (three cases); venous sampling (three cases); or combined clinical, biochemical, and imaging data (three cases). Both CT and scintigraphy detected six of the seven adenomas and the adrenal carcinoma (88%). Regarding hyperplasia, CT was correct in five of six and scintigraphy was correct in two of four cases proved by surgery or venous sampling. CT and NP-59 were concordant and suggested the diagnosis of hyperplasia in the remaining three cases without surgical or venous sampling proof. MR detected both cases of adenoma in which it was performed and showed evidence of hyperplasia in one of the four cases of hyperplasia in which it was performed. Although the number of patients in this series is too small to have much statistical power, these results suggest that CT and NP-59 scintigraphy are equivalent in the detection of adrenal abnormalities in patients with primary aldosteronism. The value of MR in the detection of small adrenal contour abnormalities was limited by slice thickness capabilities. Editorial Comment: A few important comments are in order about this study on the use of varying modalities to evaluate patients with primary aldosteronism. In the statement on the importance of using 5 mm. computerized tomography (CT) slices to detect the small hyperfunctioned adrenal adenoma, the authors are correct in stressing the importance of meticulous technique. Apparently, NP-59 also is an excellent agent to evaluate these patients but, unfortunately, it is not readily available at all hospitals. According to this study, magnetic resonance imaging (MRI) is less than ideal for evaluation of this problem but it should be noted that this study was performed on a 0.35 Tesla unit, and its imaging qualities may not be state of the art. Nevertheless, there is no question that MRI is far more expensive and probably does not yield additional information in most cases. Thus, for practical purposes CT seems to be the most logical method to evaluate and resolve the issue of ademoma versus hyperplasia in these patients. Stanford M. Goldman, M.D.
MR Evaluation of Adrenal Masses at 1.5 T M. E. BAKER, R. BLINDER, C. SPRITZER, G. S. LEIGHT, R. J. HERFKENS AND N. R. DUNNICK, Departments of Radiology and Surgery, Duke University Medical Center, Durham, North Carolina AJR, 153: 307-312, 1989 We retrospectively studied the value of MR imaging at 1.5 T to distinguish between nonadenomatous (n = 17) and adenomatous (n = 15) adrenal masses on the basis of (1) signalintensity ratios on Tl- and T2-weighted spin-echo images, (2) T2 relaxation times, and (3) T2 relaxation-time ratios. Univariate and then multivariate logistic regression were applied to these quantitative parameters to determine which of these best
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discriminated nonadenomas from adenomas, and whether or not more than one of these parameters improved the prediction. The adrenal mass/liver signal-intensity ratio on T2-weighted spin-echo images could not be used to differentiate nonadenomas from adenomas. Adrenal mass/fat signal-intensity ratios on T2-weighted spin-echo images, adrenal/liver T2 relaxationtime ratios, and adrenal mass T2 relaxation times were best for distinguishing nonadenomas from adenomas. By using a T2 value of greater than 61 msec, the true-positive ratio/falsepositive ratio of differentiating nonadenomas from adenomas was 100%/20%; at greater than 82 msec, it was 64%/0.06%. The adrenal mass/fat signal-intensity ratios on T2-weighted spin-echo images and the adrenal/liver T2 relaxation-time ratios showed similar inherent discriminatory capacity. Overlap remains despite the use of these parameters. On the basis of this preliminary information, we conclude that MR has merit for the characterization of adrenal masses at 1.5 T. T2 relaxation time of the adrenal mass shows the greatest promise for discriminating nonadenomas from adenomas. Editorial Comment: Considerable efforts are in progress at several institutions to determine how best to separate the adenoma from the nonadenoma of the adrenal. The most successful attempts at separating these 2 groups have been at low to mid field strength magnetic resonance imaging (MRI) units (less than 0.5 Tesla). Several investigators have suggested that 1.5 Tesla units are not appropriate to perform this comparison. However, the authors show that the 1.5 Tesla units can be used to discriminate between nonadenoma and adenoma. Furthermore, they show that in comparing the various previously proposed parameters the adrenal mass-to-fat signal intensity of T2-weighted spin-echo images theoretically is the technique of choice. Interestingly, the adrenal-to-liver T2 relaxation time ratios seemed to have similar discriminatory capacity in actuality if not on a theoretical basis. However, these ratios a:re not completely discriminatory and, unfortunately, there is some overlap between adenoma and no.nadenoma. However, MRI can be suggestive, if not diagnostic, in most situations. Stanford M. Goldman, M.D. Adrenal Masses: Evaluation With Fast Gnadient-Echo MR Imaging and Gd-DTP A-Enhanced Dynamic Studies
G. P. KRESTIN, W. STEINBRICH AND G. FRIEDMANN, Department of Radiology, University of Cologne Medical School, Cologne, Federal Republic of Germany Radiology, 171: 675-680, 1989 Fast gradient-echo magnetic resonance (MR) imaging of 38 adrenal masses with proved diagnosis was performed during suspended respiration with various repetition times (TRs), echo times (TEs), and flip angles. Dynamic perfusion studies after gadolinium diethylenetriaminepentaacetic acid (DTPA) administration were performed by repeated imaging at short time intervals. With more T2 weighting (TR = 60 msec, TE = 30 msec, and flip angle= 15°), malignant tumors and pheochromocytomas had a significantly higher relative signal intensity than adenomas; overlap of signal intensity led to equivocal findings in nine cases. After administration of Gd-DTPA, ad-
21]
enomas showed mild enhancement and malignant tumors and pheochromocytomas showed strong en hancement and slower washout. Five of the nine cases that were equivocal in precontrast images could thus be correctly classified. In addition to this improved classification of adrenal masses, fast, dynamic contrast material-enhanced MR imaging resulted in a reduction in total examination time. Editorial Comment: The autho:rs describe the use of 2 of the new techniques available with magnetic :resonance imaging (MRI). G:radi.ent-echo imaging permits rapid image accession, thus, dec:reasing respiratory motion artifacts. Gadolinium is a contrast agent on MRI and allows for perfusion studies. However, it :remains to be seen whether the marked enhancement and slow washout of malignant tumors and pheochromocytomas are diagnostically usable clinically. Stanford M. Goldman, M.D. Hyperfu.nctioning and N onhyperfunctioning Benign Adrenal Cortical Lesions: Characterization and Comparison With MR Imaging REMER, R. M. WEINFELD, G. M. GLAZER, L. E. QUINT, I. R. FRANCIS, M. D. GROSS AND F. L. BOOKSTEIN, Department of Radiology, Division of Nuclear Medicine, Department of Internal Medicine, and Center for Human Growth and Development, University of Michigan Medical Center, Ann Arbor, Michigan
E. M.
Radiology, 171: 681-685, 1989 The authors evaluated the potential of magnetic resonance (MR) imaging at 0.35 T to permit differentiation of nine hyperfunctioning adrenal cortical lesions from 21 nonhyperfunctioning adrenal cortical adenomas. Both qualitative data (visual assessment) and quantitative data (signal intensity ratios, Tl, and T2) were used for tissue characterization. With a 2,000/56-100 sequence (repetition time msec/echo time msec), the majority of lesions were visually isointense to liver. Of 34 quantitative measures, only lesion-liver and lesion-kidney intensity ratios at 2,000/150 showed statistically significant differences among nonhyperfunctioning adenomas, aldosteroneproducing lesions, and corticosteroid-producing lesions; however, the authors question the significance of these differences because of the abundant noise associated with the sequence. The results suggest that nonhyperfunctioning adrenal cortical adenomas cannot be distinguished from benign hyperfunctioning cortical lesions with use of MR imaging at 0.35 T. Editorial Comment: Although the final statement cannot be made to date, the authors suggest that magnetic resonance imaging has not replaced the pathological examination. Stanford M. Goldman, M.D. Malignant Versus Non.malignant Retroperitoneal Fibrosis: Differentiation With MR Imaging L. ARRIVE, H. HRICAK, N. J. TAVARES AND T. R. MILLER, Departments of Radiology and Pathology, University of California School of Medicine, San Francisco, California
Radiology, 172: 139-143, 1989
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To evaluate the features on magnetic resonance (MR) images of malignant and nonmalignant retroperitoneal fibrosis (RPF) and to assess the usefulness of MR imaging in differentiating the two conditions, MR studies of nine patients with malignant RPF were retrospectively examined and compared with those of eight patients with nonmalignant RPF. Morphologic findings at MR imaging were similar for both conditions. The lesions were, however, heterogeneous in six of the nine patients with malignant RPF and homogeneous in all eight patients with nonmalignant RPF. On T2-predominant images, malignant RPF showed high signal intensity, while nonmalignant RPF showed low signal intensity. On T2-predominant images, signal intensity and T2 were significantly higher in malignant RPF than in nonmalignant RPF. Differentiation between malignant and nonmalignant RPF appears feasible and depends on tissue contrast rather than on morphologic characteristics.
Editorial Comment: The ability to differentiate between idiopathic retroperitoneal fibrosis from that of retroperitoneal fibrosis secondary to malignancy obviously is important clinically. It is known that fibrotic tissue on magnetic resonance imaging (MRI) has a characteristic pattern, that of a low signal on Tl-weighted and T2-weighted images. In contradistinction, malignancies tend to have low signal intensity on Tl-weighted images with high areas of signal intensity on T2weighted images. Basically, the authors suggest that there is enough malignant tissue in retroperitoneal fibrosis secondary to neoplasia to be recognizable and distinguishable from the fibrosis that develops purely secondary to benign processes. If true, this would be an important observation. Certainly, it is believed that the evaluation of retroperitoneal fibrosis is best done via MRI because of the ability to do multiple projections and to differentiate the flow in vessels that may be affected by the retroperitoneal fibrosis. Stanford M. Goldman, M.D. Mature Teratoma of the Retroperitoneum: Radiologic, Pathologic, and Clinical Correlation A. J. DAVIDSON, D. 8. HARTMAN AND 8. M. GOLDMAN, Department of Radiologic Pathology, Armed Forces Institute of Pathology, Washington, D. C.; Department of Radiology, Bethesda Naval Hospital, Bethesda, and Department of Radiology and Radiologic Sciences, The Johns Hopkins University Hospital and Francis Scott Key Medical Center, Baltimore, Maryland
Radiology, 172: 421-425, 1989 The authors retrospectively evaluated radiologic, clinical, and pathologic findings in 23 cases of mature teratoma arising within peri- or para-renal spaces. Radiologic studies-including abdominal radiographs (21 cases), excretory urograms (12 cases), sonograms (17 cases), and computed tomographic (CT) scans (18 cases)-were evaluated for tumor location, mass effect, calcification, fat, tumor invasion, echo pattern, and tissue characteristics. Most patients were female (3.4:1), younger than 6 months (50%), and asymptomatic. Abdominal radiography demonstrated a mass in 95%, calcium in 92%, and fat in 60% of cases in which CT revealed these components. Similarly, sonography showed uncomplicated fluid in 76% and calcium in 50% of cases. Fat was not reliably distinguished from other soft-tissue components on sonograms. The most
characteristic radiologic findings of mature teratoma of the retroperitoneum are a complex mass containing a well-circumscribed fluid component of variable volume, adipose tissue and/ or sebum in the form of a fat-fluid level, and calcification in either a congealed or linear strand pattern. These findings are better demonstrated by CT than by sonography.
Editorial Comment: As a co-author of this paper, it is not appropriate for me to make any editorial comments other than the fact that this is part of an on-going series of evaluations of retroperitoneal tumors in the extensive experience at the Armed Forces Institute of Pathology. The Armed Forces Institute of Pathology is in a unique situtation of being able to assess a large series of rare lesions to define better the clinical, radiological and pathological correlates. Stanford M. Goldman, M.D. Sonographic Features of Focal Orchitis
J. F. LENTINI, C. B. BENSON AND J. P. RICHIE, Departments of Radiology and Urology, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts J. Ultrasound Med., 8: 361-365, 1989 High-resolution sonography is a very sensitive imaging modality for detecting intratesticular pathology and is an accurate means of distinguishing intratesticular lesions (usually malignant) from extratesticular ones (usually benign). Unfortunately, there are no reliable sonographic criteria to distinguish testicular neoplasms from focal benign intratesticular lesions such as infarction, hemorrhage, or infection. We describe three cases of focal orchitis in which the sonographic features did allow a confident diagnosis of intratesticular infection. In each case a focal peripheral hypoechoic intratesticular abnormality was seen that was poorly defined or crescent-shaped, adjacent to an enlarged epididymis. The specific sonographic features suggest the diagnosis of focal orchitis and orchiectomy can be prevented. Rapid improvement (2 to 4 weeks) should be seen sonographically and in all cases the intratesticular lesions should be followed to complete resolution.
Editorial Comment: The authors describe 3 cases with a characteristic ultrasonic picture of focal orchitis and epididymitis. However, they were unable to demonstrate skin thickening and a large amount of peritesticular fluid in the cases of acute inflammatory disease. If the clinical picture and ultrasonic findings are consistent with inflammatory disease, the authors probably correctly suggest following these patients, since inflammatory disease will resolve within 2 to 4 weeks, whereas the neoplastic processes will not change. We believe that these may be useful adjunctive signs. Stanford M. Goldman, M.D. Testicular Ischemia: Color Doppler Sonographic Findings in Five Patients
W. D. MIDDLETON AND G. L. MELSON, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri AJR, 152: 1237-1239, 1989 We studied the findings on color Doppler sonography in five men with testicular ischemia (three with acute testicular torsion
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and two with testicular infarcts after herniorrhaphies). In all five cases, no intratesticular blood flow was identified on the symptomatic side, while normal blood flow was evident on the opposite side. In the three cases of acute torsion, no gray scale sonographic abnormalities were seen, and in the two cases of postoperative infarction, the abnormalities were nonspecific. These findings suggest that color Doppler sonography can be used to show decreased blood flow in cases of acute testicular ischemia and that it may have a role in evaluating patients with suspected testicular torsion.
Editorial Comment: Color Doppler u!t:ras01.1.n.d can be added to the array of tests available to evaluate the acute testes. It is easier to interpret than noncolor Doppler ultrasound. Certainly, Doppler ultrasound will demonstrate clearly absent testicular flow in testicular torsion. When combined with conventional B mode ultrasound, mo:rph.ological information. also is obtainable. If readily available and if the diagnosis is entertained strongly, it seems to be a rapid, sensible confirmatory test preoperatively, However, it will be less satisfactory when infection or a missed torsion is part of the differential diagnosis. We believe that nuclear medicine studies still have a significant role in the evaluation of testicular tor!lion. Stanford M. Goldman, M.D. Stab W otmds of the Renal Artery Branches: Angiographic Diagnosis and Treatment by Embolization
R. G. FISHER, Y. BEN-MENACHEM AND C. WHIGHAM, Departments of Radiology, Baylor College of Medicine, Houston, Texas and Harborview Medical Center, Seattle, Washington AJR, 152: 1231-1235, 1989 Renal artery branch injury resulting from stab wounds of iatrogenic origin or street violence is an important cause of renal hemorrhage. Over a period of 10 years we accurately diagnosed the injury and successfully managed the associated hemorrhage in 15 patients by using angiography and percutaneous embolization techniques. Nine branch injuries in eight patients were due to street knifings and seven injuries were complications of invasive medical procedures from renal biopsy, two from nephrostolithotomy, and one from nephrostomy). All patients had gross hematuria at the time of angiographic evaluation. False aneurysms vvere present in six patients (one with associated frank extravasation), false aneurysm/arteriovenous fistula in three, false aneurysm/ arteriocaliceal fistula in one, and isolated arteriovenous fistula in two. Frank extravasation without associated false aneurysm/ arteriovenous fistula was present in two. One patient had two injuries, an upper-pole false aneurysm and a lower-pole false aneurysm/arteriovenous fistula. In the eight patients injured in street knifings, hematuria recurred after surgical exploration and treatment. None of the 16 injuries involved the main renal artery. Gelfoam was used for embolization of nine lesions and steel coils for four, Three others were treated with Gelfoam plus coils. Hemostasis was achieved in all and none required subsequent surgery. Renal tissue loss was small to moderate (less than 30%) in 12 patients and large (30-50%) in three patients. Transient postembolization hypertension occurred in one of the latter. We consider selective angiography/embolization to be an
effective and safe means for diagnosing and treating wounds of the renal artery branches.
Editorial Comment: This large series of successfully managed renal stab wounds treated by percutaneous embolization again shows that all perforating injuries to the kidney do not require exploration. The authors suggest that hematuria secondary to knife wounds affecting the kidney requires angiography before any exploration. They also report that delays in actually requesting angiography or embolization complicated the care of 4 of 15 patients. We agree that embolization is an appropriate form of management for renal artery branch in.juries secondary to stab wounds. Stanford M. Goldman, M.D,
PEDIATRIC UROLOGY Morphology of Testicular Germ Cell Tumours in Treated and Untreated Cryptorchidism A. HALME, P. KELLOKUMPU-LEHTINEN, T. LEHTONEN AND L.
Urological Unit, Second Department of Surgery, University Central Hospital, Helsinki, Finland
TEPPO,
Brit. J. Urol., 64: 78-83, 1989 The histolog-y of 75 testicular germ cell tumours in 73 patients with treated or untreated cryptorchidism was investigated in a group of 503 patients with testicular germ cell tumour and evaluated according to the WHO classification. The proportion of pure seminoma was associated with the height of the testis, being 87% in abdominal, 78% in inguinal and 50% in normally positioned testes. In patients operated upon for cryptorchidism, the current site of the testis seemed to be a more important determinant of this proportion than the original site. The proportion of pure seminoma which developed in testes after successful orchiopexy was equal to that in normally-descended testes (50%) and lower (39%) if orchiopexy had been performed before the age of 16 years. Similarly, among non-seminomas, a higher proportion of tumours containing teratoma tissue was found if cryptochidism was successfully treated in childhood. It was concluded that a successful orchiopexy in childhood decreases especially the risk of seminoma.
Editorial Comment: Although germ cell tumors occur mu.ch mo:re frequently in patient§ with m·yp,torchidism or a histrnry of cryptorchi.dism, it is uncertain whetheR" orchiopexy :reduces the risk of eventual tumor devefopmen.L Although the early report by Martin indicated that all patient§ who had a testis tumor after m·chiopexy had undergone the operation when they were older than 5 years, the standard practice :i.n those patient§ was to perform orchiopexy later in childhood. Presently, a number of patients with testicular cancer have been reported who have undergone early o:rchiopexy. In a recent report no correlation was found between the patient age at orchfopexy and subsequent risk of testis cancer. 1 However, in a review of 125 patients from Memorial Sloan-Kettering Cancer Center with cryptorchidism and a testis tumor essentially all patients with an intra-abdominal testis had seminoma, whereas the majority of the tumors in testes that had been brought successfully into the scrotum and that subsequently became malignant were nonseminomatous tumo:rs. 2 The
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Also, it is well known that adrenal androgen secretion decreases dramatically with age. If, as the authors speculate, flutamide is blocking the influence of adrenal androgens, then one would have anticipated the effect to be more pronounced in younger than in older patients. If so, should only younger patients be treated with flutamide and if not, why not? In addition, patients with a severe performance status (in bed more than 50% of the waking hours) who received flutamide had progression more rapidly and had a shorter survival than patients in the placebo group. Should these patients be given flutamide? Finally, this year at the annual meeting of the American Urological Association 2 large studies were reported from Europe that failed to confirm these findings. 2 • 3 If total androgen ablation prolongs life, then all patients should have the opportunity to benefit from this medical advance. However, before we reach this conclusion important questions need to be answered. Patrick C. Walsh, M.D. 1. Trachtenberg, J., Beland, G., Elhilali, M. M., Fradet, Y.,
Laroche, B., Ramsey, E. W. and Venner, P. N.: A randomized trial of total androgen ablation vrs orchiectomy in patients with metastatic prostatic cancer. J. Urol., part 2, 141: 347A, abstract 712, 1989. 2. Denis, L., De Moura, C., Smith, P., Newling, D., Sylvester, R. and Members of the EORTC GU Group: Zoladex and flutamide versus orchidectomy: first final analysis of EORTC 30853. J. Urol., part 2, 141: 311A, abstract 565, 1989. 3. Altwein, J. E., Klippel, K.-F., Holdaway, I. M., Lunglmayr, G., Tyrrell, C. J. and Varenhorst, E.: A multicentre randomised trial comparing the LHRH agonist "Zoladex" with "Zoladex" in combination with flutamide in the treatment of advanced prostate cancer. J. Urol., part 2, 141: 310A, abstract 564, 1989.
Treatment of Complicated Benign Prostatic Hyperplasia With LHRH-Analogues in Aged Patients
S.
BIANCHI, G. GRAVINA, A. PODESTA., D. BARLETTA, F. FRANCHI, P. KICOVIC AND M. LUISI, Endocrine Research
Unit of the CNR, Pisa University, Pisa, Italy Int. J. Androl., 12: 104-109, 1989 The effect of administration of an LHRH-analogue (LHRHa) was evaluated in 11 patients with benign prostatic hyperplasia (BPH) in whom there were contraindications for surgery. These patients, who already had impaired potency due to age or serious illness, were given 1500 µg LHRH-a in the first week and 1200 µg from the eighth day onwards. They all improved significantly (P <0.001) with regard to their urological symptoms on day 60 of treatment. Our results demonstrate the influence of androgen in maintaining established BPH, the effectiveness of LHRH-a therapy in selected patients with BPH and the usefulness of a salivary testosterone assay for the follow-up of treatments expected to lower the bioavailability of androgen to target tissues.
Clinical Experience: Symptomatic Management of BPH With Terazosin DUNZENDORFER, Maingau Krankenhaus, Frankfurt, Frankfurt am Main, West Germany
U.
Universitiit
Urology, suppl. 6, 32: 27-31, 1988 Several reports in the literature have suggested that alphareceptor blockade may have therapeutic value in treating the
symptoms of patients with benign prostatic hypertrophy (BPH). Terazosin is an alpha-1 adrenergic blocking agent currently marketed as an antihypertensive. A multicenter study to evaluate the safety and efficacy of terazosin in the treatment of patients with BPH was initiated. Preliminary results in 15 patients showed that terazosin significantly improved peak as well as mean flow rates, and improved obstructive symptoms in patients with BPH (P < 0.001). The results at four months of a six-month study support the conclusion that terazosin is beneficial for treatment of symptoms in patients with benign prostatic hypertrophy.
Editorial Comment: Two different approaches are presented for the medical management of benign prostatic hyperplasia: 1) decreasing prostate size and 2) decreasing prostate tone. Treatment with the luteinizing hormone-releasing hormone analogue decreased prostatic size by 29% at 6 months and improved symptoms by 40%. Treatment with the al-adrenergic blocking agent also improved total symptom score by 48%. An important question yet to be answered is whether there would there be synergy if these agents are given together. Patrick C. Walsh, M.D.
IMAGING Small Renal Neoplasms: Clinical, Pathologic, and Imaging Features
E. LEVINE, M. HUNTRAKOON AND L. H. WETZEL, Departments of Diagnostic Radiology and Pathology, Bell Memorial Hospital, University of Kansas Medical Center, Kansas City, Kansas AJR, 153: 69-73, 1989 Small renal neoplasms are being found more often because of the widespread use of abdominal CT and sonography. Little is known about their natural history. We therefore retrospectively reviewed clinical, pathologic, and imaging findings in 22 patients with surgically confirmed solitary renal neoplasms that were 3 cm or less in diameter. Eighteen lesions were first found by CT, three by sonography, and one by IV urography. Three lesions were discovered because the patients had hematuria. Nineteen were incidental radiologic diagnoses in patients without renal symptoms. Of 22 neoplasms, 15 (68%) were renal cell carcinomas, six (27%) were oncocytomas, and one (5%) was a lymphoma. Fourteen (93%) of the 15 carcinomas were confined to the kidney, and one showed microscopic capsular invasion. Metastases did not develop in any patient with carcinoma, indicating that small carcinomas usually have good prognoses. Patients with carcinomas had a mean follow-up of 42 months. All neoplasms were visible on CT. However, characterization of these lesions sometimes required a combination of CT and sonography and occasionally angiography. The carcinomas, oncocytomas, and solitary renal lymphoma could not be distinguished radiologically. Small renal neoplasms are most often found incidentally by CT performed in patients without renal complaints. Most are low-stage carcinomas, and some are oncocytomas.
Editorial Comment: With the advent of our newest imaging modalities, smaller and smaller neoplasms of the kidney, symptomatic and asymptomatic, are being
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demml§trated. As expected, the prognosis for these §maHer and often asymptomatic lesions is better. There is a bias to this series in the fact that 5 of the patients with renal cell carcinoma had either Von HippelLindau\; (4) or acquired cystic kidney disease (1). At the moment, the authors advocate radical nephrectomy for these lesions; referring to a 9 to 13% frequency of local tumor recurrence with partial nephrectomy. However, many of these small lesions ultimately were benign oncocytomas in this series (26%). We all certainly would prefer not to remove a kidney with a benign process. One could suggest performing partial nephrectomy on these smaller lesions and await the histological findings before deciding whether nephrectomy is appropriate. We still are unclear as to the need for total nephrectomy for small peripheral renal cell carcinoma and will have to await further studies in this regard. Stanford M. Goldman, M.D. Gadolinium-DTP A Enhanced Dynamic MR Imaging in the Evaluation of Cisplatinum N ephrotoxicity J. A. FRANK, P. L. CHOYKE, M. E. GIRTON, H. A. AUSTIN, C. 8IEVENPIPER, S. W. INSCOE, J. L. BLACK, M. J. CARVLIN AND A. J. DWYER, Diagnostic Radiology Department, Warren Grant Magnuson Clinical Center, and Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland; Departments of Radiology and Medicine, Georgetown University Medical Center, Washington, D. C., and General Electric Company, Milwaukee, Wisconsin J. Comput. Assist. Tomogr., 13: 448-459, 1989 Gadolinium diethylenetriamine pentaacetic acid (Gd-DTP A) enhanced dynamic magnetic resonance (MR) imaging was used to monitor the nephrotoxic effects of cis-platinum (cis-diamminedichloroplatinum; CDDP), a chemotherapeutic agent that produces damage in the proximal convoluted tubule. Ten New Zealand white rabbits (NZWs) were divided into two groups and were evaluated at two clinically relevant doses of CDDP. Group 1 (four NZWs) received CDDP intravenously at 125 mg/ m 2 over 1 h. Rabbits in Group 2 (six NZWs) were infused with CDDP at 40 mg/m 2 each day for 5 consecutive days. Dynamic MR images were performed in the axial plane at 1.5 T using a gradient recalled acquisition in the steady state sequence with an echo time of 11 ms, a repetition time of 20 ms, and a flip angle of 10° after a bolus injection of Gd-DTP A 0.1 mmol/kg. Thirty-two sequential post Gd-DTPA images (5.12 s/image) were obtained over 2 min 45 s at a single location. All rabbits underwent baseline normal and serial post CDDP Gd-DTPA enhanced dynamic MR scans. Analysis of the alterations in the normal pattern of renal enhancement caused by CDDP was facilitated by using a stacked profile image and quantitative region of interest measurements of signal intensity. Normally, after the injection of Gd-DTP A, a dark band promptly appears in the outer cortex of the kidneys and migrates centripetally toward the papilla, reflecting the tubular concentration of GdDTP A. In Group 1 rabbits, nephrotoxicity due to CDDP was observed as early as 9 h after administration of the drug, with a complete disappearance of the dark band by 7 days. In Group 2 rabbits, the band disappeared gradually and reappeared 2-10 days after the completion of CDDP treatment, indicative of tubular damage and recovery with return of the concentrating ability of the kidney. These results illustrate the feasibility of
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using Gd-DTP A MR as a sensitive mor,itor of induced alterations of renal function.
Editorial Comment: Experimentally induced nephrotoxicity with cis-plathmm was :monitored m1ccessfo.lly using Gd-DTPA-enhanced dynamic magnetic resonance l.magi.ng (MRI). Gd-DTP A, an approved MRI contrast enhancement agent, is excreted renally. N ephrotoxicity was demonstrated as early as 9 hours, even before Hght microscopic changes were observed. If confirmed in the future, MRI may be invaluable to follow patients being treated with potentially nephrotoxic agents for early signs of renal damage. Stanford M. Goldman, M.D. Prostatic Carcinoma and Benign Prostatic Hyperplasi.a: Correlation of High-Resolution MR and Histopathologic Findings M. L. SCHIEBLER, J. E. TOMASZEWSKI, M. BEZZI, H. M. POLLACK, H. Y. KRESSEL, E. K. COHEN, H. G. ALTMAN, W. B. GEFTER, A. J. WEIN AND L. AXEL, Departments of Radiology, Pathology and Urology, University of Pennsylvania School of Medicine and Hospital, Philadelphia, Pennsylvania; Department of Radiology, University of North Carolina Medical School, Chapel Hill, North Carolina, and Department of Radiology, Mount Sinai uc,0µaicc", Toronto, u11,w,,,,..,, Canada
Radiology, 172: 131-137, 1989 High-resolution magnetic resonance (MR) imaging of 24 fresh radical prostatectomy specimens was performed on an experimental 1.9-T system. Direct correlation between the findings in 7-µm-thick macrosections and their corresponding MR images was possible. Fourteen patients had macroscopic evidence of cancer. In all 14 cases, the carcinoma nodules appeared as areas of low signal intensity on images obtained with a repetition time of 2,500 msec and an echo time of 80 msec. Ten of 14 nodules had well-defined margins and consisted of packed glandular elements, which displaced the surrounding normal glandular material of higher signal intensity. Ten specimens displayed benign prostatic hyperplasia The MR characteristics of this entity were quite variable but relatively predictable, depending on the distribution and size of the glandular elements, as well as the ~v,m,,v~cc,vu of the surround" ing stroma. In BPH, the changes began in the central of the gland. The areas of highest to dilated glandular elements of lowest signal intensity <>ffr>'~,,mrm to collagen and fibromuscular stroma. Nodules of mixed glandular BPH and fibromuscular BPH were found to have intensities similar to those of well-differentiated nodules of prostatic adenocarcinoma.
Editorial Comment: groups are working intensely in an attempt to crnrrelate magnetic resonance images (MRI) of the prostate (and for that matter ultrasound images) with. th.at of the micropathology result. The authors present the on-going research. at the University of Pennsylvania to explain the image characteristics of prostatic adenocarcinoma and benign prostatic hyperplasia in relationship to the pathological findings. However, it should be noted carefully that this project was performed on a 1.9 Tesla MRI unit. It is not always possible to extrapolate the findings at one particular field strength to another. Specifically, current clinical
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imaging of the prostate usually is done at 1.5 Tesla or at less than 0.5 Tesla. The authors attempt to correlate in vivo images obtained on a 1.5 Tesla clinical unit with in vitro images performed on an experimental 1.9 Tesla unit. Presently, for example, they noted a low relative signal intensity in the peripheral zone of the prostate ex vivo (1.5 Tesla) compared to that in vivo (1.9 Tesla). The authors do not have a good explanation for this phenomenon, although they do suggest the possibility that expressible fluid was squeezed out of the glands or that devascularization may have occurred ex vivo. However, this is an important area of research that hopefully will yield clinically significant information. Stanford M. Goldman, M.D. Percutaneous N ephrostomy in Pyonephrosis F. CAMUNEZ, A. ECHENAGUSIA, M. L. PRIETO, P. SALOM, F. HERRANZ AND C. HERNANDEZ, Departments of Diagnostic Radiology and Urology, Hospital General Gregorio Maranan, Universidad Complutense, Madrid, Spain Urol. Rad., 11: 77-81, 1989 A series of 76 pyonephrotic kidneys in 73 patients were drained by percutaneous nephrostomy (PN) tube and examined to evaluate the contribution of this technique to the treatment of pyonephrosis. In 71 patients, clinical symptoms disappeared 24-48 h after the procedure. Two patients died from sepsis subsequent to anuria and underlying malignancy. Once the acute phase had remitted, interventional procedures were carried out in 39 cases, and constituted the definitive therapy in 36. In 32 cases, elective surgery was the definitive therapy, including the 3 cases not resolved after interventional procedures. Three patients in whom the obstruction cleared spontaneously following PN needed no additional treatment. Major complications included 6 cases of sepsis, all of which resolved satisfactorily with proper medical therapy.
Editorial Comment: In this large series of pyonephrotic kidneys drained percutaneously the fact that 93% of the patients had relief of symptoms within 48 hours truly is impressive. As momentous is the fact that 83.1 % of the kidneys were salvaged (59 kidneys) by percutaneous nephrostomy while radical nephrectomy ultimately was required in only 12 (16.9%). We believe that percutaneous nephrostomy should be attempted with an operation being reserved for kidneys that could not be drained successfully or when the kidney clearly cannot be salvaged. Stanford M. Goldman, M.D. The Detection of Adrenal Tumors and Hyperplasia in Patients With Primary Aldosteronism: Comparison of Scintigraphy, CT, and MR Imaging D. M. IKEDA, I. R. FRANCIS, G. M. GLAZER, M.A. AMENDOLA, M. D. GROSS AND A. M. AISEN, Departments of Radiology and Internal Medicine, Division of Nuclear Medicine, University of Michigan Medical Center, and Veterans Administration Medical Center, Ann Arbor, Michigan; Department of Diagnostic Radiology and Nuclear Medicine, Stanford University, School of Medicine, Stanford, California, and Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
AJR, 153: 301-306, 1989 We retrospectively reviewed the imaging studies in 17 proved cases of primary aldosteronism to determine the value of the procedures used to detect adrenal tumors or adrenal hyperplasia. The procedures included CT with 3-, 5-, and/or 10-mmthick sections (1 7 patients), 131 I-6/)-iodomethyl-19-norcholesterol (NP-59) scintigraphy (16 patients), and MR imaging (six patients). Proof of the adrenal abnormality was established in cases of tumor (seven adenomas, one carcinoma) by surgery and in cases of adrenal hyperplasia by surgery (three cases); venous sampling (three cases); or combined clinical, biochemical, and imaging data (three cases). Both CT and scintigraphy detected six of the seven adenomas and the adrenal carcinoma (88%). Regarding hyperplasia, CT was correct in five of six and scintigraphy was correct in two of four cases proved by surgery or venous sampling. CT and NP-59 were concordant and suggested the diagnosis of hyperplasia in the remaining three cases without surgical or venous sampling proof. MR detected both cases of adenoma in which it was performed and showed evidence of hyperplasia in one of the four cases of hyperplasia in which it was performed. Although the number of patients in this series is too small to have much statistical power, these results suggest that CT and NP-59 scintigraphy are equivalent in the detection of adrenal abnormalities in patients with primary aldosteronism. The value of MR in the detection of small adrenal contour abnormalities was limited by slice thickness capabilities. Editorial Comment: A few important comments are in order about this study on the use of varying modalities to evaluate patients with primary aldosteronism. In the statement on the importance of using 5 mm. computerized tomography (CT) slices to detect the small hyperfunctioned adrenal adenoma, the authors are correct in stressing the importance of meticulous technique. Apparently, NP-59 also is an excellent agent to evaluate these patients but, unfortunately, it is not readily available at all hospitals. According to this study, magnetic resonance imaging (MRI) is less than ideal for evaluation of this problem but it should be noted that this study was performed on a 0.35 Tesla unit, and its imaging qualities may not be state of the art. Nevertheless, there is no question that MRI is far more expensive and probably does not yield additional information in most cases. Thus, for practical purposes CT seems to be the most logical method to evaluate and resolve the issue of ademoma versus hyperplasia in these patients. Stanford M. Goldman, M.D.
MR Evaluation of Adrenal Masses at 1.5 T M. E. BAKER, R. BLINDER, C. SPRITZER, G. S. LEIGHT, R. J. HERFKENS AND N. R. DUNNICK, Departments of Radiology and Surgery, Duke University Medical Center, Durham, North Carolina AJR, 153: 307-312, 1989 We retrospectively studied the value of MR imaging at 1.5 T to distinguish between nonadenomatous (n = 17) and adenomatous (n = 15) adrenal masses on the basis of (1) signalintensity ratios on Tl- and T2-weighted spin-echo images, (2) T2 relaxation times, and (3) T2 relaxation-time ratios. Univariate and then multivariate logistic regression were applied to these quantitative parameters to determine which of these best
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discriminated nonadenomas from adenomas, and whether or not more than one of these parameters improved the prediction. The adrenal mass/liver signal-intensity ratio on T2-weighted spin-echo images could not be used to differentiate nonadenomas from adenomas. Adrenal mass/fat signal-intensity ratios on T2-weighted spin-echo images, adrenal/liver T2 relaxationtime ratios, and adrenal mass T2 relaxation times were best for distinguishing nonadenomas from adenomas. By using a T2 value of greater than 61 msec, the true-positive ratio/falsepositive ratio of differentiating nonadenomas from adenomas was 100%/20%; at greater than 82 msec, it was 64%/0.06%. The adrenal mass/fat signal-intensity ratios on T2-weighted spin-echo images and the adrenal/liver T2 relaxation-time ratios showed similar inherent discriminatory capacity. Overlap remains despite the use of these parameters. On the basis of this preliminary information, we conclude that MR has merit for the characterization of adrenal masses at 1.5 T. T2 relaxation time of the adrenal mass shows the greatest promise for discriminating nonadenomas from adenomas. Editorial Comment: Considerable efforts are in progress at several institutions to determine how best to separate the adenoma from the nonadenoma of the adrenal. The most successful attempts at separating these 2 groups have been at low to mid field strength magnetic resonance imaging (MRI) units (less than 0.5 Tesla). Several investigators have suggested that 1.5 Tesla units are not appropriate to perform this comparison. However, the authors show that the 1.5 Tesla units can be used to discriminate between nonadenoma and adenoma. Furthermore, they show that in comparing the various previously proposed parameters the adrenal mass-to-fat signal intensity of T2-weighted spin-echo images theoretically is the technique of choice. Interestingly, the adrenal-to-liver T2 relaxation time ratios seemed to have similar discriminatory capacity in actuality if not on a theoretical basis. However, these ratios a:re not completely discriminatory and, unfortunately, there is some overlap between adenoma and no.nadenoma. However, MRI can be suggestive, if not diagnostic, in most situations. Stanford M. Goldman, M.D. Adrenal Masses: Evaluation With Fast Gnadient-Echo MR Imaging and Gd-DTP A-Enhanced Dynamic Studies
G. P. KRESTIN, W. STEINBRICH AND G. FRIEDMANN, Department of Radiology, University of Cologne Medical School, Cologne, Federal Republic of Germany Radiology, 171: 675-680, 1989 Fast gradient-echo magnetic resonance (MR) imaging of 38 adrenal masses with proved diagnosis was performed during suspended respiration with various repetition times (TRs), echo times (TEs), and flip angles. Dynamic perfusion studies after gadolinium diethylenetriaminepentaacetic acid (DTPA) administration were performed by repeated imaging at short time intervals. With more T2 weighting (TR = 60 msec, TE = 30 msec, and flip angle= 15°), malignant tumors and pheochromocytomas had a significantly higher relative signal intensity than adenomas; overlap of signal intensity led to equivocal findings in nine cases. After administration of Gd-DTPA, ad-
21]
enomas showed mild enhancement and malignant tumors and pheochromocytomas showed strong en hancement and slower washout. Five of the nine cases that were equivocal in precontrast images could thus be correctly classified. In addition to this improved classification of adrenal masses, fast, dynamic contrast material-enhanced MR imaging resulted in a reduction in total examination time. Editorial Comment: The autho:rs describe the use of 2 of the new techniques available with magnetic :resonance imaging (MRI). G:radi.ent-echo imaging permits rapid image accession, thus, dec:reasing respiratory motion artifacts. Gadolinium is a contrast agent on MRI and allows for perfusion studies. However, it :remains to be seen whether the marked enhancement and slow washout of malignant tumors and pheochromocytomas are diagnostically usable clinically. Stanford M. Goldman, M.D. Hyperfu.nctioning and N onhyperfunctioning Benign Adrenal Cortical Lesions: Characterization and Comparison With MR Imaging REMER, R. M. WEINFELD, G. M. GLAZER, L. E. QUINT, I. R. FRANCIS, M. D. GROSS AND F. L. BOOKSTEIN, Department of Radiology, Division of Nuclear Medicine, Department of Internal Medicine, and Center for Human Growth and Development, University of Michigan Medical Center, Ann Arbor, Michigan
E. M.
Radiology, 171: 681-685, 1989 The authors evaluated the potential of magnetic resonance (MR) imaging at 0.35 T to permit differentiation of nine hyperfunctioning adrenal cortical lesions from 21 nonhyperfunctioning adrenal cortical adenomas. Both qualitative data (visual assessment) and quantitative data (signal intensity ratios, Tl, and T2) were used for tissue characterization. With a 2,000/56-100 sequence (repetition time msec/echo time msec), the majority of lesions were visually isointense to liver. Of 34 quantitative measures, only lesion-liver and lesion-kidney intensity ratios at 2,000/150 showed statistically significant differences among nonhyperfunctioning adenomas, aldosteroneproducing lesions, and corticosteroid-producing lesions; however, the authors question the significance of these differences because of the abundant noise associated with the sequence. The results suggest that nonhyperfunctioning adrenal cortical adenomas cannot be distinguished from benign hyperfunctioning cortical lesions with use of MR imaging at 0.35 T. Editorial Comment: Although the final statement cannot be made to date, the authors suggest that magnetic resonance imaging has not replaced the pathological examination. Stanford M. Goldman, M.D. Malignant Versus Non.malignant Retroperitoneal Fibrosis: Differentiation With MR Imaging L. ARRIVE, H. HRICAK, N. J. TAVARES AND T. R. MILLER, Departments of Radiology and Pathology, University of California School of Medicine, San Francisco, California
Radiology, 172: 139-143, 1989
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To evaluate the features on magnetic resonance (MR) images of malignant and nonmalignant retroperitoneal fibrosis (RPF) and to assess the usefulness of MR imaging in differentiating the two conditions, MR studies of nine patients with malignant RPF were retrospectively examined and compared with those of eight patients with nonmalignant RPF. Morphologic findings at MR imaging were similar for both conditions. The lesions were, however, heterogeneous in six of the nine patients with malignant RPF and homogeneous in all eight patients with nonmalignant RPF. On T2-predominant images, malignant RPF showed high signal intensity, while nonmalignant RPF showed low signal intensity. On T2-predominant images, signal intensity and T2 were significantly higher in malignant RPF than in nonmalignant RPF. Differentiation between malignant and nonmalignant RPF appears feasible and depends on tissue contrast rather than on morphologic characteristics.
Editorial Comment: The ability to differentiate between idiopathic retroperitoneal fibrosis from that of retroperitoneal fibrosis secondary to malignancy obviously is important clinically. It is known that fibrotic tissue on magnetic resonance imaging (MRI) has a characteristic pattern, that of a low signal on Tl-weighted and T2-weighted images. In contradistinction, malignancies tend to have low signal intensity on Tl-weighted images with high areas of signal intensity on T2weighted images. Basically, the authors suggest that there is enough malignant tissue in retroperitoneal fibrosis secondary to neoplasia to be recognizable and distinguishable from the fibrosis that develops purely secondary to benign processes. If true, this would be an important observation. Certainly, it is believed that the evaluation of retroperitoneal fibrosis is best done via MRI because of the ability to do multiple projections and to differentiate the flow in vessels that may be affected by the retroperitoneal fibrosis. Stanford M. Goldman, M.D. Mature Teratoma of the Retroperitoneum: Radiologic, Pathologic, and Clinical Correlation A. J. DAVIDSON, D. 8. HARTMAN AND 8. M. GOLDMAN, Department of Radiologic Pathology, Armed Forces Institute of Pathology, Washington, D. C.; Department of Radiology, Bethesda Naval Hospital, Bethesda, and Department of Radiology and Radiologic Sciences, The Johns Hopkins University Hospital and Francis Scott Key Medical Center, Baltimore, Maryland
Radiology, 172: 421-425, 1989 The authors retrospectively evaluated radiologic, clinical, and pathologic findings in 23 cases of mature teratoma arising within peri- or para-renal spaces. Radiologic studies-including abdominal radiographs (21 cases), excretory urograms (12 cases), sonograms (17 cases), and computed tomographic (CT) scans (18 cases)-were evaluated for tumor location, mass effect, calcification, fat, tumor invasion, echo pattern, and tissue characteristics. Most patients were female (3.4:1), younger than 6 months (50%), and asymptomatic. Abdominal radiography demonstrated a mass in 95%, calcium in 92%, and fat in 60% of cases in which CT revealed these components. Similarly, sonography showed uncomplicated fluid in 76% and calcium in 50% of cases. Fat was not reliably distinguished from other soft-tissue components on sonograms. The most
characteristic radiologic findings of mature teratoma of the retroperitoneum are a complex mass containing a well-circumscribed fluid component of variable volume, adipose tissue and/ or sebum in the form of a fat-fluid level, and calcification in either a congealed or linear strand pattern. These findings are better demonstrated by CT than by sonography.
Editorial Comment: As a co-author of this paper, it is not appropriate for me to make any editorial comments other than the fact that this is part of an on-going series of evaluations of retroperitoneal tumors in the extensive experience at the Armed Forces Institute of Pathology. The Armed Forces Institute of Pathology is in a unique situtation of being able to assess a large series of rare lesions to define better the clinical, radiological and pathological correlates. Stanford M. Goldman, M.D. Sonographic Features of Focal Orchitis
J. F. LENTINI, C. B. BENSON AND J. P. RICHIE, Departments of Radiology and Urology, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts J. Ultrasound Med., 8: 361-365, 1989 High-resolution sonography is a very sensitive imaging modality for detecting intratesticular pathology and is an accurate means of distinguishing intratesticular lesions (usually malignant) from extratesticular ones (usually benign). Unfortunately, there are no reliable sonographic criteria to distinguish testicular neoplasms from focal benign intratesticular lesions such as infarction, hemorrhage, or infection. We describe three cases of focal orchitis in which the sonographic features did allow a confident diagnosis of intratesticular infection. In each case a focal peripheral hypoechoic intratesticular abnormality was seen that was poorly defined or crescent-shaped, adjacent to an enlarged epididymis. The specific sonographic features suggest the diagnosis of focal orchitis and orchiectomy can be prevented. Rapid improvement (2 to 4 weeks) should be seen sonographically and in all cases the intratesticular lesions should be followed to complete resolution.
Editorial Comment: The authors describe 3 cases with a characteristic ultrasonic picture of focal orchitis and epididymitis. However, they were unable to demonstrate skin thickening and a large amount of peritesticular fluid in the cases of acute inflammatory disease. If the clinical picture and ultrasonic findings are consistent with inflammatory disease, the authors probably correctly suggest following these patients, since inflammatory disease will resolve within 2 to 4 weeks, whereas the neoplastic processes will not change. We believe that these may be useful adjunctive signs. Stanford M. Goldman, M.D. Testicular Ischemia: Color Doppler Sonographic Findings in Five Patients
W. D. MIDDLETON AND G. L. MELSON, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri AJR, 152: 1237-1239, 1989 We studied the findings on color Doppler sonography in five men with testicular ischemia (three with acute testicular torsion
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PEDIATRIC UROLOGY
and two with testicular infarcts after herniorrhaphies). In all five cases, no intratesticular blood flow was identified on the symptomatic side, while normal blood flow was evident on the opposite side. In the three cases of acute torsion, no gray scale sonographic abnormalities were seen, and in the two cases of postoperative infarction, the abnormalities were nonspecific. These findings suggest that color Doppler sonography can be used to show decreased blood flow in cases of acute testicular ischemia and that it may have a role in evaluating patients with suspected testicular torsion.
Editorial Comment: Color Doppler u!t:ras01.1.n.d can be added to the array of tests available to evaluate the acute testes. It is easier to interpret than noncolor Doppler ultrasound. Certainly, Doppler ultrasound will demonstrate clearly absent testicular flow in testicular torsion. When combined with conventional B mode ultrasound, mo:rph.ological information. also is obtainable. If readily available and if the diagnosis is entertained strongly, it seems to be a rapid, sensible confirmatory test preoperatively, However, it will be less satisfactory when infection or a missed torsion is part of the differential diagnosis. We believe that nuclear medicine studies still have a significant role in the evaluation of testicular tor!lion. Stanford M. Goldman, M.D. Stab W otmds of the Renal Artery Branches: Angiographic Diagnosis and Treatment by Embolization
R. G. FISHER, Y. BEN-MENACHEM AND C. WHIGHAM, Departments of Radiology, Baylor College of Medicine, Houston, Texas and Harborview Medical Center, Seattle, Washington AJR, 152: 1231-1235, 1989 Renal artery branch injury resulting from stab wounds of iatrogenic origin or street violence is an important cause of renal hemorrhage. Over a period of 10 years we accurately diagnosed the injury and successfully managed the associated hemorrhage in 15 patients by using angiography and percutaneous embolization techniques. Nine branch injuries in eight patients were due to street knifings and seven injuries were complications of invasive medical procedures from renal biopsy, two from nephrostolithotomy, and one from nephrostomy). All patients had gross hematuria at the time of angiographic evaluation. False aneurysms vvere present in six patients (one with associated frank extravasation), false aneurysm/arteriovenous fistula in three, false aneurysm/ arteriocaliceal fistula in one, and isolated arteriovenous fistula in two. Frank extravasation without associated false aneurysm/ arteriovenous fistula was present in two. One patient had two injuries, an upper-pole false aneurysm and a lower-pole false aneurysm/arteriovenous fistula. In the eight patients injured in street knifings, hematuria recurred after surgical exploration and treatment. None of the 16 injuries involved the main renal artery. Gelfoam was used for embolization of nine lesions and steel coils for four, Three others were treated with Gelfoam plus coils. Hemostasis was achieved in all and none required subsequent surgery. Renal tissue loss was small to moderate (less than 30%) in 12 patients and large (30-50%) in three patients. Transient postembolization hypertension occurred in one of the latter. We consider selective angiography/embolization to be an
effective and safe means for diagnosing and treating wounds of the renal artery branches.
Editorial Comment: This large series of successfully managed renal stab wounds treated by percutaneous embolization again shows that all perforating injuries to the kidney do not require exploration. The authors suggest that hematuria secondary to knife wounds affecting the kidney requires angiography before any exploration. They also report that delays in actually requesting angiography or embolization complicated the care of 4 of 15 patients. We agree that embolization is an appropriate form of management for renal artery branch in.juries secondary to stab wounds. Stanford M. Goldman, M.D,
PEDIATRIC UROLOGY Morphology of Testicular Germ Cell Tumours in Treated and Untreated Cryptorchidism A. HALME, P. KELLOKUMPU-LEHTINEN, T. LEHTONEN AND L.
Urological Unit, Second Department of Surgery, University Central Hospital, Helsinki, Finland
TEPPO,
Brit. J. Urol., 64: 78-83, 1989 The histolog-y of 75 testicular germ cell tumours in 73 patients with treated or untreated cryptorchidism was investigated in a group of 503 patients with testicular germ cell tumour and evaluated according to the WHO classification. The proportion of pure seminoma was associated with the height of the testis, being 87% in abdominal, 78% in inguinal and 50% in normally positioned testes. In patients operated upon for cryptorchidism, the current site of the testis seemed to be a more important determinant of this proportion than the original site. The proportion of pure seminoma which developed in testes after successful orchiopexy was equal to that in normally-descended testes (50%) and lower (39%) if orchiopexy had been performed before the age of 16 years. Similarly, among non-seminomas, a higher proportion of tumours containing teratoma tissue was found if cryptochidism was successfully treated in childhood. It was concluded that a successful orchiopexy in childhood decreases especially the risk of seminoma.
Editorial Comment: Although germ cell tumors occur mu.ch mo:re frequently in patient§ with m·yp,torchidism or a histrnry of cryptorchi.dism, it is uncertain whetheR" orchiopexy :reduces the risk of eventual tumor devefopmen.L Although the early report by Martin indicated that all patient§ who had a testis tumor after m·chiopexy had undergone the operation when they were older than 5 years, the standard practice :i.n those patient§ was to perform orchiopexy later in childhood. Presently, a number of patients with testicular cancer have been reported who have undergone early o:rchiopexy. In a recent report no correlation was found between the patient age at orchfopexy and subsequent risk of testis cancer. 1 However, in a review of 125 patients from Memorial Sloan-Kettering Cancer Center with cryptorchidism and a testis tumor essentially all patients with an intra-abdominal testis had seminoma, whereas the majority of the tumors in testes that had been brought successfully into the scrotum and that subsequently became malignant were nonseminomatous tumo:rs. 2 The